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Q. I am anemic, my ESR is raised, and I feel my spleen is enlarged in chest X-ray. Kindly help me.

Answered by
Dr. Padmesh Jain
and medically reviewed by Dr. Sushrutha Muralidharan
This is a premium question & answer published on Jul 22, 2021 and last reviewed on: Nov 09, 2022

Hi doctor,

I have no symptoms, and I am healthy. I had a chest X-ray last week to check my ribs due to a fall that I had. Last year I had a chest X-ray and then a chest CT and was told that I have a calcified granuloma in one of my lungs from an old infection and nothing to worry about. I also had a breast reduction last year. I just want to make sure everything else looks good on this X-ray. I worry a lot about health anxiety. Please tell me that my liver and spleen look okay. I am attaching my reports. Kindly give your opinion.

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#

Hi,

Welcome to icliniq.com.

Please do not worry so much that you turn hypochondriac. Worrying will bring in illness that you do not have. Just eat healthily, be happy, exercise, have good close friends & family, stay away from alcohol and smoking.

The X-ray you have provided (attachments removed to protect the patient's identity) does not show any significant abnormalities in the region of the liver and spleen.

However, if you are very much concerned and want to ascertain the healthiness of the liver, spleen, and other abdominal organs, I would suggest you get an ultrasonography of the whole abdomen done. In that, ask the sonographer for liver size, echotexture, fatty liver, cysts, etc., and also the gall bladder if there are any stones or polyps within.

For functionality assessment, get a baseline blood investigations done comprising complete blood count, liver function tests, lipid profile, blood sugars (fasting, post-lunch, HbA1c (hemoglobin A1c), and creatinine.

I will help and comment more if you can share images of your CT (computed tomography) scan.

I hope this was helpful.


Hi doctor,

Thank you.

A nurse friend of mine said that it looks like the spleen might be enlarged. You do not see any evidence of any enlargement, right? Do lymph nodes look normal and everything else on the X-ray?

I am not that concerned, it is just that I am a hypochondriac. I had blood work done a few days ago, and everything was normal except possible iron deficiency anemia (which I have known about for years), and my ESR was 41, which I am very worried about. However, I was on my menstrual cycle when I had my blood drawn. I take birth control, have adenomyosis of the uterus and ovarian cysts, and I am obese. I also had severe anxiety episodes in the past few weeks. For which I have seen a psychiatrist and will be taking Zoloft. I am not sure if any of that could contribute to the ESR, but what do you think?

Kindly give your opinion.

#

Hi,

Welcome back to icliniq.com.

Firstly, the spleen and lymph node cannot be adequately assessed on a chest X-ray. Like I told you before, ultrasonography is a modality to assess the same (CT scan will be even better). Lymph Nodes can be seen on X-ray when they are calcified. So I will not be able to comment on the status of the spleen or lymph nodes on X-ray.

Secondly, if you have an enlarged spleen, it may be connected to long-standing anemia, as you mentioned. Raised ESR (erythrocyte sedimentation rate) also may be related to it. We also need to rule out tuberculosis in cases of raised ESR, for which a TB-PCR (tuberculosis-polymerase chain reaction) test and Mantoux test are advised.

Obesity is an independent risk factor for metabolic syndrome, hypertension, diabetes mellitus, and adverse cardiovascular events. So please try to reduce weight by exercise and diet. That will also help in curbing symptoms of adenomyosis and improve your reproductive health and overall well-being.

I hope this was helpful. Please follow-up with the reports.


Hi doctor,

Thank you.

Does iron deficiency anemia cause an enlarged spleen?

My spleen was palpated by my doctor a few days ago, and he said it does not feel enlarged. I do not have any symptoms like feeling full after eating fast. I am probably worrying for no reason. My spleen was enlarged four years ago due to something temporary, but my hematologist monitored it, and it returned to normal. Again, would factors like menstruation, birth control, adenomyosis, or obesity raise the ESR? I also sprained my ankle on twenty-eight two months ago.

Kindly give your opinion.

#

Hi,

Welcome back to icliniq.com.

Yes, few cases of iron deficiency anemia may cause an enlarged spleen. I would like to know if the cause of your anemia has been confirmed as iron deficiency and nothing else (such as sickle disease, thalassemia trait, etc.). A few blood tests are required to confirm the diagnosis of iron deficiency anemia, such as serum ferritin, total iron-binding capacity (TIBC), and transferrin saturation. If the cause of your anemia is something else, then taking iron capsules may harm rather than cure.

