Low neutrophils, high lymphocytes

My 13 year old son's absolute neutrophil count has been low for at least 10 months starting at 1.72 in November and now to 8.8.  HIs absolute lymphocyte count has been high ranging from 2.47 to 3.99 and now 2.64.  WBC have been normal until now it is a little low, 4,64.  He has fatique, headaches and paleness a lot.  This month his Monocytes were high, 14, for the first time.  Is this anything I should be concerned about?  The doctor said it was probably a virus but we have been dealing with him not feeling well for almost a year.  

[Mochadelicious]

Does your son have any other symptoms?  Enlarged lymph nodes, fever, weight loss or night sweats?  I'm assuming you are concerned about lymphoma or leukemia since you're on this forum.  I'm not good at interpreting labs, but usually the first symptom is an enlarged node along with elevated LDH and low WBC levels.  10 months is a long time to be sick, and a lot longer than it would take for a virus to run it's course (in my opinion).  I'm not sure what is going on with your son, but I would consider seeing a different doctor if he continues to have these symptoms.  

[Mochadelicious]

Does your son have any other symptoms?  Enlarged lymph nodes, fever, weight loss or night sweats?  I'm assuming you are concerned about lymphoma or leukemia since you're on this forum.  I'm not good at interpreting labs, but usually the first symptom is an enlarged node along with elevated LDH and low WBC levels.  10 months is a long time to be sick, and a lot longer than it would take for a virus to run it's course (in my opinion).  I'm not sure what is going on with your son, but I would consider seeing a different doctor if he continues to have these symptoms.  

[Chery222]

Thank you som much for your response.  He has some lymphnodes on the sides of his neck this whole time but they say they are nothing becasue they are not getting larger, they are less than 1/2cm.  He doesn't seem to get fevers except a low grade one this week but I think it was more due to sinus infection, and it has resolved.  No night sweats or weight loss.  I agree that it is too long for a virus, which is exactly what the hematologist said in April, but now, in July and this month, he says it must just be a virus.  I do think I will get a second opinion.  Do you know what Poikilocytosis, 1+, and Ovalocytes 1+ mean on labs.  That was also on the report.  It all gets so frustrating, because I don't understand lab results either.  The doctor says because he is not having bruising, night sweats, fevers, or weight loss there is nothing to worry about.  

[Mochadelicious]

Hi Chery222,
I'm so sorry it took so long to get back to you.  Apparently I didn't add this conversation to my watch list and it got lost in the shuffle...

I'm assuming your son is no longer experiencing a low grade fever?  Did the doctor think his lymph nodes were some what enlarged in order for him to feel them?  The virus answer just doesn't add up to me.

I have never heard of those lab terms, but I did do a little reasearch on them and was able to find out that Poikilocytosis is an abnormality of the red blood cells.  I believe the 1+ is an indicator of it being mild.  The Ovalocytes looks to be a type of cell that is described by it's shape as being a cell with an oval outline.  What this has to do with anything is beyond me.  I will private message you with a link to what I found.  

Do you live near a big city?  I would recommend that you take your son for a second opinion with a hematologist at a larger research hospital.  These doctors are highly trained and specialized in blood disorders.  As a research hospital, they get a lot of grant money to do very specialized research.  I personally went to Fred Hutchinson Cancer Center in Seattle for a second opinion, even though it was a 5 hour drive for us (but well worth it).  There are quite a few large research hospitals here in the US, so most likely there is one near you.

I recommend this to you not to scare you, but to try and point you in a direction where I think you will get better answers for what your son is going through.  I wish you and your son the best and please keep me posted on how things go.

[Chery222]

Thank you again for your response.  I did switch Hematologists for a second opinion.  He is now being seen at Mass General which is a great place.  His eosinophils are still elevated, and his neutrophils continue to be low.  The ANC is at 780, neutophyls 17%.  He is going for some followup tests this week.  It is just very frustrating to not know.  This new docotor check and the Poilkilocytes and Ovalocytes are normal.  RBC's are normal right now.  Just the neutrophils and eosinophils.  They have ruled out allergies at this point.  They have alos ruled out anemia.  Thank you again!  

[Mochadelicious]

Good to hear.  I'm glad he is being reevaluated.  I know that waiting for a diagnosis is very difficult.  You just want to know what it is so you can start dealing with it.  

Good luck and keep us posted if you can.

[Chery222]

Thank you again for your replies!  This past week they did more blood work and ruled out Addson's disease.  They also did a chest x-ray and ruled out Hodgkins.  Good news so far!  We will follow up with the Hematologist in 2 months to redo blood work and discuss our next steps to figuring out his neutropenia and his eosinophilia.  Still frustrating not knowing.  I will keep you posted.  Thank you again!

