QUESTION: I am a Female, 49yrs (pre-menopause), non-smoker, non drinker 5'2 105lb. I have had an intermittent pain in my upper right femur for 6 months (can't replicate the pain- it comes and goes, twinge like, at it's will. It feels like a "growing pain"- very deep in my leg). Get full after eating only a small amount of food for going on a year. Sometimes feel like I need to yawn to get enough air. While I'm not feeling like I'm going to fall over, my energy is not what it was... naps often sound good, but I press on. Recent blood test results reveal:
Alkaline Phosphatase 32
B12 and folate normal (right in middle of reference range), ferritin 21
Hypochromasia present. Platelets enlarged and clumping.
My brain is ready to explode from all the information I have been researching on medical websites. I've sorted all this out on my own, so far, as I don't have insurance (yes, I ordered all my own blood tests as I could afford them- I realize a reticulocyte count could be helpful, but I thought it's probably time to see a hematologist and let them order the next necessary diagnostic tests).
Does this sound like possible Myelodysplastic Syndrome or myeloproliferative disorder? What would the next line of testing be? More blood, or bone marrow?
Thank you so much for your time and consideration!
ANSWER: Hello Robin,
Warm welcome to you!
Read both your mails! I dont understand what made you think you may have Myelodysplastic Syndrome or myeloproliferative disorder! First of all for diagnosing Myelodysplasia we need WBC differential count. But however though your platelets show clumping, there is no thrombocytopenia(low platelet count. You have note that in a person who has myelodysplasia, the RBC count is very low and person gets recurrent infections. Also you can see signs like enlarged spleen or liver. Patient develops rash/petechiae due to low platelet count and bleeding time is increased. WBC differntial count shows low neutrophil count. And the blood smear is pretty evident in these patients with variation in reticulocytes, target cells and different shaped RBCs etc.
So you dont have to worry you dont have any myelodysplasia. Some times the blood smear can show platelet clumping when there is internal bleeding. For example peptic ulcers or hookworms, this internal bleeding can cause mild anemia. So dont be scared by looking at the medical websites. And also the aspartame can cause little GI disturbances in the later half of the life. Like Irritable bowel syndrome.
And please can you specify whether the thigh pain is in front or back? May be i will be able to help in that matter also.
Take care. Have a good day. Bye.
---------- FOLLOW-UP ----------
QUESTION: Thank you so much for your time and quick response. I truly appreciate your advice. I would like to elaborate a bit on my symptoms. I have been running a low fever (99.1-100) off and on for a several months. I do not show positive on a FOBT. The leg pain is upper right sort of front, sort of side. It is not sciatia or muscle pain (I have closely examined anatomy diagrams, and nothing attaches there)- I cannot make the pain occur by moving a certain way, stretching, etc., and it is a very deep pain.
If I push gently on the left side of my body under my ribs I can feel pressure way up into my chest (not so on the right side). I already take a multivitamin plus iron. I have always maintained a very healthy diet (with the exception of the diet soda). Lots of fruits and veggies, whole grains, lean meats (almost NO processed foods in my diet, I cook everything from scratch, even bread). I am in good shape, physically, and have always been active. Not being able to get enough air is NOT normal, for me. (No cough or congestion), nor is deep pain in a bone.
Back to the blood:
What could be causing the hypochromasia in combination with high normal MCV (with normal B12, folate, and thyroid- these levels are smack in the middle of normal), and the RDW not corresponding to the MCV, number wise (RDW right in the middle of normal, MCV very high normal)? With iron deficiency the RDW would be lower with the hypochromasia (microcytic), but my MCV tops out the normal reference range (macrocytic). I found several sources (at least 3 reputable sources- universities, Merck manual) that indicated high MCV with normal RDW could be a first line indicator of possible MDS or aplasitc anemia.
Why would my platelets be enlarged, even thought the numbers are normal?
It is my understanding that different types of MyeloDyspasticSyndrome may represent with only one, or sometimes 2, or all, of the cell count levels being affected. Also, it is usually found by "accident", as it is mostly asymptomatic until in later stages. Perhaps my curious nature, in combination with how crappy I've been feeling, has caught something right in the beginning stages.
SOMETHING is causing the anemia, and it's not vitamin or iron deficiency, or thyroid, and I have no occult blood... Would a closer, manual, look at blood cell structure be something reasonable?
Again, I thank you very much for your time and consideration!
Nice to see you again!
I dont think your RBC are macrocytic. Because normal range is upto 99 femtolitres. Also if the pathologist would have seen any macrocytosis on your blood smear, he would have definitely mentioned it in the report. If there is myelodysplasia, that should be seen by the pathologist in your blood smear.
I think you have misunderstood the RDW. In iron deficiency anemias RDW will be increased and MCV will get reduced to cause microcytosis.
Since you are pre-menopausal, I must ask you about your mentrual cycle. Are they regular? Do you experience excess blood loss?
Since your MCV itself is in normal range then you dont need to club high MCV and normal RDW to conclude that you have myelodysplasia. In your report only RBC and MCHC are negligibly low. Did you have any recent blood loss, before giving the blood for testing(including menstrual)? So my thought is no reason for you to worry. Some b-complex supplementation and your lab reports should return to normal. Why you have not sent me Hb, vit B12 n folate values in your first mail?
Its good to know that you are following a healthy lifestyle. The thigh pain as you are describing seems to be nerve related, may be due to nerve compression. It needs further investigation by your doctor. Also my suggestion is as you are peri-menopausal you should check the calcium levels in blood. And get bone density test done for eliminating osteoporosis.
So this is my sincere opinion. For me bone marrow examination etc does not seem necessary. If your doctor suggests to visit a hematologist then you can visit. Anyway did your doctor suggest you visiting a hematologist?
Take care. Bye.