About RAVI NARENDRA PADIA Expertise well, i can answer the sorts of question up to college level and u may or may not expect me to answer the master`s level questions.
however i would try my best to answer it.
Experience WELL I AM NOW IS IN THIRD YEAR OF B.Sc WITH BIOCHEMISTRY AND I HAVE STUDIED BLOOD THOROUGHLY IN MY COURSE MATTER .I AM ALSO A VOLUNTEER IN THE BIOLOGY LABORATORY OF VIKRAM SARABHAI COMMUNITY SCIENCE CENTRE, AHMEDABD.
What would you make of a patent with resolving neutropenia, (ANC went from 888-1063) but still falling WBC (2.8-2.3) accompanied by monocytosis and lymphocytosis of recent onset? (Baso/Eso's are zero) CT of abdomen revealed no sepsis or abscess but enlarged para-aortic and illiac nodes bilaterally? Spleen unremarkable except for detection of auxiliary spleen. This is further complicated because the patient is undergoing chemotherapy)pegylated interferon/ribavirin) for chronic HCV infection. HCV has been linked to lymphoma. Neutropenia alone might be expected but not improving ANC with falling WBC and the mono and lympo cytosis with no sign of infection, and certainly not with the lymph findings.
I am sorry to disturb you with this question, but perhaps you might offer some guidance regarding the next move?
Sincerely,
Indira
Answer Hi
Indira
How are you?
About your question
As I told you earlier too, that its witty and intelligent question (of course of higher level)
I have gathered some of the information related to this topic.
And you know its very confusing and mind blowing because in this case there is so many, really numerous possibilities and it has really been a mammoth and a bit difficult task for me to concentrate on each & every possibilities so may be I hope I do not miss any of those. You know whenever I gathered some information; I also got new cross relationships in this case and I just got trapped in the cobweb and probably you too would be when you read this answer.
In my view, the most significant factor to be noted is that patient is CHRONIC HCV infected and is undergoing chemotherapy. Also HCVinfection has been linked to lymphoma.
You told me that patient is with RESOLVING NEUTROPENIA (ANC=888-1063) and falling WBC (2.8-2.3). But you did not give me the data that confirms that whether the neutropenia is resolving hence here the possibility of neutropenia being induced can also not be ruled out. According to data that you gave me, at this point patient is said to be suffering from MILD TO MODERATE KIND OF NEUTROPENIA.
Also in my view the CT of abdomen is also of significance. And that stuff about enlargement of Para aortic and iliac nodes is probabably (may) due to the LYMPHOMA, which of course is a cancer in which there is a characteristic swelling of the lymph nodes or the enlargement of Para aortic and iliac nodes may be due to the chronic HCV infection because swelling of these nodes is seen in the body when the body is fighting infection, remember here also the case is seen fighting chronic HCV infection.
And one thing I wonder about is that how can you write that there is no sign of infection when you are knowing that patient is chronically HCV infected.
And it must be noted that one is bound to show MONOCYTOSIS in the chronic infections and LYMPHOCYTOSIS is seen in the viral infections (HCV is of course a viral) and lymphomas and in many other conditions. So we can say that these lympho and mono cytosis is just because of chronic HCV infection and lymphoma.
Now about the problem of NEUTROPENIA…
You must remember one thing that when a patient undergoes a chemotherapy, the treatment itself is responsible for lowering ANC and hence neutropenia occurs. This happens because the chemotherapeutic agents tend to decrease the life span of neutrophils and as a result of which the production of neutrophils by the bone marrow is outspaced by utilization (deaths of neutrophils) in the periphery, the number of circulating neutrophils in the peripheral blood decreases and Neutropenia results. (Normally the life span of neutrophils is very low i.e. 8 hours). So due to chemo we see the rapid decrease in ANC and it reach the lowest value in 7-14 days after chemo. The lowest value is commonly called as NADIR. But this phenomenon depends on the type of chemo agents, some chemo agents cause a later NADIR (may be as long as 60-65 days) however on reaching nadir, there comes a recovery in ANC and this period may range from 8-90 days. Hence if we apply a common logic, we see that the chemo agents, which cause a later nadir, give rise to prolonged neutropenia.
