Patient: Hi,I have a history of low iron and borderline anemia, but it has been progressively worsening over the last year. 8 months ago i started taking folate per my dr, my folate levels rose off the charts but my other levels continued to fall. A little over 3 months ago my physician put me or ferrous sulphate 325mg x2 daily and I also changed my diet to contain an abundance of iron rich foods, including meat which I had not been eating previously (this was a major lifestyle change). My red blood cell count & hemoglobin came back into normal range, but everything else declined. I also have had an elevated white cell count for this entire time. 1 week ago I was also put on Levaquin.I am suffering from fatigue, my body aches as if I have a very bad flu even after the most moderate physical activity. I feel like I am getting worse by the day this week. I have an appt with a hematologist but it is another 3 weeks away and I am concerned.These are my most recent test values:Blood-White Count – high 14.2kRed Count is in range 4.91 milHemoglobin in rangeHemocrit in rangeMCV- Low 78.4MCH – Low 24.8MCHC – Low 31.6RDW – High 17.3%Creatinine – Low 0.43AST – Low 8Ferritin- normal 62Iron total- Low 33Iron binding capacity- normal 356Iron % Saturation – Low 9%Urine-Absolute Neutrophils – High 9372 cellsAbsolute Lymphocytes – High 4260 cellsI was tested for fecal occult blood and it came back negative. My blood pressure is fine, but my pulse is often high, moreso at night, and at night occasionally my oxygen levels fall. I’ve measured them @ 92, but I spot check with a home oximeter, so at times it may fall lower. Any insight you can provide will be helpful.
Symptoms: Long term: fatigue, overall feeling of malaise, body aches and pains, feeling feverish, dizziness, occasional sweating, tingling lips, feeling low on oxygen,
Doctor: Hello,Thank you for your query at AskTheDoctor.comI understand your concern.I have gone through your charts too, a nd they are not pointing towards anything in particular.But I would advise you the following and ask you to follow up-1) please get a peripheral smear done2) Ultrasound abdomen to check for liver and spleen size.Feel free to discuss further
Comments / Follow Ups
Patient: Do you suspect leukemia? Are there any additional signs or symptoms I should look for that would support or rule out that possibility?
My primary physician suggested I increase the ferrous sulfate 325 to 3x a day, do you think that’s safe?
Are my levels good enough that I am safe to wait the three weeks? Are there any trouble signs I should look out for that may require more immediate care?
Patient: Also thank you for your time
No, as of now, seeing the values, it is not suggestive of leukemia.
I feel twice a day itself is enough, no need to increase to 3 times.
If you feel too out of breath, and feel giddiness, you can go for immediate care.
Just get a peripheral smear and ultrasound done and follow up.
Patient: I still have 2 more weeks before I will get to see the specialist. I want able to convince my primary to do the peripheral smear or the ultrasound to check on liver and spleen, but he did rin a white count differential this time with the CBC :
Platelets – 334 (in range 140 – 400)
Neutrophils – high 9268 (7800 top)
Lymphocytes – high 4032 (3900 top)
Monocytes – 322 (in range 200 – 950)
Eosinophils – 308 (in range 15 – 500)
Basophils – 70 (in range 0 – 200)
I psuhed very hard but he has chosen to refer me to an oncologist at this point. Luckily the hemotologist I booked the other week is also an oncologist so saved some wait time there.
My primary also ran me for most blood born illnesses such as HIV, Hep A through C, etc, and all came back nefative. He is unwilling to order any additional testing, though he dpes agree the smear is important hefeels ordering that test would be stepping beyond his bounds. He feels it is sugestive of Leukemia, but doe to my age (35) he still feels it could be another type of cancer or chronic disease. Thank you for your time again. Any insight is helpful. Also in the evenings my heart races and I have a fair amount of pain in my legs. It makes it very difficult to fall asleep at night. My primary said it is part of anemia, and I beliece him, but what can I do to help myself fall asleep?
Patient: I apologize for typos, I am not very good typing on my tablet 🙂
Yes the history could be suggestive of leukaemia.
But before we call it that, let’s have the peripheral smear report as well as the ultrasound that I mentioned. And then we can come to a conclusion.
Patient: Thank you. It is not for lack of trying on my part for the suggested tests. I have pushed my primary to do both but he only would run the differential, and after receiving those results chose to only run the tests for HIV, Hep, etc. He is unfortunately not interested in ordering the ultrasound or the smear for reasons I do not understand. When I see the oncologist / hematologist I will request those tests if the specialist does not suggest them himself. Thank you.
Doctor: Yes, those tests are mandatory to reach a diagnosis.
I will keep this consult open, once you can manage to get them done, please do follow up.
Patient: I saw a hematologist / oncologist monday. He wanted to run his own CBC and teats first before ordering smear. These are results of note. I have not heard back from him yet but can view tests online.
New test shows iron up but white counts increasing:
Iron saturation – up from 9% to 13%
Serum Iron – 47 if same as “iron total” in other tests up from low 33
White Count – from 14.2k up to 17.4k
Neutrophils – from 9268 up to 12441
Lymphocytes – from 4032 up to 4263
MCV dropped slightly from 78.4 to 77.9
MCH almost unchanged from 24.8 to 24.9
New values of significance:
Sed rate – high 45mm/hr
Haptoglobin – high 308mg/dl
Alpha 1 – high 0.5 g/dl
Alpha 2 – high 1.0 g/dl
Note on test says:
“The protein electrophoresis pattern, characterized by increased alpha-1 and alpha-2 globulins, is consistent with an acute phase response. Elevation of beta-2 is suggestive of acute inflammation.”
Doctor: It is indicative of an inflammatory response,
What are your current symptoms?
The increase in sedimentation rate as well as haptoglobin is indicative of the inflammation.
The increase in hemoglobin is an encouraging sign.
It is better that the hematologist is handling your case, as he is the most apt to do it.
Patient: My main simptom is fatigue that gets worse throught the day. I am tired like I have never been before. I work a desk job, the more physical activity my day includes the harder it is on me. Basic chores around the house or running errands give me what feel like flu aches and pains in my muscles, especially my legs. I feel like I have a fever but I dont believe I actually do. Most nights my pulse races by bedtime, sometimes my oxygen drops to 92 -93, but is usually 96 -97 by the time I wake up. Vitals are usually good in the AM. Occasionally I get dizzy, I get dizzy after giving blood for tests and very dizzy when they take multiple vials and I have difficulty recalling words later at night / difficulty putting together sentences. For inflamation I do have swelling in my left foot cutrently from where I tore my joint capsules a few months prior. Podiatrist says swelling will go down with physical therapy. Probably does not factor in as I did this after I already was displaying anemia and high white count, but wanted to mention it just in case. Anemia and high white count have been ongoing for 8+ months. Thks most recent blood test was first time iron showned jmprovement after almost 4 months on ferrous sulfate.
Patient: I also have history of kidney stones and migraines. I habe duodenal ulcers from taking excedrin / long term nsaid use for migraine, but they have not been particularly bothering me. I am h. Pylori negative.
Doctor: It is better you get the peripheral smear and based on that we can take a decision.
The white cell count would just be from the ongoing inflammation.
We would need to again review in 3month’s time, your blood work, but as of now, the smear is a must.