Aplastic or not?

[lacanada1]

I am a normally healthy 20-something male. I am being treated with prednisone (40mg/day) for a preliminary diagnosis of aplastic anemia after a last blood count had HGB 8.6 (RBC 2.31), PLT 79, WBC 2.6, with levels generally going down or staying at that level a little bit test-by-test over the last couple months. I also had a bone marrow biopsy, which revealed no malignancy but did note hypocellularity and "considerable red cell anisopoikilocytosis."

But my last reticulocyte count was 4.55%. My hematoligist says that this is a good sign, but how can my Hgb/RBC levels be so low, but my reticulocyte count be so high? It's been like this for a couple weeks now, and I continue to tired and more light-headed than before. My question is if with such a high reticulocyte count, can I be considered to have aplastic anemia?

[Ruth Cuadra]

Hi, welcome to Marrowforums. You've asked an interesting question and one that puzzled me at the time I was diagnosed with aplastic anemia. The reticulocyte count measures how fast red blood cells are made by the bone marrow and released into the blood. In the presence of a disease like AA where blood cells are being destroyed as fast as they are being produced, the body tries to compensate for the loss by pumping out new blood cells as fast as it can, resulting in a higher reticulocyte count. Your doctor sees this high count an as indication that your bone marrow is responding to the prednisone therapy. But if your counts are continuing to go down, it may be time to consider other treatments. The most commonly used treatment for AA, as you probably already know, is ATG (anti-thymocyte globulin). Have you discussed this option with your doctor?

Regards,
Ruth Cuadra

[Marlene]

So sorry that you have a need to be here, but WELCOME.

A couple of quick thoughts on your retic count.....

First, a better measurement to look at is your absolute reticulocyte count (ARETIC). This is the actual number of new red cells. The percentage can be misleading especially if it's not adjusted for the anemia (lower blood volume). At this point you want your ARETIC to be high.

Second, If you're producing a lot of new red cells....say an ARETIC of 97K, then I would expect to see a rise in HGB. If they're on the lower end of normal, then it may just be enough to keep you where you are. Has your doctor ruled out PNH or other disorders that actually destroy the red cells. They should make sure you're not bleeding anywehre.....but at your age, with that platelet count, I would not expect this to be an issue...but you never know.

Third, have they checked your iron levels, B12 and folate? Those all need to be in the middle of the normal range.

Lastley, prednisone is not normally used in the treatment of AA so you may want to explore that further.

When it comes to SAA, its always good to get another opinion especially from a doctor who deals with it on regular basis.

Please contiue to ask questions....this a complex disease and many docs have never seen it before.

Marlene

[lacanada1]

Thanks very much for your response.

My B12 and folic acid levels were low before, but are all normal now. #I tested negative for PNH.

I didn't know about the Absolute Retic count, but I will ask about it. My hematologist has mentioned the ATG therapy as a next step if this current therapy doesn't work out so I do know about it. I am just a bit scared of going to that point, because I've heard that the side-effects (the serum sickness and all that) can be quite nasty. I'm from California, but I am working overseas right now and I would have to return home for the ATG therapy so that adds another element to all this. How long does a 'round' of ATG take? How long should I expect to be in 'recovery'?

[Marlene]

Interesting that your B12 and folate were low at one point. Hopefully, they are continuing to monitor and treat this. There's a reason why it was low and unless that has been corrected, you need to keep on top of it. I will just tell you that it's very important to keep your B12 levels >500. This is very easy through dietary supplements and B12 is non-toxic.

I trust they checked your Iron also?

On the treatments.....ATG/Cyclosporine is the the typical protocol. Everyone responds to it differently so you really cannot predict how you will react or how long it will take for a response. Some repond within 3 -4 months but it can take up to year. Some need a second treatment.
If you get a chance, you may want to contact Dr. Young at NIH for a second opinion and get info on their clinical trials. They focus on ATG as the first line of treatment. A second option is High Dose Cytoxan at Johns Hopkins with Dr. Brodsky. A third is a BMT since you're under 40.

The actual treatment happens over a short period of time (less than a week). More time is spent waiting for a response and undergoing any needed supportive treatments during that time.

It is very overwhelming and scarey, but remember, lots of people with AA are doing well and leading fairly normal lives.

[michelle_lapuz]

hey there:

sorry about your diagnosis, it is tough. your numbers are still quite acceptable, I assume you are nowhere near transfusion? they usually recommend ATG after your neutrophils drop to somewhat concerning levels (below 1.0) above that, they wait. i'm from California too and being followed at UCSF where they have a wonderful hematology and BM clinic. ATG recovery is different for everyone but since you are so young it would probably be really quick. serum sickness can be avoided with Prednisone (which is probably the most horrible drug to be on at high doses for long periods of time)......

good luck and I hope your numbers come up without intervention!

Michelle