[Mochadelicious]

Yay...I'm glad they were able to rule out Addison's and Hodgkins disease.  Hopefully, whatever it is they find, will be minor and easy to treat.  It's good to hear that they aren't going to give up trying to find a diagnosis.  It took a total of 3 years to get my diagnosis on Non-Hodgkin's lymphoma, so don't give up!  (I'm sure it will be a much shorter time for your son.)

You are very welcome, although I wish I could be more help.  I'll be watching for your future posts.  :-)

[Chery222]

Sorry to hear about your Non-Hodgkin's lymphoma and that it took 3 years to diagnose.  Why did it take so long?  How are you doing now?  My son had been feeling pretty good until last night.  Very bad stomach pains and ended up so tired.  He stayed home today due to being so tired.  Once he gets extra sleep and rest he seems to do better.  I can't imagine it taking another couple of years to find out why his Neutrophils are low.  Ugh!  

[Mochadelicious]

It's kind of a long story.  My diagnosis took so long because it was presenting in my breast, something that isn't very common with NHL.  I developed a small lump in my breast back in 2007.  I had a mammogram and ultrasound done which showed a "thickening", but nothing to worry about (thier words...not mine).  The following year, I developed another lump on the same breast.  I had a biopsy of both lumps and they came back as benign.  Then, in 2010, I developed a third lump on the same breast.  I went to a different doctor who did a needle punch biopsy and that came back as "suspicious for lymphoma", which was later confirmed.  It was also realized that my previous biopsy was really malignant, not benign as they first thought.  Looking back, I think it was missed because they were looking for breast cancer, not NHL.  I was stage 3, grade 3, which is more advanced, but the good thing about the kind of NHL I have is that catching it early doesn't really matter as they often wait until your more advanced anyways before they treat it.  I went through chemotherapy for 6 months and then two years of maintenance treatments.  My last one is actually on Monday.  (Whoo-hoo!)  

I'm sorry to hear your son is still not feeling well.  It must be very frustrating and concerning for you to watch him feel ill and not be able to know why or how to fix it.  I also have two teenage sons and I can't imagine how scary that would be.  I really doubt though that it will take as long as it did for me to get a diagnosis.  My advice to you is be your sons' advocate...you have to be.  Question everything and seek second opinions, especially when dealing with a serious diagnosis (which I hope you won't be).  

[railroaded]

My son presented with Acute Lymphoblastic Leukemia WITHOUT any previous symptoms. One day, when he was 5 he came home from school and said, "Mom, I'm tired but I'm not sleepy". I looked at him, and not only was it not like him to be tired...evr practically, but he looked deathly sick, and it was suddenly! I'll make a long horrible story short by saying he was admitted to UCSF in San Francisco because I convinced my Family Doctor, (He had NEVER been sick before, he was the healthiest baby, child, up until that moment I had ever known...he was my youngest out of 3 children, and my only boy. He kept giving "dry taps" sticky cells during his L.P's, so they were almost positive when              they looked at his bloodwork he had leukemia, but without the L.P. results, they kept looking and hoping, for it to be ANYTHING else. I was praying for Ebstein-Barr, which took the longest to get the results back from, but EVERYTHING was negative, and then he presented with 99.9% Blasts and it was confirmed. His Neutrophil count was ZERO, and that was always the scariest part, always, (It would linger so low, even when he was on chemo, and during periods he was at his "best". There were no symptoms that tipped me off before that day he came home from kindergarten, just what he said, and the fact he LOOKED tired, during the day...was SO out of character for him, he never took naps, was always running, NEVER sat still....until that day. He never got the enlarged glands or bruises before presenting either, although during the 5 years of treatment, I knew MOST of the children did. His neutrophil count and his Blasts were the first signs, and even they couldn't believe he wasn't "sick",  (of course he had to be) until the day he was dying. So I know all kids are so different, and I had a wonderful Family doctor and was referred to Ucsf, and it there we had ALL our treatment. The oncology nurses were wonderful, and they keep you so informed at a teaching hospital, (I had the same access to the Leukemia information and books, pamphlets they were using, and would have the combination to the physicians library at the hospital) I HOPE your son doesn't have anything at all, and I hope if he does present with something, you have support, and wonderful nursses, (I was a single parent, and the nurses became MORE than just friends) The hospital you choose makes a big difference. (I had to use a couple of local ones just a very few times....they didn't WANT me to, and I didn't WANT to use them! They had NO experience with the critical nature that even 5 minutes can make, and I had to really tell QUITE a few local doctors off, or he would have died! It becomes second nature when your child is the issue. I hope you keep posting, there was nothing like these forums when I went through it. When he died at 10, FRIENDS didn't know what to say, so it was really hard, I didn't want them to say anything, but please, don't just avoid the person because it is so scary. I know just them saying his name would make he feel better. I never thought, like the saying goes, "It would happen to me, or HIM), but it does happen, to anybody, and maybe that is what scares people, the thought of a beautiful happy little boy getting sick and dying comes a little too close to home. I hope you keep posting, and I know what you are going through (well, I realize everyone is different, but you know what I mean).

