What is the initial workup for a patient presenting with polycythemia (excessive red blood cell count)?

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Polycythemia Workup

Initial Diagnostic Approach

Begin the workup by confirming elevated hemoglobin/hematocrit values adjusted for sex and race, then immediately measure serum erythropoietin (EPO) level, followed by JAK2 mutation testing if EPO is low or normal. 1

When to Initiate Workup

Trigger diagnostic evaluation when: 1

  • Hemoglobin/hematocrit exceeds the 95th percentile for sex and race
  • Documented increase above patient's baseline regardless of absolute value
  • Borderline-high hematocrit accompanied by PV-related features: thrombocytosis, leukocytosis, microcytosis, splenomegaly, aquagenic pruritus, unusual thrombosis (Budd-Chiari syndrome), or erythromelalgia

Step 1: Confirm True Polycythemia

Exclude relative (apparent) polycythemia by: 2, 1

  • Assessing hydration status and clinical context (dehydration, diuretics, severe burns, diarrhea, vomiting)
  • Recognizing that most plasma volume depletion causes are clinically obvious and don't require specialized testing
  • Identifying smoker's polycythemia (carbon monoxide-mediated, resolves with cessation)
  • Avoiding red cell mass measurement - this is costly, redundant when hematocrit >60%, and doesn't rule out PV 1

Laboratory Testing Algorithm

Step 2: Serum Erythropoietin Level (First-Line Test)

Low EPO is highly suggestive of polycythemia vera with >90% specificity, but sensitivity is only ~70%. 1, 3

Interpretation: 1

  • Low EPO: Proceed to JAK2 mutation testing and bone marrow examination
  • Normal EPO: Does NOT rule out PV; proceed to JAK2 testing
  • High EPO: Evaluate for secondary polycythemia causes

Critical caveat: Rare cases of PV can present with elevated EPO levels, so JAK2 mutation testing remains essential when clinical suspicion is high. 4

Step 3: Complete Blood Count with Differential

Assess for additional features: 1, 3

  • Thrombocytosis (present in 53% of PV cases)
  • Leukocytosis (present in 49% of PV cases)
  • Microcytosis with low MCV/MCH/MCHC - this distinctive pattern strongly suggests PV with iron deficiency, not simple iron deficiency anemia 5

Step 4: JAK2 Mutation Testing

More than 95% of PV patients harbor JAK2 mutations, which distinguishes PV from secondary causes. 3, 6

Step 5: Bone Marrow Examination

Indicated after abnormal EPO results (low or normal): 1

  • Assess for hypercellularity
  • Evaluate megakaryocyte number, size (giant forms), and pleomorphism
  • Check iron stores - decreased stores are characteristic of PV

Evaluation for Secondary Polycythemia (If EPO Elevated)

Hypoxia-Driven Causes

Measure: 1

  • Arterial hemoglobin-oxygen saturation
  • Carboxyhemoglobin level

Investigate: 2, 1

  • Chronic lung disease
  • Sleep apnea
  • High altitude exposure
  • Cardiac right-to-left shunts
  • Hemoglobinopathies with increased oxygen affinity

Hypoxia-Independent Causes

Perform imaging studies of: 1

  • Kidneys (renal cell carcinoma)
  • Liver (hepatocellular carcinoma)
  • Central nervous system (meningioma)
  • Adrenal glands (pheochromocytoma)
  • Uterus (leiomyoma)

Specialized Testing (When Diagnosis Remains Unclear)

In approximately 10% of cases where standard workup is inconclusive: 1

  • Megakaryocyte TPO receptor (c-mpl) expression
  • Peripheral blood neutrophil PRV-1 expression assay
  • Spontaneous (endogenous) erythroid colony assays

Important limitation: These specialized tests complement but do not substitute for standard diagnostic procedures, and their sensitivity/specificity have not been rigorously validated. 2

Critical Pitfalls to Avoid

Do NOT give iron supplementation before establishing the diagnosis - if PV with iron deficiency is present, iron replacement worsens hyperviscosity and dramatically increases thrombotic risk. 5

Do NOT assume microcytosis always means simple iron deficiency - the combination of elevated RBC count with microcytosis specifically suggests PV with iron deficiency. 5

Do NOT rely solely on EPO levels - normal EPO does not exclude PV given the 70% sensitivity. 1

Do NOT order red cell mass measurements routinely - this test is unnecessary in modern practice when hematocrit is clearly elevated and other diagnostic tools are available. 1

References

Guideline

Diagnostic Approach to Polycythemia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Diagnostic Approach to Polycythemia Vera with Iron Deficiency

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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