Dear Friends and colleagues, Summer heat is s...

Dear Friends and colleagues, Summer heat is scorching in Nashik amidst new challenges for doctors and hospitals. We have to fight with everyone for our survival including our PM! We will continue our services with honesty to all the people in the society. In the current issue, we will focus on an interesting but important clinical problem of thrombosis and stroke…why a hematologist for stroke?? Case 1: 46 yr old male was referred for high hemoglobin (polycythemia) to our OPD. He was seen by a neurologist 7 days back with transient ischemic attack (TIA) and on investigations he had Hb of 18.4.his WBC was 15, 200 and platelet count of 4.9 lakhs. He was a non smoker and did not consume alcohol. He did not have family history of thrombosis. He did not have palpable splenomegaly and no renal disease. Investigations: His USG showed mild splenomegaly. His uric acid was 6.9. LFT and Creatinine were normal. Serum Erythropoietin was very low (this is a hormone produced by our kidney to control the Red blood cell production ) and a special test called JAK 2 mutation study was positive (JAK2 is a gene which regulates the red cell growth in bone marrow and if it is mutated can lead to “unregulated” red blood cell production and hence polycythemia). He was diagnosed to have “Primary Polycythemia” leading to stroke. Treatment: He underwent venesection or phlebotomy (to remove blood as we do in blood bank, but this blood which is removed cannot be used !!). He was started on hydroxyurea therapy to reduce the red blood cell production and the aim is to maintain the Hematocrit at 47% level. He will need lifelong hydroxyurea therapy. He will also need Aspirin therapy lifelong. A new drug JAK2 inhibitor called “Jakavi” is now available in India for such diseases but the cost is 1 lakh rupees a month!! Many patients with polycythemia have high wbc and platelets also. Some of these patients with myeloproliferative disorders can progress to acute leukemia or myelofibrosis and hence need to be monitored closely. Past History: Interestingly, 4 years ago he had stroke in right MCA territory with improvement in 5-7 days and for which he took aspirin for 1 year and stopped on his own. On looking back at his investigations 4 years ago his Hb was 16.9 gm/dl, wbc count was 14, 100 and platelets were 4.67 lakhs. He underwent carotid Doppler and 2DEcho which were normal. So this patient probably had Polycythemia 4 years ago. Young stroke: We routinely investigate “young stoke” for embolic causes and we think of vasculitis, cardiac defects, carotid Doppler etc. mildly raised Hemoglobin leading to polycythemia is also a known cause of stroke. Learning points: 1. Close look at CBC in every case of stroke and thrombosis or coronary artery disease especially in young patients. 2. Even slight Hb increase in appropriate clinical situation should alert us for a diagnosis of polycythemia. 3. Easy treatment is available for this disease which is not expensive. 4. If we miss this diagnosis a patient may present with life threatening coronary heart disease. 5. Health check up can be useful to spot the diagnosis. Lotus Update: With your blessings we have started8 bedded state of the art ICU with 2 isolation cubicles. We have also opened a third Bone marrow transplant room with HEPA filter. We have todate performed 50 bone marrow transplants at Lotus HOSPITAL