EOS Level climbing after BMT

[ljvoight]

My daughter Danica just turned 12 in October. She had VsAA. It will be one year since her BMT on 11/29/07 her Faternal Twin Sister was a perfect match for her, we feel pretty lucky Danica has been very lucky so far in that she has had no GVHD not even a rash and is off all meds except for the antifungal meds.

The Dr's have recently noted that her EOS level has been increasing. For example since 6/07 to 10/07 her level has increased from 4.4 to 14.8 She is exibiting no outward signs of allergies and is not complaining about anything. Our Dr. is saying they are "Monitoring the Situation" that her EOS level is not high enough to be a concern.

I am worried!!! what should I be asking the Dr. and what could elevating EOS levels be saying after a BMT??????

[Wendy Beltrami]

I have no idea what an EOS level is and haven't seen it mentioned here before. Can you give a little more information?

[Neil Cuadra]

EOS refers to the count of eosinophils, one of the white blood cell types. You'll see the EOS count, usually as a percentage, in a Differential blood test, which is sometimes performed along with a Complete Blood Count (CBC).

Depending on who you ask, the normal EOS range is 0% to 5%, 0% to 6%, or even 0% to 8% of white cells. Elevated eosinophil levels in the general population can indicate allergic reactions or the presence of parasites. Eosinophilia is the condition of having a high EOS concentration.

There is a very good description of eosinophils and their actions (written for asthma patients) by the Midlands Asthma and Allergy Research Association in the U.K.

Because eosinophils develop in the bone marrow, they are affected by bone marrow failure. You'd hope to see perfectly normal counts a year after transplant, so it's not unreasonable to have concerns and to ask the doctors more questions about it. There may not be many statistics about continuing high EOS counts for adolescent post-transplant AA patients, but the doctors should explain whatever they do know.

Does "monitoring the situation" mean getting regular differentials to keep an eye on Danica's EOS and other white cell percentages? You might ask the doctors at what point they would consider an elevated EOS to require more than waiting and watching?

Have any other of Danica's blood counts been unusually high or low?

[ljvoight]

Hi Neil,

Thank you for responding!!! her some of her counts are still a little on the low and high side. Her WBC 3.4 RBC 4.05 Nuets ABS 1.73 are on the low side, her EOS 14.8 MCH 32.5 RETIC 1.6. are on the high side. PLT are nice at 204.

Her EOS count has been the one that have had this climb that seems to be inching upwards every time we go in. We go in every month to check her CBC with a Dr. Visit. Since she is not exhibiting any symptoms at all he feels it is a wait a see situation to see if her numbers will normalize on their own or if she starts having symptoms. Since she is off all steroids he wishes to keep her there unless they feel the need arrives.

I just have a pit in my stomach that every time we go in and it is up again!!!
On the other side I am happy that he is being cautious about putting her on medications which may have other side effects.

Linda

[Neil Cuadra]

Can you confirm that those EOS values are percentages? I want to make sure because sometimes the absolute EOS, in units of cells per microliter (cells/mcL), is shown on CBCs instead of the EOS percentage.

For absolute EOS, a count of less than 350 cells/mcL is typically considered normal.

When EOS and WBC are both expressed in cells/mcL, you can use these formulas:

absolute EOS = WBC x EOS percentage

EOS percentage = absolute EOS / WBC

[ljvoight]

Hi Neil,
Once again thank you for responding!!! This was Danica's last CBC with DIFF

WBC 3.5, RBC 3.97, HGB 12.8, HCT 36.9, MCV 93.0 MCH 32.4, MCHC 34.8
RDW 12.2, PLT 250

DIFF-
Neuts% 43.3, LYMPHS% 35.1, MONOS% 6.0, EOS% 14.8, BASOS% 0.7 NEUTS ABS 1.51, LYMPHS ABS 1.2, MONOS ABS 0.2, EOS ABS 0.5

Linda

[Neil Cuadra]

That confirms that Danica's EOS of 14.8 is a percentage. Although it's high, Danica's other counts are good and she has a lack of symptoms. Since her EOS was 14.8% last time and 14.8% this time, it's holding, not getting higher. These facts could be why the doctors aren't especially worried about her overall counts.

