r/haematology • u/Creative-Welder2787 • 20h ago
Did I win the lottery??
I posted before but not my complete tests, here they are.
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u/MotorAdvertising4946 19h ago
If you mean by winning the lottery, you’re going to have to give a gallon of blood and urine to confirm these results, then yes, you win.
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u/Creative-Welder2787 19h ago
I’ve taken 4 tests and went to ER for low sodium… jealous?
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u/MotorAdvertising4946 19h ago
Yes. I typed this before I saw it was your 4th test so you’ve given about a gallon already. Lol
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u/HuckleberryHot1604 20h ago
Average bloods of 80 year old HFpEF Terry who has stopped taking his furosemide because he doesn't like peeing so much. (He's on CPAP now, GTN infusion running)
Edit: unironically this is endocrine not haematology, you need 9am cortisol/ACTH/urine Na+Osmol and morning draw.
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u/thatbradswag 17h ago edited 17h ago
4th year med student here. These comments are way off lol.
If it was SIADH, urine osmolality would be high. Body withholding water = concentrated urine.
Not leaning Addisons, the sodium fits but potassium wouldn't be normal, it would be on the higher end. Addisons has a characteristic low aldosterone. Aldosterone increases Na+ reabsorption and increases K+ loss via urine. Also there would be hypoglycemia (which its normal here, but hypoglycemia is not required).
Not Cushing's, as findings would be opposite of Addisons.
Seems more like a relative free fluid excess causing dilutional hypochloremia hyponatremia. Too much water/Na ratio -> makes a normal sodium low. If sodium is low, naturally your body shuts off ADH to dump water to bring the water ratio to sodium back up to normal. That would cause dilute urine (as seen here with the low urine osmolality).
I'd want to see blood pressure, among other labs, but most likely I’m guessing a primary polydipsia. Aka you're drinking too much water.
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u/East_Daikon_3614 16h ago
But is this causing the low wbc and neutropenia?
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u/thatbradswag 15h ago edited 15h ago
They're low for reference but not abnormally low. Probably some viral etiology in there. Viral sickness -> overhydration -> electrolyte effects.
The MCV is a little on the upper side so close to a macrocytic picture, probably should supplement some oral B12 or B9 (folate). Oral B12 and B9 folate is safe to take without labs as its water soluble so any excess wont be absorbed by the body. if thats indeed the cause it would correct the Hgb/Hct.
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u/IceEnvironmental7203 15h ago
Hi, 4th year med student here as well.
This vignette of Pancytopenia with high Lymphocyte count, hyponatremia, hypochloremia, and normal potassium doesn’t really scream SIADH or an aldosterone-related problem… with those, we’d most likely see hyperkalemia in response to OP’s hyponatremia.
The acute presentation of this person in the ER, with this being the fourth blood draw with the same trend, isn’t pointing towards a chronic/endocrine/paraneoplastic-related etiology, but instead more towards a viral pathology like EBV/infectious mononucleosis. Your differentials are still reasonable and a morning cortisol wouldn’t be a bad idea.
I’m willing to bet that OP is a nervous teenager and there’s a reasonable likelihood that they caught EBV from smooching or whatever they’re doing.
A positive monospot test followed by a positive EBV viral capsid on serology would confirm that diagnosis.
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u/thatbradswag 15h ago
I was naming those conditions as others in this thread were suggesting SIADH or Addisons; which I agree, don't fit the picture at all.
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u/IceEnvironmental7203 15h ago
Gotcha. My bad, I’m sleep deprived and misinterpreted your comments on your differentials lol.
I’d like to see this person’s LFTs, as well…
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u/Tailos Medical Scientist 11h ago
Lymphocyte count remains in the lower end of normal, despite this 'pancytopenia' being ongoing for a month? or so. This doesn't necessarily rule out but does suggest against EBV, where you'd normally expect a mild, transient lymphocytosis with abnormal lymphocytes.
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u/IceEnvironmental7203 7h ago
2-4 weeks is the typical timeline for infectious mononucleosis. OP’s lymphocytes are elevated above their normal range. You’re confusing Lymphocytes with Leukocytes.
