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JAMA Clinical Challenge

Progressive Anemia and Left Upper Quadrant Pain in a Patient With Polycythemia Vera

Image of Computed tomography scan of the abdomen. A, Axial view. B, Coronal view.

Jordan A. Roberts, MD
Mariela Morales, MD
Lawrence Rice, MD

A 72-year-old man with a 23-year history of polycythemia vera presents with a 2-week history of left upper quadrant pain. Three years earlier, red cell scintigraphy documented a splenic hemangioma, which remained stable on periodic computed tomography (CT) scans.

There is no history of abdominal trauma, melena, or hematochezia. The patient had lost 6.75 kg (15 lb) and experienced increasing fatigue during a period of 1 month. On physical examination, vital signs are normal. The spleen edge is palpable 6 cm below the left costal margin (increased from 1 month prior). There is no hepatomegaly or lymphadenopathy. On rectal examination there is no gross blood, and no stool to perform a guaiac test. Laboratory studies show a hemoglobin level of 6.8 g/dL (from 12 g/dL 2 months earlier and 8 g/dL 1 week earlier), white blood cell (WBC) count of 15.76 × 109/L, and platelet count of 266 × 109/L. A CT scan of the abdomen was performed (Figure).

See the full article for an explanation and discussion.

Author Affiliations: Dr Rice (lrice@tmhs.org) is affiliated with the Division of Hematology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College. Dr Morales is affiliated with the Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College. Dr Roberts is affiliated with the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Weill Cornell Medical College.