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pancakes

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24 y/o female with h/o iron deficiency. Had a CBC with Diff. In 6 months, Baso increased 1.0-1.1%. Eosinophil increased from 3.1%-8.8%. Lymph decreased from 45.4%-44.4%. ABS neut% decreased from 1.30 - 0.99. . Platelet count has steadily been decreasing from 253 month 1 to 197 month 3 (she had wisdom tooth surgery a week before the draw) to 181 at month 6. WBC has also decreased from 2.91 - 2.61. She was being treated for her iron deficiency and RBC values/h&h look good. No other history of health problems or trauma. The only medications she was on at the time was her ferrous sulfate 325mg once daily and she used some ear drops. Not a smoker or a drinker. Denies recent illnesses. No blood in urine or stool. Not pregnant. Extremely stressed out and low on sleep at the time of the last draw.

Based on lab values, the only things out of range are abs neut and WBC. Eosinophil is at 8.8% but abs eosinophil is normal... Why is WBC decreasing but eosinophil increasing? Platelet count is still within normal range but the drop has been extremely rapid, IMO. Cutoff for normal range for the lab is 150. She dropped from 253 to 181 in 6 months. WBC has been low since the start (which she was told by a previous provider not to worry about) but it's continuing to drop which is concerning, especially with no other signs or symptoms. I have no clue on how to approach this. Any insight??

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Appetite?  Weight changes?  Occupation?  Travel history?  Do you have an etiology for the iron deficiency anemia?

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Normal appetite. Has gradually lost 77 pounds over the past 7 years through exercise and portion control. Denies recent travel. Low on iron (perhaps through her diet)

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21 minutes ago, pancakes said:

Low on iron (perhaps through her diet)

So was she worked up for this or no?  I'm assuming her MCV was low and a ferritin level drawn?  Was it due to heavy menstruation?  Any associated GI symptoms or occult bleeding?  Inflammation?  I don't want to go down the rabbit hole here but we can't help too much without more info.

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Right, so she had a previous history of iron deficiency in high school which was treated. Now at 24, her MCV and H&H, etc. were all over the chart on month 1. She was put on ferrous sulfate 325mg one tablet daily for 6 months. She had her blood drawn at month 3 to if the anemia was improving with the pills, and was kept on the the tx for another 3 months, which brought her in for her 6 month blood draw that I have listed the results to above. Her RBC, H&H, MCV, MCHC, MCV, MPV are all within normal range now and she is off the ferrous sulfate.

Ferritin levels were drawn and they were fine. Menstruation used to be very heavy but has gotten lighter throughout the years. No inflammation.

She was recently tested for celiac. Results were negative. She believes she has "some sort of IBS." Bowel movements have not changed. 

The information may be scattered, so I apologize! I have been going through this for what seems like eons and I can't figure it out.

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Eosinophilic leukemia or parasitic infection? Check ECG, bone marrow bx, IgE, Serum tryptase, Immunophenotyping of peripheral blood T cells

Spitballing, still in didactic so I have a narrow view. 

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The number of eosinophils didn't increase...the number of another type of WBC decreased causing the percentage of eosinophils in relation to others rise 

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And by abs neut % do you mean ANC or absolute neutrophil count?  This isn't a percentage if so and neutrophil % is very different from ANC

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abs neut meaning ANC.

A little bit more reader friendly: over a 6 month period

WBC: 2.91 -> 2.61k/uL

Platelet: 253 -> 181k/uL (still within range)

Neut%: 44.7 -> 38%

Abs Neut (ANC): 1.30 ->0.99k/uL

Lymph%: 45.4 -> 44.4%

Abs Lymph: 1.32 -> 1.16k/uL

Mono%: 5.8 -> 7.7%

Abs Mono: 0.17 -> 0.20k/uL

Eosin %: 3.1 -> 8.8%

Abs Eosin: 0.09 -> 0.23k/uL

Baso %: 1.0 -> 1.1%

Abs Baso: Unchanged at 0.03k/uL

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FWIW I'm not sure a plt drop of 250ish to 180ish over 6 months constitutes 'rapid'.  

If there's no parasitiic (or other) infection, I'd think a BM biopsy might be justified at some point if the #s keep dropping.

Also, plenty of people don't have symptoms with HIV unless it's the very early acute phase illness or very late stage.  Not sure that is what's causing things here, but that's why patients get screened regularly - otherwise you might not know until it's too late.

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I would say the lab work is not overly impressive.  If her travel history isn't significant, if she doesn't eat off the wall foods like raw or undercooked meats, and if she doesn't have any other concerning constitutional symptoms (like for myeloproliferative disorders, etc), just give her reassurance and f/u with blood work at a later date.  I do like the idea of screening for HIV if she hasn't recently.

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