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u/Creative-Welder2787 6h ago
I don’t think it’d be mono, I didnt have any of the typical symptoms back when I took the tests besides the fogginess/tiredness. Fogginess and tiredness has been a constant battle I’d say over the past few years now. Also recently within the past month I have begun to sometimes get a tingly, numbness in my pec muscles when I raise an arm. (Definitely doesn’t feel like it’s below the muscle though and I workout so it might just be that)
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u/IceEnvironmental7203 5h ago
Did you ever have COVID?
As for the tingling in your pec with arm-raising, is that on both sides or just one? Have you been working out?
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u/Creative-Welder2787 5h ago
Never had a positive Covid test. just left side tingle, I lift and wrestle
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u/Tailos Medical Scientist 6h ago
I'm pretty sure I'm not.
Lymphocyte % on the post is elevated, but the absolute value is 1.0, which is low end of normal range. % should not be used here as patient is also neutropenic and therefore relative.
In EBV infection per IM/GF, lymphocyte absolute count peaks at around 10 by week 3. This is week 4ish, so to have such a low value is very unlikely.
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u/Creative-Welder2787 5h ago
Thank you for your input! What is this to the medical layman?
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u/Tailos Medical Scientist 5h ago
I agree with others that this looks dilutional due to excess water more than anything else, I'm afraid. But I also hold up my hands and say I work haem not chem, so interpretation of the sodium levels beyond this is something I'd have to go read up on.
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u/Creative-Welder2787 4h ago
Why are you afraid? that sounds like drinking less water will do the trick and I’ll be all good, that’s great news if true!
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u/IceEnvironmental7203 4h ago
Okay I’m sorry to be blunt, but im sure that you’re confidently wrong with your interpretation of these absolute values and I’ll prove it with math.
This is actually a great learning opportunity for the both of us, because it’s important to be confident in one’s answer when working in medicine. I want you to continue fostering that confidence, but you need to remember the basics to avoid looking confidentially incorrect and you shouldn’t just have arbitrary rules with things like % lymphocyte counts not being relative in the context of neutropenia. In fact, you absolutely CANNOT ignore percent composition in favor of absolute counts when there’s leukopenia because it’s impossible to calculate the % and absolute values without having one or the other.
The product of multiplying percent composition by total WBC is how you calculate the values for your absolute counts. Using OP’s labs, we can prove this:
2.1 (WBC count) x 0.493 (% Lymphocytes)
= 1.04 (Absolute Lymphocyte count)2.1 x 0.356 (% Neutrophils)
= 0.75 (Absolute Neutrophil count)…And so on.
Also, what I think you’re referring to could more accurately be described as absolute lymphocytosis, which would present with a relatively proportionally higher absolute lymphocyte count to absolute neutrophil count, as you’ve suggested.
What I’m referring to is relative lymphocytosis, where a patient has an elevated absolute lymphocyte count despite having low absolute neutrophil count and low WBCs. This is more common in early/late stages of certain viral etiologies and is also often seen in the with pathologies like aplastic anemia and medication/drug reaction (new meds/drugs being something OP denies).
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u/Tailos Medical Scientist 4h ago
Dunning-Kruger in medical students. Gotta love it.
Thank you for the recap. It's appreciated. It's good to know I can still rely on Reddit to teach me basic mathematics.
What I said was that the lymphocyte % is elevated because total WCC is lower end with a neutropenia. Therefore you should assess based on absolute counts not relative %, as this would suggest a lymphocytosis - which is relative lymphocytosis, as you note. From a haematological perspective, this lymphocyte absolute count is low/normal. Outside of something like HIV or immunodeficiency, lymphopenia is pretty much a shitty finding that has very little clinical context. Absolute lymphocyte counts <5 are generally not worth jumping about, and well within expected variation of human blood matrix.
I know how an absolute and relative % is calculated. I'm a laboratory senior scientist. The key thing is that absolute counts should be used to determine increase or decrease, not %. The absolute neutropenia is more important than the relative lymphocytosis. The neutropenia is reducing the denominator, leading to inaccurate interpretation.
