Could RA or medications result in abnormal blood test levels?

Question

Hi doctor,

I have RA, and I do the blood tests every three months. The last few CBCs with differential counts are slightly abnormal. When I asked my doctor, they said it was not anything in particular and did not explain clearly. I have mild to moderate sensorineural hearing loss in both the left and right ears. I did tests, and the results show a high-riding jugular bulb on the right side with no acoustic neuroma. Now, I have fatigue and breathlessness, have had weird rashes, joint pain, numbness, muscle weakness, low-grade intermittent fevers, and generally feel unwell some days. For the last two months, I have had a wheeze when I breathe out. Earlier, I used to walk everywhere. For the past 5-7 years, I have not been able to walk for 15 minutes at a stretch without needing to sit down in the middle, and I have used a powered wheelchair for a year now. My feet become red and burn at night. I also had a hairline fracture of the spine when changing a tire, and it got worse. I have degenerative discs in all three sections of the spine.

According to my doctor, the thoracic cord is indented but not affected, and it has no crushing, according to the MRI. The motor radiculopathy of the left leg is greater than the right leg. I also had trigeminal neuralgia of the face, left body numbness, and right eye blindness that was intermittent. It was due to a thalamic infarction. The MRI for the knee shows red marrow conversion.

I have been taking Methotrexate for a year, and recently added Enbrel about three to four months ago. I also take Amlodipine, Hydrochlorizide, Statins, Lisinopril, Hydrazine, Pantoprazole, and Vitamin D.

My CBC four months ago had lower numbers than usual, but all were within normal range. My monocytes were low, and my neutrophils jumped up higher. But the CBC two months before showed burr cells, teardrop cells, and platelets clumped with toxic granulation. They wanted to repeat after a few months. I repeated, and the monocytes were still low, and there were immature granulocytes. I asked what could cause that, but they said it was not anything specific. Can you explain the reason for these differences?

I had an MRI of my chest because of persistent breathlessness, and it said I had mediastinal lipomatosis and subcentimeter enlarged lymph nodes. I recently had a lymph node behind my head enlarged. It was 1 cm.

I have been missing periods with one about every three months for almost a year. Hormone tests were all normal. They said it was fine. I highly doubt any of this is cancer, but I would like to know if it is messing with my bone marrow because of my family history and the medicines I take. My RDW has been high, as much as 18 percent, for a couple of years. Also, with my current medication, are the numbers not supposed to be lower? The doctors did not give a proper explanation for this also. Kindly help.

Answer 1

Hi,

Welcome to icliniq.com.

The word "leukemia" means white blood cell cancer in the peripheral blood. "Leukemia" is a relatively old term. Nowadays, it is called hematopoietic and lymphoid neoplasm. A good share of circulating white cells comes from lymphoid tissues such as lymph nodes, the spleen, the thymus, etc. And the rest of the cells come from bone marrow. Lymphoid tissue is present all over the body, even in the intestine, lungs, liver, etc. The neoplasms of lymphocytes (white blood cells) are called lymphomas, which are rarely present in the blood.

They are present in lymphoid tissue. However, they do infiltrate blood and bone marrow at some later stages (stage 4 disease). Now, certain neoplasms are arising from bone marrow. They are myeloid or lymphoid leukemias. They are most of the time present in peripheral blood. In addition, leukemia and lymphoma are not merely the presence of certain types of abnormal cells. It shows anemia, leukopenia or leukocytosis, high ESR (erythrocyte sedimentation rate), thrombocytopenia, unexplained fever, weight loss, arthralgias, and myalgias.

Peripheral smear findings may also show features such as toxic granulation in neutrophils in certain reactive or inflammatory states. These are diagnosed using FNAC (fine needle aspiration cytology), bone marrow biopsy, immunohistochemistry, flow cytometry, radiological surveying, etc. These are treated with chemotherapies selected according to the type of cells involved in lesions.

Lymphomas are neoplasms of lymph nodes or other lymphoid tissue. Lymphomas are subdivided into Hodgkin’s and non-Hodgkin’s lymphoma. Lymphomas usually involve multiple lymph nodes in multiple areas of the body. These are associated with weight loss, loss of appetite, and low-grade fever for many days to months. The cause of lymphomas is genetic mutations, viral diseases such as EBV (Epstein-Barr virus) or HIV (human immunodeficiency virus) infections, anti-cancer drugs, and sometimes unknown etiologies.

The diagnostic workup includes:

ESR.
CRP (C-reactive protein).
FNAC test of the swollen lymph nodes.
Tissue biopsies.
Ultrasound.
Chest x-rays.
PET scan.
Immunohistochemistry.

The tissue biopsy sections provide the lineage of the lymphoma, whether it is Hodgkin’s or non-Hodgkin’s. Non-Hodgkin’s lymphoma is further subdivided into B-cell and T-cell lymphomas. B-cell lymphoma is less aggressive and treatable with chemotherapy. T-cell lymphomas are more aggressive and challenging to treat. Multiple organ involvement, including the spleen, bone marrow, and other tissues, indicates a widespread advanced stage and aggressive disease.

This needs intense chemotherapy. Lymphomas can affect all age groups and genders. Some, but not all, lymphomas are spilled in peripheral blood and can be detected in the CBC report. Lymphomas are sometimes associated with better proteins detectable by protein electrophoresis.

Primary causes of lymph-node enlargement should be ruled out at the first step, for example, infections, especially the local deep tissue infections, autoimmunity, viral infections, etc.

Methotrexate therapy is associated with blood dyscrasias, especially red cells (that is why your hemoglobin is borderline low, and RDW (red cell distribution width) is raised. There is nothing to worry about. It is treated with high-dose Folic acid, Vitamin B12, and Pyridoxine. It also affects the skin.

Lymph nodes are also increased in autoimmune disorders such as RA (rheumatoid arthritis).

I hope this helps.

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

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I went through the latest photos (attachment removed to protect the patient's identity).

I could not see any evidence of cancer in it. Your vitamin B12 is adequate, but in the scenario of RA, you should maintain it around 1000 mcg (current is about 400 mcg). Your skin lesions are associated with the therapy. For your respiratory condition, you need either a chest HRCT (high-resolution computed tomography) or spirometry. Enbrel (Etanercept) does have such side effects, mainly related to the skin and respiratory system.

Monocytopenia (deficiency of monocytes) might also be associated with Enbrel therapy, though it is not a severe side effect. Traditionally, immature granulocytes refer to immature neutrophils. In your report, it is 0.3%, which is relatively low. Up to 2% in adults and 8% in neonates is normal. So in your case, it is negligible. I find no evidence of any blood cancer or a related disorder.

I hope this helps.

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

Thank you.