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Forum Name: Leukemia

Question: Bone marrow hypoplasia


 Anonymous - Tue Feb 11, 2003 2:16 pm

Dear Doctor:

I'm not sure I'm posting on the right board, but I'm seeking a second opinion.

Seven years ago I was diagnosed with moderate bone marrow hypoplasia at a time when I was dieting overzealously. My WBC count was 3.0 at that time, and my platelet count was 106,000. My red count was normal then. Because the pathologist noted focal serous fat atrophy along with moderate marrow hypoplasia, it was suggested the cause was nutritional, and I was told to take a vitamin and put on a few pounds, which I did. My white count returned to normal, but my platelet count remained around 125,000. My B12 and folic acid levels were tested then and were normal. I have not seen a hematologist since then, but my internist has been monitoring my counts now for seven years; the last CBC showed the following: WBC 5.8, RBC 3.72, MCV 101, plt 130,000. My counts have fluctuated a little. Last year at one point, everything was normal. This past year, however, is the first time the red count has been affected. I was tested again for folic acid, RBC folate, and B12, and all were normal. My reticulocyte count was 1.1%. I've done some research over the years in an attempt to determine the cause. I discovered that marrow hypoplasia is common in anorexia nervosa but corrects itself upon refeeding. (Please note: I was not diagnosed anorexic. At 5'4", I weighed 100 lbs and still had regular periods. I currently weigh 120 lbs).

Can you share with me the possible causes for my situation? No one has mentioned aplastic anemia to me, but is it possible I have a mild form of this disease? Could the dieting have caused irreparable damage? Do you recommend I see a hematologist again, or is it reasonable to just say that we don't know the cause and since my counts are not severely decreased, why worry?

Thank you for your time, Doctor. Your response is truly appreciated!

Autumn
 Dr. Jeffrey Gordon - Sat Feb 15, 2003 11:00 am

Autumn,

The blood numbers that you report are fortunately not rock bottom low. However, I would recommend your being re-evaluated by a Hematologist. I cannot say if another bone marrow biopsy will be performed, but consideration of such is reasonable. I would expect a Hematologist to carefully review your prior and current blood numbers, perhaps do some detailed blood testing of the B12 and folate pathways in your body (i.e.- tests beyond just a simple serum B12 and folate), review a peripheral blood smear, detail any medications or health supplements that you may be taking to discern if they may be causing a problem, and, if another bone marrow biopsy is done, perform cytogenetic and flow cytometry analyses. If consideration of aplastic anemia, then certain tests can be done. One can also check to make certain that the problem does not lie in your bone marrow, but rather elsewhere in the body. That is, is your body destroying or hemolysing the blood. Are there any antibodies being produced that are causing your blood cells to be low in the blood instead of in the bone marrow? I am limited in recommending any specific tests to you since I am not privy to your medical history, test results, look at the prior bone marrow and blood smears, and an examination of you. Nevertheless, it is always best to obtain a repeat Hematology evaluation. Hopefully nothing of concern will be found. My best to you.
 Anonymous - Wed May 07, 2003 1:39 am

Dear Doctor:
It's me, Autumn, again. Thank you for your kind reply to my last post. I have since made an appointment with a hematologist, and I will be seeing him in a week. However, my internist also ran some additional tests, and I'm a bit confused about the results. I was hoping you might be able to reassure me.

My serum iron was 154 (slightly high by the lab's range), ferritin 28, TIBC 321, iron saturation 48%. WBC count was 3.8, RBC 4.17, hg 14.2, MCV 100, platelets 121,000. Reticulocyte count was 0.7%. Comparing these results to those I noted in my last post, the WBC went from 5.8 to 3.8, RBC from 3.72 to 4.17, and platelets from 130,000 to 121,000 in about 1-1/2 months' time. I'm puzzled, first of all, by the erratic results. My counts seem to be "all over the place" within a mildly decreased range. How might that be possible in light of a history of marrow hypoplasia? Also why would the serum iron be slightly high while the serum ferritin is on the low end? Does this suggest iron deficiency??? Could iron deficiency cause a drop in the white cell and platelet counts too? I (rather unfortunately) read a little on PNH, and I'm a little afraid that might be what's going on. With my limited medical knowledge, it seems that intermittent hemolysis might indeed cause an erratic picture, but how could the red cell count rise when the reticulocyte count wasn't elevated? Did we just miss it? The white count dropping now when it has always been normal is also a concern to me. I know I'm throwing a lot of questions out here and the data is insufficient to give any definitive answers, but can you give me your impression on the ups and downs and on the iron status and share your thoughts with me on the possibility of PNH?

Thanks, Dr. Gordon, for giving me a little of your time. You've been really helpful to me!

Autumn
 Dr. Jeffrey Gordon - Thu May 08, 2003 10:28 am

Autumn,

First, it is O.K. to have the results of various lab tests return back with different numbers, as long as the numbers are within the defined reference or normal range. The proteins, hormones, and blood cells in the body are not static, but rather produced continuously throughout the day at varying levels of production. In addition, blood cells have a defined lifespan and are thus affected not just by the levels of production, but by the degree of their removal from the blood (and the body). The change in the platelet count is minor and I do not put much significance into it. Rather, I would look at the platelet count and the other blood cell counts in the view of their absolute number. That is, are they low, high or in normal range. Your iron numbers are not bad. The ferritin at that level can be normal and does not in and of itself imply iron deficiency.

It is good that you will be seeing a Hematologist. I am a Hematologist and my approach to your case would be as follows: 1.) look through all available lab tests, both prior and recent, to see what the trend in the numbers has been; 2.) look at the differential count of the various white blood cells to see if any clues are present as to what is going on; 3.) obtain a careful medical, family, medication, and alcohol history; 4.) check on the status of the bone marrow production of these cells (this is done via a bone marrow biopsy); 5.) consider issues that are affecting the blood not in the bone marrow, but elsewhere in the body (any immune-mediated processes or increased spleen function causing the early removal of the blood cells).

PNH (paroxysmal nocturnal hemoglobinuria) is one of several causes of bone marrow hypoplasia. Bone marrow hypoplasia can only be diagnosed based upon the results of a bone marrow biopsy. Other causes of such hypoplasia, include medication effects, nutritional problems, low iron, low vitamin B12, low folate, myelodysplasia, aplastic anemia, and the effects of various infectious agents (such as viruses). This list is not fully inclusive, but touches upon some of the more commonly seen etiologies of bone marrow hyoplasia. PNH can be tested via specific tests.

Before jumping to any conclusions, some blood numbers can fluctuate low or high, then after a period of time, "normalize", without the cause ever being identified and no apparent "harm" being seen. Some people run slightly low or high blood numbers. The "normal" range does not define 100% of the population, but usually is a bell-shaped curve that defines 95% of the population, with a small percentage of people being below or above the defined range. However, if the test results are too low or too high, then an investigation is always warranted. One last point: different ethnic backgrounds can have their own "normal" ranges. For example, African-Americans can have white blood cell counts slightly lower than Caucasians, which is normal.

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