A 53-year-old female patient presented to the emergency department with a history of vomiting of ingested matter and passage of dark tarry stool of one-day duration with associated abdominal pain. At presentation, her vital signs were stable. Physical examination revealed mild pallor and an enlarged spleen (5cm below the left costal margin).
Her investigations revealed a leukocytosis of 17, 500/l (neutrophil - 85.5%), moderate anemia (10.5 gm/dl) with a platelet count of 325,000/l and raised bilirubin (TB-2.9mg/dL DB-0.98mg/dL). Otherwise, laboratory studies were all in the normal range. Abdominal ultrasound identified normal-sized liver and normal liver echo pattern with splenomegaly (23.4cm) secondary to portal hypertension secondary to chronic portal vein thrombosis. The endoscopic evaluation revealed grade three esophageal varices without red spots and PHG. EVL was done and the patient was started on propranolol. On follow-up visits, the patient had consistent leukocytosis ranging from 16,300/l-26,200/l without any sign of infection. Her hemoglobin ranged from 11.8 gm/dl - 13.8 gm/dl, while her platelet count ranged 183,000/l-243,000/l. Thus, the patient was linked to a hematologist for further workup and management. Peripheral morphology revealed leukocytosis mainly of band cells and neutrophils and a few basophils. The patient refused BM examination. Jak 2 mutation screening turned out to be positive, BCR-ABL was not done for financial reasons. Hence, with diagnosis of JAK2-positive MPN, the patient was started on Hydroxyurea and warfarin. She, later on, had a smooth course except that she discontinued medications for social reasons two times and experienced episodes of UGIB which required EVL. She currently is adherent to her medications and her symptoms are well controlled.