So according to me the neutropenia in the questioned case is probably due to the chemotherapy and lympho & mono-cytosis is due to chronic HCV infection.
I suggest the following point that needs to be under observation----------
· The ANC count must be checked regularly and if observed below 1000, the chemotherapy as a mean of treatment should be reviewed. In this questioned case, you should take notice of this point. Generally doctors does not opt for chemotherapy if the patient's ANC<1000. However in this case if its resolving neutropenia, its ok. (More about this is to come in the writings below this)
And what we can discuss is that (if its a real case, I mean not a homework or hypothetical question) you keep in mind the period of treatment of HCV by chemotherapy. I mean that would confirm that whether its resolving neutropenia or its getting induced (starting), this can be confirmed by comparing the time with the NADIR related stuffs that are discussed above in this answer.
In my knowledge, I have known of some of the drugs whose prolonged use may induce Neutropenia. Such kind of neutropenia is caused by an idiosyncratic reaction to a drug that causes either direct suppression or immune destruction of neutrophils or myeloid precursors. Historically, women and older individuals experience these reactions more commonly than men and younger patients. A particular individual's tendency to develop. Neutropenia becomes evident 1 - 2 weeks following an initial exposure to the drug, or swiftly following a recent re-exposure to any offending agent. Treatment of such kind of neutropenia is obviously, the rapid withdrawal of any drug suspected of causing the idiosyncratic reaction.
ANTIBIOTICS: chloromphenicol, penicillin, Sulfonamides
ANALGESICS: Aspirin, Acetaminophen, phenybutazone,
SEDATIVES: barbiturates, benzodiazepines
ANTITHYROID AGENTS: propythiouracil
TRANQUILIZERS: Chlorpromazine, phenothiazines
ANTIRHEUMATICS: gold
It's just a small (I mean not a comprehensive) list. I know that it has nothing to do with this question but am providing you just for the knowledge sake. Or if any of these is used for the patient's treatment, the prolonged use should be avoided.
I hope I am enough clear about this answer. I know it's a bit confusing but have tried my best to answer.
I have answered assuming all the possibilities that are under my knowledge and also have explained the causes assuming that you might be interested in knowing a lot more than what you asked in the question.
Now
About the further guidance…
All I can say is that as being a chronic HCV patient, we can not terminate the chemotherapy for the patient but on the other hand, controlling neutropenia is also an important task because if the ANC falls below 500, it would indicate a life threatening situation.
In such situation, at this time, I just see the possibility of a treatment that is widely used in the neutropenic cases and it is taking the help of BIOLOGICAL RESPONSE MODIFIERS (BRMs) or can call it as BIOTHERAPY. The most widely used and trusted are COLONY STIMULATING FACTORS (CSF), the first of them to be developed were G-CSF (Granulocyte-CSF) also known as filgrastim, also as lenograstim, (however leno & filgra.. have different sources from which they are synthesized but no clinical or therapeutic consequences of the differences between filgrastim and lenograstim have yet been identified. Another one that is used is GM-CSF (Granulocyte Macrophage-CSF) and in my knowledge the use of GM-CSF can be more effective in this case.
These therapies, I think is generally given to the patients having the similar cases to the patient here in question. This therapy has several applications in the AIDS treatment, supplementary to chemotherapies for cancer, HCV, for febrile neutropenia, for chronic neutropenia and much more
But it's a very very very very costly therapy and like other therapies, it too has got its side effects but after reading so many articles I don't find them very threatening.
I wish to give you the detailed information about these therapies but I think the answer (however its already a very long one) would be too long and it would be better if I send you those articles about these therapies, which I feel are most easy to understand.
Ok
I have just copied them down to my floppy so I am not sure of the addresses of those WebPages but I guess they were--- http://www.australianprescriber.com/magazines/vol17no4/granulocyte.htm http://www.aegis.com/pubs/gmhc/1990/GM040301.html
Ok
It has been a very long answer and may be still I think that many stuffs are left that needed to be discussed but I have just dropped them for the time being because its hard for me to predict your reaction to this answer as I fear that I might have explained the unrelated things hence I pray that this answer does not bore you.
Ok