[railroaded]

Oh, I forgot something, I was going through a divorce and my son had come to sleep in my bed within a week or 2 before his "I am tired" remark. He HAD woke up with night sweats one night, which I only noticed in the morning, that is the only symptom I ever could think of, and I don't remember if the other parents mentioned it, they usually always mentioned bruises, which he never got.

[just4me1]

Has your son been checked for mono &/or chronic Epstein-Barr virus? I had mono at age 18. A couple of yrs later, presented with mono-type symptoms again but was told you could only have mono once. This kept happening every few yrs. Finally found a Dr. that said, true mono only once, after that, chronic Epstein-Barr virus. Was told I would just have to live with it and rest whenever I had flares.

Now, 35 yrs later, I am seeing Dr. A. Martin Lerner in the Detroit area & being treated with antivirals. I am finally starting to see some progress after 1-1/2 yrs of treatment. I wish I had known yrs ago that I could be treated for this. Symptoms for me include fatigue, headaches, body aches & pain, memory issues, sore throat, swollen glands, insomnia even though exhausted. If I get any type of illness or go through too much stress, I will have a flare where it will feel like full-blown mono again. My neutrophils are sometimes low & my lymphocytes high. I also have HHV6 & he was the first Dr. to find this, it is a co-virus that tends to go with CEBV. If mono test is negative, the EBV test may also be positive. They must run the right test to get the correct info on this & many Drs are not that familiar with it. If you need more info from me, let me know.

[Chery222]

@railroaded...I am so sorry for your loss and all that you have gone through.  I can't even imagine.  What was your son's name?  My son does not have bruises or night sweats.  They say that he is not presenting with any serious signs that would make them think Leukemia, but it hasn't been ruled out.  They said if children get leukemia it is usually the acute form of Leukemia and they said that it would be extremely rare for him to have a chronic kind of leukemia because he is only 14.  He just turned 14 yesterday.  He still gets pale and looks sick somedays but not everyday.  Gets headaches.  Gets fatigued frequently.  I just knew something wasn't right last fall/winter.  The only thing they know is that his Neutrophils have continued to drop.  Now they are at 780.  They have never gone up.  His eosinophils are always up, Lymphocytes have been elevated.  So they continue to try to figure it out.  We follow up with the Hematologist on November 16th.  I think if the Neutrophils are still low they will be doing a bone marrow biopsy.  
@just4me1...yes he has been checked for mono and EBR, both negative.  They have also ruled out Hodgkin's, Addison's, anemias.  I feel like I know what you are going through.  I also had mono, very bad, when I was 19.  Now at 47 and for the past 10 years I have suffered from fatigue, joint pain, and headaches, and noone can figure it out.
Thank you all for posting.  It makes me feel better being able to talk about my son while we try to figure it out.  I worry all the time and hopefully it is something that is not serious.  

[Chery222]

@just4me1...yes he has been checked for mono and EBR, both negative.  They have also ruled out Hodgkin's, Addison's, anemias.  I feel like I know what you are going through.  I also had mono, very bad, when I was 19.  Now at 47 and for the past 10 years I have suffered from fatigue, joint pain, and headaches, and noone can figure it out.
Thank you all for posting.  It makes me feel better being able to talk about my son while we try to figure it out.  I worry all the time and hopefully it is something that is not serious.  

[Chery222]

My sons anti-neutrophil antibody test came back negative.  Now we wait and see the next step.  