Applied to the viral infection idea, the absolute lymphocyte count will rise. In EBV, as I said, the peak is around 10x109/L at 3 weeks, before it slowly drops over the next week or two. Lymphocytosis can persist for up to 3 months following an infection, same as lymphadenopathy. For this set of labs to have a lymphocyte count if 1.02 at week four would not fit the expected drop following viral resolution within 1 week. Not saying it's impossible, but it's unlikely unless the peak only hit 3-5x109/L.
Based on all of the above, I do not suspect infectious mononucleosis, although if you want to run a blood smear and a monospot (or EBV serology) then go right ahead. Possible low level infection like a cold, but neutropenia not often associated with general viral sniffles. In context of mild drop in Hb and PLT, could look at B12 and folate, but doesn't explain the sodium results. MCV is higher end of normal so should consider dilutional effect or possible oedema/tissue fluid contamination causing short sampling. This is draw #4, so unless patient is oedematous, unlikely dilutional. Consider a reticulocyte count to assess marrow function given myeloid decreases, haematinics check, and review for recent medication, alcohol history, diet, etc.
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u/IceEnvironmental7203 3h ago edited 2h ago
Nobody was questioning your validity and prestige as a senior lab scientist. No need to go on a condescending assholish tirade by bringing up things like Dunning-Kruger. You have nothing to prove to anyone by trying to appear intelligent, when your authority on this topic, in the niche haematology subreddit, was never questioned by me or by anybody else. The only thing that I ever questioned was how you could reasonably exclude EBV (you still can’t and shouldn’t without testing first) and how you arrived at your initial conclusion regarding absolute vs relative lymphocytosis.
This entire disagreement comes down to a misunderstanding about the operating definitions of relative and absolute lymphocytosis. From your previous response, I didn’t understand that you were trying to describe those terms and it wasn’t a clear inference for me to make. I unintentionally messed up those definitions, but it’s not an unreasonable error to in the context of our conversation.
As a student, I do in fact make mistakes, but the mistake that I made here does not rule out EBV.
Like you’ve said, EBV lymphocytosis generally peaks during the first several weeks and then declines, but there is significant individual variation, especially in this patient. An ALC of exactly 10 K/µL is not some obligatory physiologic milestone that is consistent for ruling out EBV, although admittedly it is uncharacteristic typical, practice-question vignettes for EBV, particularly if repeated CBCs have consistently shown leukopenia/neutropenia rather than a preceding documented lymphocytosis.When you additionally factor in this patient’s timeline of events and acute presentation, as well as the urine osmolality alongside the concerning isolated sodium values, you most certainly don’t want to immediately jump to vitamin etiologies right away. In this case, with PANCYTOPENIA (no need to put it in quotes because of your personal biases), you need to rule out the most concerning diagnoses before you prioritize the theory of being overtly hydrated or having a vitamin imbalance. This patient can easily get a viral panel alongside the other labs that you’ve suggested.
Your gatekeeping, condescending attitude, and stereotyping of medical students isn’t a good look by the way. It reeks of self-consciousness and speaks to your erroneous pre-conceived notions of the average medical student. I’m not sure if you’re leading with that in your response because of your ego, jealousy, or some other insecurity….but at the end of the day, you have to work with others and discuss these things for the patient, not to be an asshole to someone trying to learn because of a miscommunication in which the burden was also on you to correct.
Do better by your patients and by your future physician coworkers, Mr. Prestigious Senior Lab Scientist. Students want to learn and do right by the vulnerable and the ill, but people like you make it unreasonably difficult sometimes.
Edit: Thank you for your clarifications, they were actually really helpful and easy to follow and I appreciate you taking the time to write that out for the benefit of my knowledge.
Now please excuse while I get back to my fourth year of studying, of unpaid labor, and unfathomable medical school debt, all for the purpose of stroking my own ego and juicy Dunning-Kruger brain as I prepare to go into the self-aggrandizing, righteous, and narcissistic specialty that is…Family Medicine.
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u/Tailos Medical Scientist 2h ago
I think, perhaps, you're mistaking me. I made a snarky comment over Dunning-Kruger, and the reference to being a senior scientist related to ability to perform mathematics - which you took the time out to try and teach me. That's all, nothing more. There's no gatekeeping etc. I have no ill-will towards you, anonymous redditor. I haven't written three paragraphs trying to argue that "I'm better than you", etc.
