Brief Answer:
Anemia with a possible thrombocytopenia developing?

Detailed Answer:
Good evening. I am in receipt of this question which has also been answered by at least 1 other colleague, Dr. Zografakis. I believe what my colleague is very accurate and definitely takes into consideration a wide range of possible diagnoses that could explain these blood test results. It is not fruitful to necessarily everything that he has said because I concur. However, I will add this thought which is that since the peripheral smear shows essential NORMOCHROMIA AND NORMOCYTOSIS (occasional macrocytes, nothing significant) but at the same time this is in the face of and context of dropping RBC counts and platelets as well then, I would (in addition to everything that has been said) add LOSS OF BLOOD to the list of mechanisms by which these data can come about.

With respect to myelodysplasia let me say that TEGRETOL is a well known myelosuppresant medication and in some individual they can become downright immunocompromised the bone marrow goes down so low. I know you stopped that drug a month ago but if your father had been taking it for any length of time and then, stopped it only a month ago it could be that it is going to take time for things to right themselves. In fact, if tegretol were responsible for any of this picture we can see that the WBC's are starting to come back already.

One other thing to look at is his urine specific gravity which is HIGH and creatinine which is also HIGH NORMAL although it may be consistent for his age. We generally take norms into consideration for creatinine but in fact, norms can be slightly higher in the aging population which fall outside the published norms of the laboratory. In other words, his creatinine being at what we might consider a HIGH NORMAL END as far as the laboratory is concerned may be closer to lower end of HIGH spectrum or even perhaps, high mid-range level depending upon his specific parameters which would have to be plugged into an equation that takes his age, gender, etc. into consideration.

The high specific gravity may represent a low grade dehydration going on which could also be reflective of a potential loss of blood. The most common place for your father or anyone to lose blood in this type of situation would be through the GI tract and therefore, I would consider the appropriate rule out testing for blood in the stool, both obviously as well as, not so obviously. I think both an endoscopy and colonoscopy are worth performing.

I know B12 was performed and found quite normal. In fact, as high as it is compared to other things going on I'd say that there was a good chance that he was obtaining B12 from some source....am I right? I did not see FOLATE levels which I think should be done in a case like this.

Has your father's THYROID FUNCTIONING BEEN THOROUGHLY been tested? Have his copper, ZINC, and iron panel studies been done? For thyroid I would do a minimum of Total T4, Free T4, and TSH. I might throw in more than that depending what showed up.

Finally, here's something you may shake your head at and you might even say, "Why didn't the Good Doctor mention this First?" Well, because in my opinion, you never start a show with a SHOWSTOPPER. You end it with SHOWSTOPPER.

And here's the showstopper--- Your father's Vitamin D levels are horribly low....in fact, I surprised the lab even reported a level. But if the level is accurate then, he is at risk for not only having ANEMIA of the type he has...but if not careful he could develop OSTEOMALACIA which is the adult form of rickets. However, in your father's there's something else going on....HIS ANEMIA.....Vitamin D levels which are low or deficient are clearly now associated and accepted to be related to IRON DEFICIENCY and consequently ANEMIA.

Therefore, his Vitamin D absolutely needs immediate correction. If you find him to be iron deficient (which you may or may not since the peripheral smear said he was normochromic) though some of his other parameters do suggest a possible macrocytic anemia though the smear again was curiously negative....but IF YOU FIND HIM IRON DEFICIENT then, DO NOT CORRECT the iron unless you check ZINC levels. iF ZINC levels are low in blood and IRON levels are low then, until and unless you correct the ZINC first the IRON will never correct no matter how many tablets you throw at him daily which are going to make him constipated as heck.

Therefore, correct Vitamin D, check iron studies (full panel), check zinc and then, correct accordingly. Also, get everything else I mentioned.

I hope these answers satisfactorily address your questions. If so, may I ask the favor of a HIGH STAR RATING with some written feedback?

Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

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The query has required a total of 60 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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