es/o2,2eis 15:2S

es/o2,2eis 15:2S 2125352830 =Am el August 28, 2015 To: Elliott Howard, M.D. Richard Kutnick, M.D. GERARD HCLLMAN. N.O. wtraafOrlatetaY ItlYERWIZ. mrtme Nit This letter is written pursuant to ow conversations over the pest few days - I hope it will document some of my thoughts, although richer data are awaited. Mr. John Brockman was evaluated in my office on August 25. 2015, after Dr. Howard noted him to have evidence for polyrythemie The high red cell paramaen were found on a CBC done earlier this month, and represented a departure from earlier Ievels. Indeed, a Hb of 15.6 was documented on Nov. 7, 2013, had risen to 16.8 on Jan13. 2015, and had risen (tether to 17.9 on August Sm, 2015. Leukocyte and platelet counts have been in the normal range. Examination of a peripheral blood film did reveal significant rtwrbers of mcgathrombocytes, some of which were hypogranulated, as well as uccasional atypical lymphoid cells. These findings prompted measurement of erythropoietin, which was elevated at 30.4 (normal range 2.6-18.5). Therefore, it is hard to reconcile the particulars with any one cause of poiyerhemia. As there is a strong history suggesting sleep-apnea, this diagnosis has to be strongly considered. and a search made for nth= causes of hypoxernia. His development of rapid AF and cardiomegaly mandates father attention to his cardiac status. One always has to consider other causes of high EPO (tumors, endocrine pathology. etc.), although they seem less likely at this time. A preliminary reading of the :List completed PET/CT does mention renal cysts, and these have been associated with polycythen-ja, but the amount of eyrie change found may be too minimal — Tam researching this possibility. High EPO levels are usually not seen with mycloproliferative disease, but the large platelets make such pathology plausible (markers are awaited). An unexpected finding has been significant panhypogammaglobulinemia (and the atypical lyrnphs). I told Mr. Brockman that this deserves further consideration, and he will be returning to my offloc. I cautioned him not to receive Zostavax in the interim. I look forward to discussing further with you after the final test results arc received. Sincerely yours. Gerard He -s M.D. EFTA01196910