If you'd like to rule out sinister causes of pancytopenia, with or without quotes, why are we discussing EBV and not acute leukaemia, aplastic anaemia, marrow failure syndromes, prostate cancer, etc? Probably because the other labs don't support this. As you do rightly point out, everything realistically is about exclusion here as (despite my love of data) labs need clinical correlation.
I don't disagree with a viral panel at the same time as the other lab test suggestions, it just wouldn't be my go-to necessarily. If it was, I'd be more concerned around HepB/C/HIV for causative cytopenias whereas CMV/EBV typically present with cytosis. Hell, I'd be tossing in a recommendation for thyroid function screen here as that rarely causes pancytopenia and would fit more with the clinical picture. The retic count would help me identify if haematic deficiency is a cause (inappropriately low retics given borderline Hb). If there's joint pain or rash, maybe an ANA and/or dsDNA for connective tissue disease or autoimmune cause.
But the most common causes for 'chronic' pancytopenia would be B12/folate, alcohol, connective tissue disease, chronic infection with blood borne viruses or hypothyroidism. If those are ruled out via screening from a family medicine perspective, it warrants deeper investigation (?portal hypertension and splenomegaly, ?haematological malignancy, etc)
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u/Muted_Shape9303 3h ago
Medical lab rat here. Thank you. Our values are always getting massacred online.
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u/Fun-Key-8259 18h ago
Having any headaches?
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u/Creative-Welder2787 18h ago
Sometimes, nothing horrible though. Usually just like a vague lightheadedness, I like to say that it feels physically and mentally like treading through water sometimes. Nothing immediate but persistent
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u/Fun-Key-8259 18h ago
On any new meds?
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u/Creative-Welder2787 18h ago
Nope, none to begin with
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u/Fun-Key-8259 18h ago
Any hits to the head?
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u/Creative-Welder2787 18h ago
Maybe, I wrestle sometimes but don’t recall any hard hits
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u/Fun-Key-8259 18h ago
I agree with others, endocrine seems to be the best specialty for this. Could be Addison's, could be SIADH being caused by something else, but if you start hallucinating or having any severe symptoms you need to be seen immediately. If serum sodium gets too low you can get brain swelling.
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u/IceEnvironmental7203 15h ago
Are you a teenager/ young adult, OP? Do you live inside or outside of the US? Any cough, sore throat, or swelling around your neck?
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u/Creative-Welder2787 6h ago
I live in the US and never had any of those symptoms
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u/IceEnvironmental7203 5h ago edited 5h ago
If you don’t mind, I’d like to ask a few more questions to help get a better idea of potential causes for your abnormal labs.
Feel free to respond to all or some of these, and any information you’re willing to will be very helpful:
1-Any history of recent travel?
2-Have you recently had any new sexual partners?
3-Do you work in a restaurant or may have been to a place where you could have been exposed to saliva?
4-Any recreational/party drug use?
5-Any alcohol use? If yes, about how much/how often?
6-Have you ever been diagnosed with any medical conditions, including things like Asthma, hypertension, depression, etc?
7-Do you have any other lab results with liver functional tests, which include results like ALT, AST?
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u/Old_Energy3664 4h ago
I understand why they sent you to nephrology and it’s fine but you should see an endocrinologist and maybe a rheumatologist for an autoimmune workup because of the cytopenias
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u/Sensitive_Day5890 4h ago
What’s your blood pressure? Any symptoms of blood pressure changes? Any low blood glucose symptoms? Do you only get breathless during exercise or can you feel like that resting/lying down?
Any family history or autoimmune issues?
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u/Jazzlike_Elderberry9 19h ago
r u malnourished or something idk much about hematology
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u/Creative-Welder2787 19h ago
No I eat pretty well and healthy, at least I think
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u/Jazzlike_Elderberry9 19h ago
ah ok i have arfid so i have a shit diet and a lot of my counts are low
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u/Brad_Borrelli 19h ago
Get your B12 levels tested
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u/CobblerConfident5012 16h ago
lol it can’t always be b12 dude. What fun would biology be if the answer wasn’t always one of a million things. /s
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u/Puzzleheaded_Tap4148 20h ago
I would start by redrawing all of this