Question: Dear Dr. Ryne,

I did a routine blood test on November 6th (first in 30 years).

White Blood Count: 3.7 (normal: 4.0 - 10.0)
Red Blood Count: 4.8 (normal: 4.2 - 5.7)
Platelets: 63 (normal: 140 - 500)
Lymphocytes: 1.2 (normal: 1.0 - 4.0)

My blood count was low and I have been referred to a hematologist with an appointment on January 5th. I did a follow up test on December 17th since my test with the hematologist wasn't for some time.

White Blood Count: 3.5 (normal: 4.0 - 10.0)
Red Blood Count: 4.7 (normal: 4.2 - 5.7)
Platelets: 66 (normal: 140 - 500)
Lymphocytes: 0.9 (normal: 1.0 - 4.0)

Platelets went up a little but WBC and RBC dropped. Lymphocytes dropped 25% over the course of 31 days and were now below the normal range, albeit borderline. I stopped taking Echinacea as I read that it lower platelet count (a side effect of a stronger immune system). I was previously taking it daily as a preventative measure (but I have read that this is not advised anyway).

I hadn't done a blood test since my family doctor retired 30 years ago, so I don't have any kind of past benchmark. All I know is my WBC is low (and dropping), my lymphocytes dropped significantly and are now below normal, and my platelet count is very low. I don't feel any symptoms other than fatigue, but I am a first time father with a one year old baby that sleeps in our bed at night, so I attributed it mostly to that. Also, I often have difficulty falling asleep (and back asleep) and my sleep is often very disturbed at night with nightmares and strange things that jolt me awake.

One of the things that I read that can cause a low white blood cell count (and low platelet count) is lymphoma that has spread to the bone marrow and of course I am terrified. I am 44 and my first child just celebrated his one year birthday.

I have a small soft lump (like a flattened olive) on the back of my head, just right of the center/spine about an inch above the hairline lined up roughly with my ear. Not painful or growing in size. When I had it looked at, the assumption was that it was a lipoma (or similar harmless mass) as I had gone from 170 pounds to 205 pounds over a 4 year period. I notice there are "occipital nodes" located in the same general vicinity however no one ever mentioned that possibility. I am hoping that this is not a swollen occipital node as I have had it 3 or 4 years now! I don't have dandruff but if I rub my finger against my scalp, it feels as though a little piece (like a grain of sand) can be dislodged each time and I always thought this was a little strange. I read that scalp psoriasis may overwhelm the occipital node... There's no visible rash or dryness at any of the edges of my scalp where the hair stops.

Also, I noticed a little cylindrical mass where my lower back meets my obliques (my side) about inch above my waist. I just assumed this was another small lipoma. It feels as though it's 1 cm long and maybe 1/4 cm in diameter. But I notice there is something called a lumbar lymph note located in that general vicinity...

I also have what I assumed was a lingual varice on the underside of my tongue (the vein kind of bubbles out when I lift my tongue to look at the underside). I know there are submental lymph nodes in the floor of the mouth and submandibular lymph nodes in the anterior tongue. But this is more where the salivary gland is. My dentist wasn't worried, but referred me to an oral surgeon but I have not yet been.

I had an inguinal hernia operation back in 2000. I had an olive sized protrusion that would stick out when I leaned backwards a bit while standing and assumed it was a hernia. I saw a surgeon and he operated on it. Now I see there are illiac lymph nodes in this region and am wondering if it could have been a swollen iliac lymph node instead? Sorry to sound paranoid...

Lastly, I have a rash around my knee that worsens whenever I have sugar. I had something similar a year or two ago in the groin around and on my bum. I thought it was jock itch or candida. I applied different powders and lotions and after several months it disappeared after really cutting down on sugar. I was drinking many high sugar energy drinks at the time. It popped up again on the inner thigh area a few months later and again, after a while went away after greatly reducing the sugar in my tea. It came back a few months ago on my knee and elbow. Now I have it mainly on my right knee (the front not the underside). By REALLY cutting down on sugar it starts to go away (but comes back immmedately if I each too much sugar)...

I apologize for throwing so much information at you!!! But I thought it might be helpful to paint a complete picture. I realize that only a hematologist can truly answer some questions, but I was hoping maybe there was SOMETHING that you could add.

Thank you, and god bless for helping a stranger.

I just remembered that I also have a small soft rubbery mass (slightly smaller than a grape) near my elbow on the inside of my left arm just to the right of the elbow. When I first noticed it I didn't make much of it. I found a similar "thing" about half the size on my right arm that seemed like it should be there. I figured it was from leaning my left arm on my armrest at my computer all day like an internal callous. However when researching lymphoma I noticed there are lymph nodes in that exact location called supratrochlear (or epitrochlear) lymph nodes. When I play around with the lump (to measure the size/texture) my forearm can get a bit tingly. I kind of regret not having these things looked at more carefully earlier.

Thank you Dr. Sanghvi.

I thank you in advance for your patience and for helping a perfect stranger. With regard to the most pressing concern in my blood test which is the low platelets, I ruled out a lot of the causes I saw listed such as medication (don’t take any), chemotherapy (nope), drugs/steroids (nope), anything of the diseases that affects red blood cells because those are OK (aplastic anemia, hemolytic uremic syndrome) and diseases that produce symptoms I don’t have (e.g. TTP).

The number of "good" explanations that remained were outnumbered by "bad" ones... And when I look at the commonality it becomes even more worrisome...

Multiple Myeloma: 4 in 100,000
Lymphoma: 14 in 100,000
ITP: 3 in 100,000 ("ideal" explanation)
Myelodysplasia (MDS): 5 in 100,000
Lupus: 2 in 100,000 males
Bacterial blood infection: ?

I also see Leukemia listed as a possible cause of low platelets.

I've been hoping it was simply ITP. I had it in my head somehow that ITP was much more common than the other disease. But I have learned that it isn't. :-( I don't want to seem like I'm jumping to conclusions or doing the doctor's job. I'm simply trying to do a risk-assessment based on the little information that's available right now. And I've read that 25%-50% of the people diagnosed with some of the cancers listed don't have physical symptoms upon diagnosis.

So, my question is, am I looking at this the right away (i.e. probability of a diagnosis from a mathematical point of view)? Is there any information at all you can add in terms of how I should be evaluating things based on the little that is known right now? I realize it's a little like looking at a fully dressed person and trying to guess the color of their underwear, but heck it doesn't hurt to ask... maybe you have some knowledge about some of the causes... I know that Lymphoma would also (unfortunately) explain my low lymphocyte count (borderline low at 0.9 but low nevertheless and down 25% from the previous month). But then again this could also be explained by a common cold though I see this cited less often in my research.

Thank you again! If you could reach into my heart, you'd see how truly grateful I am.

Thank you. Here's a fascinating question for you... I have read two things with regard to low platelets that really seem to contradict each other.

1. The latest review study reports that the incidence of adult ITP (how many people get diagnosed each year) is 3.3 per 100,000 adults/year. The prevalence (how many adults have ITP at any time) is approximately 9.5 cases per 100,000.

2. A small proportion of the population (approximately 2.5 percent) will have a baseline platelet count lower than 150,000/microL, because normal values are typically determined based on the 95% confidence intervals around the mean.

If 2.5% of people have a normal value under 150, wouldn't 250 per 100,000 adults have ITP (as opposed to 3 or 9)?!? Does this discrepancy in part have to do with the fact that many people who have mild to moderate Thrombocytopenia have no symptoms and therefore don't generate a case/diagnosis of ITP?