[railroaded]

My son's name was David. He got sick about 2 months earlier, and he looked pale and was tired, they checked him for everything, and everything, even leukemia, came back negative....because they couldn't extract cells from his bone marrow, he had "dry taps", I don't know what the real name is, it was what everyone just called them, they said the cells were too sticky to extract. He was at UCSF, and gradually got better, within 3 weeks, but I could tell he was still sick, and within that 3 week period EVERYTHING had been ruled out.. Within a month he presented within one afternoon with Acute lymphoblastic Leukemia, and a neutrophil count of 0 (ZERO!). He had been being checked weekly during that month we went back home and even though his counts were abnormal, now that I can read them, it wasn't until that one afternoon he just was going to die...and that is what WOULD have happened, if I wouldn't have questioned the on-call doctor who had been arrested for a DUI, and was always drunk! I hope your son has just low counts, and I know it IS unusual for a child to have chronic leukemia, they usually present very fast with Acute, but my son DID get sick a couple of months earlier, and he was hospitalized, and when I look at photos from5-6 months earlier he DID look pale, but he was always so unusually active, I didn't notice him slowing down, until much later. I wish you the best of luck, and I would recommend a good hemotologist or a pediatric Oncologist, preferably at a teaching hospital, they have seen everything. I am praying for your son, really.  Teresa

[Chery222]

Hi Teresa,
Thank you so much for all you have explained to me about your son.  I really appreciate it.  You have been through a lot.  We will be going back to the Heamtologist in 3 weeks.  I will keep you posted.  
Take care,
Cheryl

[Hope4diagnosis]

I have been reading this post about your son. I hope they have found the reason for his symptoms. It is the most frustrating thing waiting and searching for a diagnosis. My daughter went through the swine flu at 15. She was very ill. She recovered from it but from then on began having very bizarre symptoms such as swollen joints with heat and pain, swollen lymph nodes, headaches, extreme fatique, anemia, and slightly abnormal blood problems. In July, her hemoglobin was 3. I was horrified! The doctors just had her on over-the-counter iron tablets. She has had low platelets at times, low hemoglobin, her B12/serum is extremely high (she eats no foods containing this as she doesn't like them), currently her neutrophils are slightly low and her lymphocytes are extremely high. She has bruising and petechiae at various times. We have been to every kind of "ologist" there is and have cast 2 hemotologist/oncolgists to the curb! We are now at another oncologist/internal med doctor. Not one doctor was willing to do a BMA on my daughter! The thing is when they do a CBC, it always comes back normal. Her PCP ignores that test and always does further testing on her blood which shows the abnormalities. The hematologist take that test at face value. It has been 3 years now and still no diagnosis. I have watched my child go from a happy, fun loving, outgoing teen to staying at home, resting all the time, and always feeling bad. She is now on meds for anxiety as well. I am at my wits end with doctors! The current oncologist is taking her seriously and has seen the blood abnormalities. She may have a diagnosis for my daughter soon and may do the BMA next week hopefully. After all this time, my daughter is about to lose her healthcare coverage. She turns 19 next month and that ends the coverage. We are so concerned. I hope your son's diagnosis comes soon. I understand the pain you are in dealing with it all and watching your son suffer.

[Chery222]

I definitely understand what you are going through.  We are on our 2nd Hematologist.  My son had an appointment 2 weeks ago and the Hematologist said that they may never know the exact reason for the low neutrophils and other abnormal blood work.  She feels it is autoimmune and they can't always find out why.  She is willing to do the bone marrow.  My son will have it in a couple of weeks.  She really feels it will not show anything but she is willing to do it because we are anxious about his blood levels.  She said if the cells are normal levels in the bone marrow (where all the cells are made), then they will know that someting is happening to the blood after it leaves the bone marrow, which is autoimmmune a lot of the time.  It is so frustrating!

[Mochadelicious]

I think a bone marrow biopsy would be very helpful, although I can tell you that after I was diagnosed with lymphoma via lymph node biopsy, they decided to do a bone marrow biopsy to see if it had spread there too.  The results: my bone marrow was 100% clean.  So my point is it is possible to have lymphoma and not have it in the bone marrow.  Leukemia might be different though.  I'm not as familiar with that.

I'm keeping my fingers crossed that you start getting some real answers soon and the bone marrow biopsy sheds some light on what is going on.

[janna77]

hello
i have read all the comment and im really interested because my daughter has some lymph node around her neck and has low neutrophils and high lymphocytes, i hope your son is ok, what the result say about the bone marrow biopsy?

[Ken_PA]

Hi, Emma. I'd suggest writing to Chery222 directly and that might increase the chances that she'll notice. The part that stands out to me is the similar abnormalities that are found in the Red Blood Cells.

[janna77]

ok ken i will try to send her an e mail, so do you have any idea about the reason of the abnormality in red blood cells, thank u so much

[Ken_PA]

Well, ovalocytosis (oval-shaped RBCs, instead of the usual round-donut shape) is uncommon as far as I know, except in certain ethnic populations. Are you a descendant of people from Southeast Asia or Africa?

The first thing anyone would think of when seeing elevated lymphocyte counts is a virus infection - because that's what lymphocytes normally do, they multiply to fight viruses. When they multiply inside lymph nodes, they make lymph nodes swell. A virus can also cause a reduced number of neutrophils. But I don't know of how a virus would cause abnormally shaped RBCs. (Maybe it can do that, but I haven't read anywhere that it can.)

