Hookah (narghile) smoking: A new emerging cause of secondary polycythemia
Authors: Tamar Tadmor, Elena Mishchenko, Aaron Polliack, Dina Attias
Journal: American Journal of Hematology (2011)

Acquired secondary erythrocytosis due to tissue hypoxia is most frequently caused by cigarette smoking [1]. Hookah (naghile) smoking, a habit originating in the Middle East, has recently been revitalized as a novel "social activity and a fashionable style" of "tobacco smoking" among young adults, and has unexpectedly become quite an alarming health problem [2, 3]. Secondary erythrocytosis due to abuse of hookah smoking may not be that rare as we think but has not been reported in the hematological literature until now. Recently, we encountered a young male, who was admitted to our department because of recent onset of abdominal pain. Laboratory results showed that hemoglobin of 22.7 (n.v 13.5–17.5 g/dL), hematocrit 69.1% (n.v 40–52%), WBC, differential count, and platelets were within the normal limits. Blood chemistry analyses were all within the normal limits including lactate dehydrogenase, uric acid, and Vitamin B12. He denied cigarettes smoking but did admit using the hookah. An urgent abdominal CT angiography was performed and was normal. Polycythemia vera was excluded as JAK2 (V617F) and JAK2 exon 12 mutation were not present, and the erythropoietin level was mildly elevated 80.4 (n.v 3.7–19.6 mIU/mL; Ref.1). All previous blood counts from 2001 to 2010 were normal, as were those of his parents and only brother, which excluded the possibility of congenital or familial polycythemia. A diagnosis of acquired secondary erythrocytosis was made and cardiac echo, lung function tests, and total body and brain CT scans were all normal. A more detailed medical history was now taken regarding his personal smoking habits and his reply to the question about daily hookah smoking was "No, you misunderstand, I don't smoke every day but all day!" Carboxyyhemoglobin levels were then examined and found to be 27.2% (n.v < 1.5% for nonsmokers and 1.5–5% for smokers) which confirmed the diagnosis of acquired erythrocytosis due to excessive hookah smoking. 1 A hookah, an oriental instrument for smoking, a pipe containing tobacco, connected by a long flexible tube which draws the smoke to a bowl of water that cools the smoke as it is drawn through. A hookah is an oriental pipe containing tobacco, often mixed with molasses and fruit flavors, connected by a long flexible tube which draws the smoke to a bowl of water. The tobacco smoked is referred to as narghile or shishaand contrary to ancient folklore and popular belief, the smoke emerging from the water pipe does contain numerous toxicants known to cause lung disease, lung cancer, heart disease, complications during pregnancy [4-6] and increase of carcinoembryonic antigen, a known marker of malignant transformation, and chronic inflammation [5]. Other health risks include the transmission of infectious diseases, such as tuberculosis, due to the sharing of the hookah at social gatherings [7]. Based on all the above, in 2007, due to increased use, and growing popularity and the "unfounded assumptions" of its medical safety, the WHO found it necessary to publish a warning that hookah may pose the same health risks as cigarette smoking, informing the public that an individual inhales more than 100 times smoke in a hookah session than from a single cigarette [8]. Recently, two cases of hookah CO intoxication were widely advertized in the French media [9], but this failed to have a big enough public impact. Evaluation of hypoxia as a possible cause of erythrocytosis usually includes performing studies to exclude lung diseases with perfusion or ventilation abnormalities and congenital heart disorders, as well as renal artery stenosis and anemic hypoxia due to methemoglobinemia or sulfhemoglobinemia [1]. Because of its growing popularity, awareness of the new "fashion" of hookah abuse should be taken into consideration when evaluating erythrocytosis. Addiction to excessive hooka abuse can easily become a "full time" activity, as in the case described here, and can result in a severe secondary erythrocytosis. Tamar Tadmor*, Elena Mishchenko*, Aaron Polliack , Dina Attias*, * Hematology-Oncology Unit, Bnai-Zion Medical Center, Haifa Israel, Department of Hematology, Hadassah University Hospital and Hebrew University Medical School, Jerusalem, Israel.