Page 20 - Journal of Special Operations Medicine - Winter 2016

and numerous downstream effects. There are many hematuria, proteinuria, anemia, or secondary hyper-
31
cases of hyperviscosity syndrome in the literature, and parathyroidism. Additionally, this patient sustained an
symptoms range from headache, 32–34 concentration dif- iatrogenic pneumothorax. A pneumothorax is disquali-
ficulties, and dizziness to more severe hemorrhagic fying from submarine service as well, but the physical
33
34
stroke-type symptoms with MR evidence of hyperdense standard may be waived provided certain conditions are
middle cerebral arteries In this case, the patient had bi- met. The first condition is that the pneumothorax is not
35
lateral, progressive, throbbing headache similar to other spontaneous and a definite cause of the pneumothorax
cases reported. 32–34 Management of hyperviscosity syn- must be identified, which is usually trauma or, as in this
drome targets removal of the abnormal component of case, surgical. Next, the resolution of the pneumotho-
the blood through phlebotomy or managing the primary rax must be associated with normal lung function, as
etiology for the hyperviscosity. Symptoms of hypervis- measured by pulmonary function tests and normal pul-
31
cosity often resolve with resolving erythrocytosis. monary imaging after pneumothorax. In this case, the
patient’s serum creatinine level was normal (1.38mg/dL),
and there was no hematuria, proteinuria, anemia, or evi-
Conclusion
dence of secondary hyperparathyroidism.
Although other causes are possible, the complete resolu-
tion of erythrocytosis, HTN, and headache after surgi- The patient had normal findings on CT imaging of
cal resection of a large cystic kidney lends support to the his lungs and normal pulmonary function testing after
hypothesis that URCD caused erythrocytosis and HTN neph rectomy. The patient met criteria for a waiver for
in this patient. Erythrocytosis leads to hyperviscosity of submarine duty; however, he was at the end of his enlist-
the blood, with an associated headache. Erythrocytosis ment and opted to leave the Navy.
evaluation should include serum EPO measurement, as-
say for JAK2 mutation, and renal imaging to evaluate Disclaimer
for cystic renal disease.
The views expressed in this article are those of the authors
Management of URCD will vary depending on the pre- and do not necessarily reflect the official policy of position
sentation of the patient; however, in instances such as of the Department of the Navy, Department of Defense,
this case, a nephrectomy may definitively treat the HTN or the US government. Because this is a case report, it was
and erythrocytosis. Future directions for research in the not directly funded by any sponsor, nor was any research
field of URCD should explore the association of EPO protocol reviewed. This work was prepared as part of of-
with renal cysts. It also will be important to document ficial duties; copyright protection is not available for any
additional cases of erythrocytosis, secondary HTN, and work prepared by a military Servicemember or employee
URCD, because, to our knowledge, this is the first re- of the US government as part of their official duties.
ported case of this clinical association. This case high-
lights the importance of due diligence when presented Disclosures
with a patient with headache and HTN, a common
complaint with a broad differential. As was important The authors have nothing to disclose.
here, routine blood work to include a complete blood
cell count will provide diagnostic clues and generate an
improved differential diagnosis. References
1. Bisceglia M, Galliani C, Senger C, et al. Renal cystic diseases: a
The military disposition in this case is worth discussing. review. Adv Anat Pathol. 2006;13:26–56.
The patient was a US Navy submariner. Similar to Spe- 2. Hwang D, Ahn C, Lee J, et al. Unilateral renal cystic disease in
adults. Nephrol Dial Transplant. 1999;14: 1999–2003, 1999.
cial Operations duty, submarine duty is unique in that 3. Neyaz Z, Kumar S, Lal H, et al. Localized cystic disease of the
immediate medical care is often not readily available kidney: a rare entity. J Radiol Case Rep. 2012;6:29–35.
except for routine issues. As such, there is a high stan- 4. Bergman H, Nehme D. Unilateral polycystic renal disease. NY
dard to meet before one can be cleared for submarine State J Med. 1964;64:2465–2469.
duty. These physical standards for both Special Opera- 5. Hutchins K, Mulholland S, Edson M. Segmental polycystic dis-
ease. N Y State J Med. 1972;72:1850–1852.
tions and submarine duty requirements are contained 6. Cho K, Thornbury J, Bernstein J, et al. Localized cystic disease
in the Manual of the Medical Department and further of the kidney: angiographic-pathologic correlation. AJR Am J
amplification of the submarine standards is contained in Roentgenol. 1979;132:891–895.
Chapter 15-106. A nephrectomy is disqualifying from 7. Bisceglia M, Creti G. AMR series unilateral (localized) renal
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submarine service, but the physical standard may be cystic disease. Adv Anat Pathol. 2005;12:227–232.
waived, provided certain conditions are met. The first 8. Slywotzky CM, Bosniak M. Localized cystic disease of the kid-
ney. AJR Am J Roentgenol. 2001;176:843–849.
is that renal function should not be impaired. Addition- 9. Branger B. Unilateral form of polycystic kidney disease.
ally, there can be no stigma of renal disease, including Nephrol Dial Transplant. 1999;14:2775–2776.

4 Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016