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Erythrocytosis as the presenting manifestation of recurrent metastatic colorectal cancer

  • Ami Schattner
    Correspondence
    Corresponding author: Ami Schattner, Professor of Medicine, The Faculty of Medicine, Hebrew University and Hadassah, Jerusalem, Israel. Phone 972 8 939 0330.
    Affiliations
    Chief Consultant, Meuhedet HMO, Rehovot; and The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel
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Published:November 06, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.10.013
      Hematocrit of 51.5% (HB 17.8 gr/dL) developed in a 71-year-old man who never smoked and whose previous hematocrit values were 45.9-46.9% in 7 consecutive determinations. Over the next 16 months, hematocrit gradually increased to 55.4% (HB 18.7 gr/dL), with new-onset mild increase of cholestatic liver enzymes (Table 1). One year later, a hospital-based hematologist initiated extensive investigations. White blood cell count (7.5 × 109/L) and platelets (190 × 109/L), glucose, electrolytes and proteins were normal; C-reactive protein 7.4 mg/dL (N<5); Serum creatinine was 1.4 mg/dL, unchanged over years. Chest X-ray, abdominal ultrasound and echocardiography were non-contributory. A search for a myeloproliferative disorder or hypoxemia including sleep study was negative. Erythropoietin was 8.9 mIU/ml (N 4.3-29). At last, computed tomography revealed multiple hepatic lesions and biopsy showed cores of liver tissue infiltrated by metastatic adenocarcinoma morphologically and immunohistochemically consistent with colonic origin. Carcinoembryonic antigen (16 ng/ml, N<5) and CA-125 (42 U/ml, N<35) was increased. PET CT demonstrated extensive hypermetabolic lesions in the liver and a peripancreatic lymph node.
      Table 1Changes in the patient's hemoglobin, hematocrit, acute-phase reactants, and cholestatic enzymes over 19 months.
      At RightHemicolectomyT2N0M0
      Values in this column remained stable over 13 months. Transaminases and bilirubin were always normal. Abnormal results are underlined.
      After 14 months After 16 month After 25 months After 30 monthsAt Diagnosis of Liver Metastases
      Hb, g/dL

      N 13.5-16.5
      14.6
      Values in this column remained stable over 13 months. Transaminases and bilirubin were always normal. Abnormal results are underlined.
      16.8 17.8 18.7 17.5
      Post-phlebotomy ND = Not done
      Hematocrit, %

      N 38-50
      44.3 51.5 53.5 55.3 54.7
      Post-phlebotomy ND = Not done
      Ferritin, ng/ml

      N 22-275
      104 ND ND 50.1 244
      CRP, mg/L

      N 0-5
      2.3 ND ND 5.6 7.4
      Alkaline Phosphatase, U/L

      N 30-140
      108 185 173 164 180
      Gamma-Glutamyl Transferase, IU/L

      N 9-55
      35 ND 81 ND 76
      ^ Values in this column remained stable over 13 months. Transaminases and bilirubin were always normal. Abnormal results are underlined.
      low asterisk Post-phlebotomyND = Not done
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