Leukemia

Leukemia is a blood cancer, specifically of our white blood cells (WBCs) (a.k.a. “leukocytes”), which are the major component of our immune system.  There are different types of WBCs (see link, and diagram below), thus there are different types of Leukemia, which can be either acute or chronic.  But even though the Leukemias are diseases of WBCs, the 2 other types of blood cells are also affected: Red Blood Cells (RBCs) and Platelets.

©Terese WinslowUS Gov’t has certain rights……….nci-media.cancer.gov/

We see above that our primordial original Stem Cell in the bone marrow produces subsets: Myeloid Stem Cells and Lymphoid Stem Cells; both produce types of WBCs.  Most granulocytes are Neutrophils, the main actor of innate immunity, our first line of defense to immediately attack and destroy anything that enters our body like germs, splinters, etc. (see also link WBCs).  Lymphocytes comprise our adaptive immunity, which can remember germs that have previously invaded us, then produce antibody and other long-term protection from future infection. 

The Leukemias can be very complex; there are many different types, and all have additional sub-types.  Here we briefly outline the two main types: Myelogenous and Lymphocytic (see diagram above).  Either can be Acute or Chronic.  So the most common Leukemias are:

  • Acute Myelogenous Leukemia (AML)
  • Acute Lymphocytic Leukemia (ALL)
  • Chronic Myelogenous Leukemia (CML)
  • Chronic Lymphocytic Leukemia (CLL)

Acute Leukemias  (AML and ALL)

Similarities  —  Patients with AML & ALL may have the same symptoms.  These include:

  • Fevers
    • In AML, fever is usually from infection (maybe serious)
    • In ALL, fever may be from the leukemia itself
  • Shortness of breath (from Anemia)
  • Bruising or bleeding (from low Platelets)
  • Fatigue

Diagnosis can usually be suspected from a basic lab test Complete Blood Count (CBC), but must be confirmed by a bone marrow biopsy.  The latter is crucial for determining the subtype of AML or ALL, which guides choice of treatment and suggests the prognosis.  Most patients require intensive chemotherapy initially (“induction”), then ongoing chemotherapy courses.  Some benefit from bone marrow transplants, which might cure the disease but may themselves run a 10% risk of death.

Differences  — 

  • AML is much more aggressive than ALL.  Patients may die soon without treatment
  • Sepsis and Neutropenia (low neutrophils) occur more often in AML.
    • Normal Neutrophil count is 2,000-6,000
    • <1,000 raises concern; <500 is dangerous; <200 critical
  • ALL is much more common <18 years-old, while half of AML patients are >65
    • For both, the older the patient, the less successful treatment
  • Swollen lymph nodes, large liver, swollen spleen suggest ALL

Chronic Leukemias (CML and CLL)

CML and CLL involve different types of WBCs: granulocytes (esp. Neutrophils) and Lymphocytes, respectively (see above diagram, also WBCs).  Still, they have many Similarities:

  • Both tend to occur at older age; half of CML patients are >60 at time of diagnosis, with CLL half are >70.
  • Both tend to be discovered accidently when a CBC blood test is drawn for other reasons, and shows obvious abnormalities:
    • Very high Neutrophil count for CML, very high Lymphocyte count for CLL
  • While many patients have no symptoms at time of diagnosis, some may have weight loss, drenching sweats, fatigue, fevers
  • Both CML and CLL may cause enlargement of liver and/or spleen
  • Both tend to last for years without symptoms before suddenly becoming worse
  • Both can be managed well with treatment, which does not require the intensive type of chemotherapy with many side effects as is given for acute leukemias (AML and ALL).

Differences between CML and CLL:

  • Complete Blood Count (CBC):  With CML, there are very high neutrophil counts; also maybe high eosinophils, basophils, and platelets too.  With CLL, lymphocytes are very high; there may be low platelets (never with CML)
  • CML usually requires a bone marrow biopsy to confirm diagnosis and plan treatment; CLL usually does not
  • CLL often causes many swollen lymph nodes
  • CLL may occasionally cause an exaggerated skin reaction to bee stings or mosquito bites, providing a clue to diagnosis

Once again, in contrast with Acute Leukemias, the treatment for CML and CLL is not toxic, and is often very effective.

