My WBC counts are falling down. What is the reason?

Hi,

Welcome to icliniq.com.

I can understand your worries. First, it is of utmost importance to have a glass slide reviewed by a hematologist to check for the morphologic abnormalities, that is, the dysplastic features of the cells. Not only does it depend on the count, but also on the appearance of the cells that give the diagnosis of myelodysplasia. In your case, none of the absolute values of neutrophils, Hb, or platelets qualify for meeting the threshold criterion for MDS (myelodysplastic syndromes) (attachment removed to protect patient identity).

These are called prerequisite criteria, and they are Hb less than 110 g/L, neutrophils less than 1.5 g/L and platelets less than 100 g/L. A glass slide review will also cover whether any abnormal cells are present. If there are dysplastic features and abnormal cells present, then a further diagnostic workup is definitely needed. In your case, the prerequisite criteria are not met. If a glass slide has not been reviewed, I suggest doing it once.

Secondly, it is important to check for hematinic deficiencies such as vitamin B12, folic acid, and iron. You have your serum levels of folic acid checked because you may be deficient, since folic acid normally does not have proper stores in the body.

Your vitamin B12 is close to the lower limit, which means that there might be a functional deficiency, causing megaloblastic changes in the bone marrow, and this may be the reason behind the low neutrophil counts. Consider the intake of any medications that may cause suppression of bone marrow.

Non-steroidal anti-inflammatory agents and Paracetamol are the reason behind the low count of neutrophils. I would consider these points before taking a diagnostic workup for MDS.

I hope this helps.

Thank you.

Hi,

Welcome back to icliniq.com.

Yes, the report says that there are no abnormal cells, like blast cells, as well as dysplastic features. The report describes a finding regarding the lymphocytes (these are white blood cells that are produced by the immune system and not by the bone marrow) that they are reactive. This means that they have a more abundant appearance, which can be present when they are active and trying to produce antibodies. This does not imply an infectious state.

Normally, our bodies come into contact with many foreign particles, and they struggle to prevent them from entering the body. Usually, when this process functions properly, no disease develops. These reactive lymphocytes are a sign that the immune system is competent and active. Sometimes, they indicate an overactive immune system; therefore, the pathologist is supposed to check for viral infection or autoimmune state.

But, if you have no concomitant complaints, I would suggest that this is just a normal reactivity, and I will advise you to go for checking folic acid and iron.

I hope this helps.

Please feel free to reach out in case of further queries.

Thank you.

Hi,

Welcome back to icliniq.com.

Vitamin B12 is responsible for the normal division of cells. When it is not sufficient, something like a "stop," an arrest in normal cellular division, occurs, i.e., cells are frozen at a certain stage of their development. However, since it normally takes time for a cell to undergo division and produce offspring when therapy with vitamin B12 is initiated, something like a time lag occurs between when the hungry cell takes up the vitamin and the real production of cells is put in motion.

This is because DNA (deoxyribonucleic acid) synthesis, for which vitamin B12 is responsible, takes time. So, if there is a patient with vitamin B12 deficiency, anemia, a paradoxical drop in hemoglobin is usually observed before a real steady increase in hemoglobin levels is seen. Then, I suppose the same paradoxical drop of counts should be applicable to other cell lines, such as neutrophils, because their production is also dependent on vitamin B12 by the same mechanism.

Try taking vitamin B12 for 21 days in total; have your reticulocytes checked right away. They will show how well the bone marrow actually responds. If they are increased, that is very good. If they are not increased, either your bone marrow does not need B12 or the reason for low neutrophils might be something else. 21 days is optimal for testing vitamin B12 deficiency state, i.e., if a deficiency is indeed present.

Then, if there is no response, it is fine to undergo a bone marrow examination. I would only advise allowing at least 10 days between the end of vitamin B12 and the test itself because vitamin B12 alters the morphological picture since it stimulates cells, and in order to have an objective picture of bone marrow, vitamin B12's effects need to wane at first.

I hope this helps.

Thank you.

Hi,

Welcome back to icliniq.com.

I am more than happy to know that things turned out successfully for you. It is very motivating for me as well.

I reviewed your reports (attachments removed to protect the patient's identity). I would suggest that you finish the 21-day treatment course with vitamin B12, but no more. Usually, the treatment scheme for vitamin B12 deficiency is very aggressive, but I do not think that you should undergo that since your levels were close to normal.

After you finish the 21-day schedule, you can have one shot after 15 days, then one month afterwards, then one shot after three months, and finally six months after the previous shot. Then stop. I can also suggest that you do a gastroscopy to check for the possible gastric reasons for the malabsorption of vitamin B12. Keep in mind that after several weeks of vitamin B12 treatment, iron deficiency might develop, as well as folic acid deficiency.

This is because they are all used for hematopoiesis. So, it is good to have serum iron and ferritin checked and start a short course of prophylactic iron if deficiency is present. Folic acid does not need to be checked by a blood test. You can just start taking the oral supplement for a month. Because even if it is not deficient, it does no harm at all.

I think this is sufficient, and you can relax now. You can have your CBC (complete blood count) every six months to follow up counts, but more often than that is not necessary.

I hope this helps.

Kind regards.