Temporary enlargement of the spleen is very common in many illnesses. So do not worry. Birth control pills and adenomyosis may raise the ESR a bit but not up to 41. Similarly, obesity and hypercholesterolemia may alter the ESR to some extent.

However, severe anemia will cause more rise of ESR, which may be the thing in your case. Please share your hematological reports to give me a better insight into your issues. Once your anemia gets better, the ESR will also improve.

Sprained ankle usually resolves in a couple of weeks with adequate rest and anti-inflammatory medications. I suggest you do the blood investigations mentioned above.

I hope this was helpful. Kindly follow up with reports.


Hi doctor,

Thank you for the reply.

Here is the latest bloodwork. Unfortunately, my CRP is not back yet. As for the ferritin, it has not been tested in 4 years since my spleen was temporarily enlarged. I do remember it being low, though. So I am going to attach that bloodwork as well. But again, please note the dates on the screenshots. I was supposed to take iron supplements but discontinued them because of side effects. So I will start an iron supplement that is more gentle on the stomach if it is okay too. I am worried about the ESR. Based on my bloodwork, is iron deficiency anemia the main culprit for why it is raised?

Thank you.

#

Hi,

Welcome back to icliniq.com.

I understand your concern.

I went through the blood workup reports (attachment removed to protect the patient's identity).

I am happy that they are good. Your sugar level, as denoted by glycosylated hemoglobin (HbA1c) of 4.6, is very good, indicating good sugar control. Also, Kidney function, as suggested by Creatinine ( 0.77), eGFR and electrolyte levels, is normal. Similarly, liver function, as indicated by normal values of proteins, bilirubin, AST, and ALT, is good. However, amongst your lipid profile, triglyceride levels are high, which can be managed by dietary modification (cutting down on the intake of fats), and lifestyle changes (cardio, aerobics, etc.). At this stage, I will not recommend medicine (Fenofibrate) for lowering triglyceride as it is slightly above the upper limit of the normal range and can be well managed by diet & exercise. Now, coming on to your anemia part. As per your reports your hemoglobin level is 13.5 g/dL which is well within the normal range and thus excludes the diagnosis of anemia. However, a slightly lower value of mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) with a slight increase in iron binding capacity (IBC) indicate mild iron deficiency. A higher reticulocyte count indicates that your bone marrow is responding well enough to keep red blood cell levels good in your body.

As far as oral iron tablets are concerned, you may take "Ferrous or Iron carbonate" preparations as they are shown to have fewer side effects and are better tolerated by patients. Overall, your reports are good, and you seem to be in a good state of health. Do not lose your sleep over the isolated finding of raised ESR (which can be just incidental and innocuous). I suggest you get the following tests done after eight weeks and follow up: Serum Lipid profile. Complete blood count with ESR, Reticulocyte count. Iron studies.


Investigations to be done:

Get the following tests done after eight weeks and follow up:

1) Serum lipid profile.

2) Complete blood count with ESR and reticulocyte count.

3) Iron studies.

Regarding follow up:

Get the following tests done after eight weeks and follow up:

1) Serum Lipid profile.

2) Complete blood count with ESR and reticulocyte count.

3) Iron studies.

Hi doctor,

Thank you for the reply.

I want another opinion on my ultrasound and mammogram. It has been two years post-breast reduction. I had pain in my left breast that started with my period. After my period ended last week, the pain has been subsiding. My plastic surgeon also felt there was a lot of scar tissue in this area. I went for an ultrasound and mammogram. The doctor told me she saw a mass that could be a fibroadenoma and wanted to do a biopsy. I did not get a good feeling from this doctor. When I received the radiology report, another radiologist interpreted it, and it said BI-RADS 3 and 6-month follow-up. I feel that this local imaging center is pushing for unnecessary tests, as there were reviews online of other women saying that they were told to do unnecessary biopsies. A few days later, I received an updated radiology report with BI-RADS 4b and a biopsy.

I had a second opinion from another radiologist that told me he only saw an atypical cyst and to follow up in 6 months. I also saw a breast specialist locally with over 50 years of experience, and she agreed with BI-RADS 3 and 6-month follow-up. So I will attach an ultrasound and mammogram from four months back which is my first baseline since my breast reduction. I will also attach the one with the new finding from last month. I am very nervous and worried and need peace of mind. Thank you.

#

Hi,

Welcome back to icliniq.com.

I understand your concern.

