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Dr. Andrew Rynne

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Hypertensive and moderate splenomegaly. Low platelet count and enlarged spleen. What's wrong?

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Dr. Robert Galamaga

Oncologist

Practicing since :2002

Answered : 2577 Questions

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Posted on Fri, 25 Jan 2013 in Blood Disorders
Question: Hi,

I am trying to get an opinion re the symptoms faced by my 66 year old mother. The case details are as follows:
Age 66 years
Gender Female
hypertensive (on medication 133/85 with Rx), FBS (no medication) 110
weight 69kg
MODERATE SPLENOMEGALY (around 19cms)
BONE MARROW BIOPSY= no fibrosis, no MDS,no granulomas and no metastases, few hyperplastic lymphoid follicles with prominent germinal centers. The clinical impression of biopsy is normal marrow with reactive lymphoid follicles.

Case history: In July 2012, mom faced an episode of dizzyness and profuse sweating. Immediately took her to a hospital and the doctors there did an ecg and 2d echo. those came back normal. The cardiologist then referred to GI specialist, who recommended abdomen ultrasound. Ultrasound showed enlarged spleen. GI then recommended abdomen CT, which confirmed splenomegaly but no ascites. Then endoscopy and colonoscopy were performed, which came back normal (no portal hypertension signs), but with mild diverticulitis.

It had been 6 months since enlarged spleen was found and the GI did not see any size reduction of spleen in 6 months, so referred to hematologist. Hematologist recommended CBC and blood picture (Dec 2012). CBC showed WBC at 7500, neutrophils 58%, lymphocytes 38%, haemoglobin 11.6, platelet 0000. The blood picture clinical impression was mild thrombocytopenia with occasional giant platelets. Haematologist then recommended bone marrow study. Bone marrow biopsy showed no fibrosis, no MDS,no granulomas and no metastases. It also showed a few hyperplastic lymphoid follicles with prominent germinal centers. The clinical impression of biopsy is normal marrow with reactive lymphoid follicles. The bone marrow aspirate clinical impression is reactive marrow changes.

The haematologist has asked us to see him again after a few weeks with fresh cbc and blood picture. He has not indicated what he suspects. Over the last few months (July-Dec 2012) multiple CBCs were taken and the CBC results were similar to the last one mentioned above

The question is what are we potentially looking at here. Is follicular lymphoma possible with such counts? Is there a possibility of some other malignancy? Lymph node enlargement has not been observed so far. Have attached bone marrow and CBC report. both tests were done in December 2012
doctor
Answered by Dr. Robert Galamaga 1 hour later
Thank you for sending your question.

Your question is a very good one and I will work on providing you with some information and recommendations.

I want to reassure you at this point that I do not see any immediately life-threatening problem going on. I do agree that additional investigations are indicated to help get to the bottom of why we see a mild degree of anemia as well as low platelet count and enlarged spleen.

There are many possible causes of enlarged spleen. It does not appear that there is portal hypertension as you mentioned. I there is some type of active autoimmune process this could cause activation of the spleen an a drop in blood counts. It might be worth requesting a sed rate, platelet autoantibody screen, XXXXXXX and rheumatoid factor as well as a Coombs test to help rule out immune causes of lowered blood counts.

A follicular lymphoma is a consideration in this case although we do not see any enlarged lymph nodes. It is unlikely but still worth considering. One additional test which might be helpful would be a PET scan. This type of scan might help us identify areas which could reflect some type of active lymphoma.

If there is lymphoma going on it is most likely low-grade and not something that would need any treatment at this time.

Thank you again for sending your question. If you have any additional specific items that you would like to discuss I would be happy to review those with you.

Sincerely,

Dr. Robert




Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Robert Galamaga 5 hours later
Hi Dr XXXXXXX Thanks for your prompt response. I will get those autoimmune tests done. As far as PET scan, will that be definitive? ie, will we know for sure whether we are dealing with malignancy or not, even if we are at the initial stages of lymphoma? Also, we did do a LDH test, LDH was 210. Please let me know re sensitivity of PET test, as we'd like to know for sure if there is malignancy so that we can start planning around care etc. So far, none of the tests performed have been able to give a definitive answer in that regard

Thanks!
doctor
Answered by Dr. Robert Galamaga 6 hours later
Hello and thank you for sending your question.

I completely understand your level of anxiety and frustration with trying to get to the bottom of this.

The PET scan is not 100% sensitive but it might provide additional information in helping to assess what is going on.

At this point there does not appear to be any type of malignancy. Until a malignancy can be definitively declared I would not worry about that. However I would continue to try to investigate this until someone can give you definitive answers.

Also one thing I did not mention previously is that the spleen can become enlarged as a reaction to an infection such as a virus. This could possibly be the case for her. A follow-up measurement of the spleen at some point in the next year might be reasonable in that sense.

Thanks again for sending a question and allowing me to participate in your health concerns.

Dr Galamaga
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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