About the other high counts:

Danica's MCH (mean corpuscular hemoglobin, the amount of hemoglobin in her red blood cells) is at the high end of normal, or perhaps just off the high end, depending on whose range you use. Both hemoglobin and hematocrit are used to calculate this number. The high number shows she's definitely not anemic!

A RETIC (reticulocyte) count is a measure of how fast bone marrow is making slightly immature (young) red blood cells called reticulocytes, and releasing them into the blood. You said Danica had a RETIC count of 1.6 in the earlier test. That count also shows that her marrow is making red blood cells. Although the normal RETIC range is often said to be 0.5% to 1.5%, the maximum is higher for women and children, so up to 2.5% may be considered normal for them.

[ljvoight]

Hi Neil,
Still looking at the EOS levels. Danica's EOS level jumped to 26. everything else is staying the same with no outward symptoms.

Let's say her level keeps going up. What could this mean????

[Neil Cuadra]

You don't want to encourage unnecessary tests or treatments, but Danica's eosinophil count certainly seems unusual.

I think it's time to quiz Danica's doctor again. You should ask about the possible explanations for the high and rising EOS count, ask whether it is now a medical concern to the doctor (and if not when it will be), and make it clear that this is of concern to you because you don't have enough information about it. Please let us know what the doctor says.

It's part of a doctor's job to keep you informed, not just treat the disease. If the doctor can refer you to another source (a person or resource) for the information you need, that's fine, but your question should not be shrugged off.

Overall, you and your family must be very pleased that your daughter's other counts (the ones of primary concern after a transplant) are good and that she is asymptomatic.

[ljvoight]

Hi Neil,

Yes we are very happy with her other counts. In addition Danica is back in scool, playing soccer again and is happy to be at 6th grade camp this week.

Danica's Dr. has a wait and see attitude. He wants to see if her body starts to tell us what is going on: Rash, tummy problems, etc!!!! He wants to know if it is GVHD what is being affected. He is a very good Dr. and we have been very pleased with his professionalism and care, Danica has been through so much that I am just worried.

I will ask him next time when are the counts high enough to be of a medical concern. If and when it becomes a medical concern do you think it it out of line to ask for a BMT biopsy to make sure her cells are normal

As you stated; I do not want them to start any unnecessary tests or treatments just to pacify me!!

Linda

[Neil Cuadra]

If and when the doctor decides that Danica's elevated EOS count requires action, I'd follow the doctor's guidance about what to do next. Someone with more expertise than us would have to say if that would involve a bone marrow biopsy (BMB). If the doctor doesn't think one is warranted, I personally wouldn't be anxious to dissuade him.

Is the doctor already following a schedule of routine post-transplant biopsies? For example, will Danica have one in November this year, at the two-year mark? My wife had BMBs annually after the first year, for a few years, until it was decided they were no longer worth the expense, discomfort, and minor surgical risks. If Danica will be having one anyway, that may be the time you get the reassurance you are after.

It's clear that Danica has another factor working in her favor: you! Your concern for her, your willingness to ask questions, and your attention to her condition all put her in the best hands possible, Linda.

[ljvoight]

Hi Neil,

Thank You for the kind words!! it made my day. Danica has not had a post BMB I will ask to see if one is planned. Our next appointment is in about 4 wks I will keep you posted... Thank You for the great info!!!!

[skoopman]

Linda,

I don't know what to say about the elevated Eos, however I wanted to comment on the routine BMB's. My daughter had her BMT with Dr. Margolis in Milwaukee for AA and he does not do routine BMB's after transplant as long as all the numbers are normal.

I think you had said you consulted with him in a different post. If so, why don't you send him a quick email asking what his opinion is on the elevated counts with lack of other symptoms.

Suzanne