I hope your earlier health issues and concerns have been resolved and you are in a better state of physical and mental health. I went through your current query. I also went thoroughly through the mammography and sonomammography images you have provided. It looks like you have scar tissue and complex cysts visible on the scan images. The cysts are usually water or fluid-filled structures. To the best of my knowledge and experience, it looks like a BI-RADS 3 (breast imaging-reporting and data system) lesion, which is most probably benign to me. Usually, the protocol is to follow up after six months. The biopsy is only done if clinically indicated, as these cases usually have less than a two percent chances of being malignant. So relax and get a scan done after six months.


The Probable causes:

Aberrations of involution, degenerative, post-surgical, hormonal imbalance.

Investigations to be done:

Mammography and sonomammography after six months.

Differential diagnosis:

1) Focal fibrocystic disease of the breast.

2) Atypical cysts.

3) Fibroadenoma.

Probable diagnosis:

Focal fibrocystic disease of the breast.

Treatment plan:

Analgesics and anti-inflammatory SOS.

Oral vitamin E, Lycopene, and Evening Primrose oil.

Preventive measures:

Avoid alcohol and smoking.

Regarding follow up:

Follow-up after six months with mammography and sonomammography reports.

Hi doctor,

Thank you for the reply.

Did you view the compression spot images? The area labeled two by the doctor is the area she said she wanted to biopsy. Other doctors disagreed. Could you tell me what this is? Her updated radiology report said, “high-density focal asymmetry.” This is the area that I am worried about the most.

1. Is this a high-density focal asymmetry? If not, is it low-density, or how would you classify its density? Is it an area of great concern, and what do you believe this is?

2. You rated a BI-RADS 3 lesion. Is that the cyst that you are referring to?

#

Hi,

Welcome back to icliniq.com.

I understand your concern.

Yes, I did go through the compression spot images, and it is mid to high-density focal asymmetry. So its margins are not spiculated, or it does not show obvious signs of cancer. Depending on your clinical history, I would not recommend a biopsy at this stage and would like to follow up. Yes, as the cysts are atypical and there is focal asymmetry, I labeled it BIRADS 3.

Hope this helps.


Probable diagnosis:

Atypical cysts and focal breast asymmetry.

Hi doctor,

Thank you for the reply.

Could you explain further the area labeled two on the compression spot images marked by the doctor?

1. What is your overall impression of what this area could be? Scar tissue? Something that is just normal?

2. Another radiologist said that focal asymmetry is a technical error and an opacity. Do you agree?

3. If the margins are not spiculated, does that mean that it is not suspicious?

#

Hi,

Welcome back to icliniq.com.

I understand your concern. I think the area labeled two on compression spot images is due to a scar with superimposition of breast tissue leading to apparent focal asymmetry. It does not look suspicious. I do second the other radiologist that it does not look like true focal asymmetry.

Hi doctor,

Thank you for the reply.

The original report said that it was not visualized on ultrasound. So if it is not visualized on ultrasound, is that a good sign?

#

Hi,

Welcome back to icliniq.com.

I understand your concern. If it is not seen on ultrasound, it is a good sign and may indicate that what we saw on the mammogram may be due to summation or superimposition of shadows. I have been doing breast ultrasounds for the past 12 years and can say that it does not look suspicious, and you can relax.

Hi doctor,

Thank you for the reply.

My primary care doctor asked me a few questions about your findings because he could not get the images uploaded.

1. Why did you label the cyst as atypical or complex? What features does it have to classify it as that?

2. Do you believe that the cyst and focal asymmetry are related? I know you said that the focal asymmetry could not be a true asymmetry or scar tissue from my reduction, but he still would like to know if you believe they are related.

#

Hi,

Welcome back to icliniq.com.

I understand your concern. Typical simple cysts have thin imperceptible walls with a clear anechoic lumen. However, I found low-level echoes in your cyst, which I labeled atypical. These echoes could be inflammatory in etiology or just plain inspissated secretions. A cyst may or may not be related to focal asymmetry on a mammogram. Fortunately, in your case, there was no sonographically appreciable lesion corresponding to the focal asymmetry on a mammogram. So in your case, I do not think they are related. Best regards.

Hi doctor,

Thank you for the reply.

My doctor would also like to know if the cyst has thick walls and if there are low-level echoes. Do you mean septation or other contents? Also, I would like to know if the focal asymmetry was visualized in last month's mammogram images. Thank you.

#

Hi,

Welcome back to icliniq.com.

I understand your concern. The cyst does not show thick walls. However, I can see incomplete internal septations and minimal debris (secretion). No true focal asymmetry is seen in last month's mammogram images. Furthermore, ultrasound also does not reveal any suspicious lesions.


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