Everything I see about ovalocytes says that it is only ever hereditary. It's not caused by cancer. So that's a plus.


http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001589/

"Expectations (prognosis)

Most persons with hereditary elliptocytosis have no problems, and are unaware of their condition.

Complications

Elliptocytosis is frequently harmless. In mild cases, fewer than 15% of red blood cells are elliptical-shaped. However, some people may have crises in which the red blood cells rupture, especially if they have a viral infection. Persons with this disease can develop anemia, jaundice, and gallstones."


That's all very encouraging. Maybe your daughter had the condition (of oval/elliptical RBCs) all the while, but it was only discovered because docs are investigating her swollen nodes.

Do you have a family history of autoimmune diseases? Bad allergies? Very bad mono? These are signs of a possibly very reactive immune system. Having nodes swollen for 4 months from an infection is rare, but still possible.

Those are my guesses. Here is another (but I'm much more familiar with lymphoma than ALL): having enlarged nodes from ALL without really high WBC counts is probably not usual. That'd be from a more advanced condition. I don't think your daughter's WBC number is really high.

You might as well also press on her spleen and see if it's tender.

Are all of the swollen nodes near to each other?

All of the replies in this thread are very helpful and they show the wide variety of symptoms and possible causes.

[Ken_PA]

Do you have any reason to suspect a deficiency in vitamin B12 or folic acid?

Any history of coeliac disease?

[janna77]

we have just a family history of blood cancer in my mother side and my father side and liver cancer, and the swollen lymph nodes are in both sides of her neck, 2 in etch side and the 2 are close, about the deficiency of B12 and folic acid i dont think so, for how long do you think for a virus  to clear up? so we can have an other blood test and see whats gonna happen
and thank u so much for helping its really nice of you

[janna77]

i forgot she has also a high RBC

[Ken_PA]

Some viruses van keep nodes swollen for years, e.g. "chronic Epstein Barr"

I had noticed the elevated RBCs, I assume that if her RBCs are small (microcytic) and shaped wrongly (ovalocytosis), then her system makes more of them to keep up the supply of oxygen in her blood. (If a person goes to live at a high altitude where oxygen is low, then they make more RBCs.)

Is she getting enough iron in her diet?

I'll stress this which I'd posted earlier: "...some people may have crises in which the red blood cells rupture, especially if they have a viral infection."

In other words, if she has a condition of hereditary ovalocytosis, then a virus makes it worse.

Did you press on her speen? (below ribs on left side)

[Ken_PA]

That would be "spleen", of course.

Also, I'd want to be sure that an actual person has looked at a slide of her blood - not that only a machine did it.

Also, when a person looks at her white blood cells, they can probably rule out leukemia.

If you get another CBC today, please post the results. You should get a copy immediately.

[Chery222]

Hi Everyone,
Sorry I did not reply right away.  My son had his bone marrow which came back clean.  They have diagnosed him with autoimmune neutropenia.  Possibly caused by a virus at some point.  They said that they will probably never know what is causing it and there are no other tests they feel are necessary.  They are just going to have his PCP monitor his bloodwork periodically.  I do feel confident that his hematologist ran every test they could at this point.  Right now we are just going to have his bood watched and hope he stays healthy.  Right now he feels pretty good most of the time but does start to feel lousy if he gets run down.  I hope are able to get a diagnosis soon.  It is soooo frustrating.  

[Mochadelicious]

I am so glad that he finally has a diagnosis (as I'm sure you are as well).  Not knowing is the hardest part, and now that you know what it is, you can focus on getting him better.  I've never heard of autoimmune neutropenia, but it just goes to show that there are so many blood diseases out there and trying to interpret blood labs and what they mean is nearly impossible for the untrained person.  

Can you please explain what autoimmune neutropenia is and what kind of treatments are required when blood levels require it?  This information may be helpful for others who may be experiencing similar symptoms.  Thanks Chery and I hope you continue to check in and keep us posted on your sons progress.

[janna77]

hi ken
we don't leave in a high altitude we live near san francisco CA.
and i believe she is getting enough iron

and i press in her spleen i believe its soft so really im confused. i googled a little and i found that low MCV  and high RBC can be cause by thalassemia

and ken we did't get an other CBC maybe we will during the week so im gonna  post the result a soon as we get them

thank u so much you are such a help, thank u soooooooooo much so nice of you

[janna77]

thank you so much chery to share this information with us and im so happy that your son is ok and i hope that he stay that way
happy for you
and thank you so much for answering my question