Patient's Query
Hello doctor,
One week ago, my mother had a CBC done, and the results were all perfectly normal. However, the laboratory forgot to order a peripheral smear review (which her doctor requested). So a week later, the CBC was repeated with a smear.
Oddly, the results of this new CBC were,
At the time of this second laboratory draw, the laboratory technician commented this is going to bruise, and it did. A huge dark bruise and bump formed on my mother's arm very soon after the blood was drawn.
I assume this is a hematoma. My question is, can a laboratory draw technique error (as evidenced by the large bruise and hematoma painful) be the cause or reason for the low WBC, low RBC, and low neutrophils?
Please note that the smear result was normal (unremarkable). I should also point out that this CBC was manual (versus automated).
I know it is essential to repeat the CBC with smear again to verify, but I want to know if improper drawing or laboratory techniques could cause the odd results, and if so, what the mechanism of action would be.
I can show you her actual results, plus a photo of the bruise or hematoma.
Please help.
Hello,
Welcome to icliniq.com.
I understand your concern.
I have reviewed your query and attached images (the attachments were removed to protect the patient's identity) as well. You are having superficial thrombophlebitis, most likely as per the given history and attached image.
It is most likely due to a technical error during collection. However, your low red blood cell count, low ANC (absolute neutrophil count), and the low total count could not be due to a technical fault.
It can be a temporary finding due to some unnoticed infection. I suggest you repeat CBC (complete blood count) after a few days, approximately after seven to 10 days, and it will be standard.
Your peripheral smear examination report is normal, so no need to worry. You can revert with reports once done after a few days. For thrombophlebitis or bruising, I suggest you apply ice wrapped in a thin cloth frequently, like five to six times a day. Thrombophob (Heparin) gel can be beneficial.
I hope I have answered your question.
Let me know if you have more queries.
Thank you.
Patient's Query
Hello doctor,
Thank you for your reply.
But I have read that things like improper draw technique could cause things like hemolysis or clotting, which can lead to low RBCs. Is that not the case? Also, since the CBC differential was manual, could that cause the low neutrophils?
Kindly suggest.
Hello,
Welcome back to icliniq.com.
I can understand your concern and will help you by answering as accurately as possible.
Let me tell you that improper venipuncture can lead to hematoma formation, but never lead to clotting of blood. The blood clotting occurs in vaccute if proper mixing of blood with anti coagulant not done by shaking the vacutainer.
The improper venipuncture can lead to hemolysis of collected blood, but in that case, CBC could not be possible,e and thepicture reflectedd in the peripheral smear examination report as well. In such a case hemoglobin level also goes down.
In a few cases, the prepared blood slide also shows changes in cells. So it could not be the cause in your case, and the pathologist cannot make such a mistake. So do not worry about blood clotting and hemolysis asa cause.
The low red blood cells can be due to beginning of iron deficiency anemia because your hemoglobin level is borderline. I suggest you repeat CBC after a few days, as I have suggested, then we will discuss further findings if they come back abnormal.
Meanwhile, for thrombophlebitis, apply the ice and mentioned gel as advised. If no improvement, then consult a nearby doctor for a detailed evaluation.
Hope I have answered your question. Let me know if I can assist you further.
Best regards.
Patient's Query
Hello doctor,
This might help us to know that her iron levels were low, and her total iron was slightly elevated, and saturation was also slightly elevated. What could that mean?
Her ferritin was normal.
Please help.
Hello,
Welcome back to icliniq.com.
I have to check how much elevation of transferrin saturation is present. So either you can attach a report or provide numerical values.
Kindly follow up with the answers.
Regards.
Patient's Query
Hello doctor,
Yes, I have attached her comprehensive results from one week ago. As a reminder, these results were drawn and included everything except the smear review, which the lab forgot to draw.
So we repeated just the smear a week later (which you have already seen). Her medical history is cancer many years ago (fallopian), and she is in what we believe is remission for the past four years.
She feels fine, and these laboratory reports were all part of her routine follow-up. Her VEGF is always a bit low because she takes supplements to help keep these levels low.
Kindly suggest.
Thanks for having a look at everything.
Hello,
Welcome back to icliniq.com.
I have gone through your attached reports (the attachments were removed to protect the patient's identity). In the attached report, total iron binding capacity and ferritin are within limits.
Transferrin saturation and serum iron level were elevated slightly. Now it does not indicate any specific hematological problem. Usually, in the case of iron overload, transferrin saturation increases. But in that case, ferritin level should be raised, which is normal here.
So these findings could be due to some iron-containing supplement intake or some error while running the analyzer. It doesn't need to be concerned much, as other values do not favour iron overload.
I hope I have answered your question.
Let me know if I can assist you further.
Regards.
Patient's Query
Hello doctor,
So, as you told in the previous response, her low hemoglobin in the latest CBC (the unusual one) could be due to iron-deficient anemia; that would not be the case then, since her iron levels were normal (and even a little bit high).
You mentioned infection, but she has no symptoms of that.
Please suggest.
Thank you.
Hello,
Welcome back to icliniq.com.
Initially, I was thinking of iron deficiency anemia. But iron profile reports are not suggestive of any iron deficiency anemia. So, iron deficiency anemia might not be the cause. The low white blood cell count can be due to an unnoticed infection or some drugs.
She is using medication to lower VEGF (vascular endothelial growth factor). So it can decrease total count. However, we cannot neglect laboratory error as well.
The development of a large hematoma with superficial thrombophlebitis could be in favour of some technical error as well. Rather than thinking all that, I suggest repeat CBC after a week.
If the values are abnormal, then we will discuss further.
Hope I have answered your question. Let me know if I can assist you further.
Regards.
Patient's Query
Hello doctor,
Thank you for your response.
Hello,
Welcome back to icliniq.com.
I can understand your concern.
In one vaccute two milliliters (ml) of blood is collected. So in 14 tubes maximum of 28 to 30 ml of blood can be collected. Such minor loss of blood cannot decrease red blood cells and WBC.
In phlebotomy, around 300 ml blood is withdrawn. So it cannot be called phlebotomy in any way. So your blood collection is not related to low red blood cells.
Hope I have answered your question. Let me know if I can assist you further.
Best regards.
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Answered byDr. Goswami Parth Rajendragiri
Medically reviewed byDr. Nithila. A
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