Bone Marrow Biopsy

Our bone marrow is what makes our blood cells — red blood cells (RBCs), white blood cells (WBCs) and platelets. Actually it’s “red marrow” which makes them, found in the vertebrae, pelvis, sternum (breastbone), skull, and hips. A bone marrow biopsy obtains a specimen, usually from the pelvis or maybe the sternum. This is sometimes done for patients with Anemia, more commonly in cases of Leukemia, and sometimes for symptoms like fever when diagnosis remains puzzling.

The bone marrow biopsy is not a complicated procedure; it’s done with local anesthesia in the office. Sometimes only bone marrow fluid is needed through a thin needle (“aspiration”), but usually a tiny piece of solid marrow is also obtained through a thick needle. There may be a little pain briefly, more commonly uncomfortable pressure. The entire procedure takes about 30 minutes, except for those few patients who desire IV sedation (rarely necessary).

Palpitations

Defined as sensation of heart pounding or fluttering, oftentimes rapidly but not necessarily

………………..Causes

**  Anxiety (including Panic Attack)  —  most common cause

**  Heart Arrhythmia (abnormal rhythm)

  • Not Serious  —  Common
  • Serious  —  Uncommon
  • See link for explanations

**  Medical Conditions  (uncommon causes)

**  Drugs, Medications, lots of caffeine

xxx

xxx

………………..Diagnostic Work-Up

History

Palpitations only last secondsExtra Heart Beats, never serious, very common
Lasting minutes or moreAnxiety; Arrhythmias (usually not serious)

Sense of about to faint (or actual faint)  →   Arrhythmias (quite possibly serious)

Only at night, in bed  →   Surely Anxiety

Start, & esp. Stop, abruptly  →   Arrhythmia (not serious)

Irregular heart rhythm  →   Arrhythmia (serious or non-serious)

Heart Rate >160 (if able to count pulse)  →  Arrhythmia (serious or not serious)

Occurs with Exercise  →   If completely new, may be an Arrhythmia
            Hearts normally beat fast with exercise, but shouldn’t be a new occurrence
Goes Away with Exercise  →   Anxiety most likely

Certain maneuvers make it go away  →  Arrhythmia (not serious)

  • Bend completely over, looking back between legs; OR
  • Prop self with feet up, shoulders down, against a wall
  • Other maneuvers: Massage pulse in neck / Strain hard
  • What always works: Thrust face into pan of ice water !!!

Family History of unexplained sudden death, or Wolff-Parkinson-White disease  →  could be those same diseases

Exam in Clinic

Only useful if symptoms present at time of exam

Electrocardiogram (EKG)

If Symptoms Present at time of test  →  EKG will make diagnosis if cause is cardiac

No Symptoms present  →  EKG may have clues to likely diagnosis if cardiac cause

Blood Tests:  Rarely useful

Ambulatory EKG (portable; brief showers OK)

  • Done for 1-2 days, or 2-4 weeks (or ongoing — see below)
  • Finds heart Arrhythmias (or not) at moment of symptoms

………………..Diagnostic Work-Up

Palpitations only last seconds  →   Extra Heart Beats

  • This is Normal.  No tests or treatment. No worry

Blood Tests are Positive  →   Diagnose those conditions (see above)

Arrhythmia found  →   See link for the different types

  • If palpitations occurred during time of Arrhythmia, that’s the Diagnosis
  • If no palpitations during time of arrhythmia:
    • Anxiety likely cause of symptoms (unless serious type of Arrythmia)

No Arrhythmia with up to 2-4 week Ambulatory EKG:

  • If palpitations occurred during monitoring  →   Anxiety is likely cause
  • If no palpitations occurred during monitoring, we consider an ongoing monitor (implanted under the skin).  Usually only for patients who:
    • Faint (with or without palpitations); or
    • Feel like they’re about to Faint; or
    • Palpitations infrequent but disabling (e.g. with shortness of breath / chest pain).

………………..About Anxiety

If palpitations do occur during Ambulatory EKG monitoring, but there are no arrhythmias found at that time, then the cause is like Anxiety.  This can be ongoing chronic anxiety, or merely temporary stressors that act subconsciously.  Oftentimes nothing is actually identified, and the palpitations go away with time.

Arrhythmias (Cardiac)

We speak of Heart Rate (how fast it beats), and Heart Rhythm (whether it’s regular or not).  Heart beats begin in the fetus at about 6 weeks of pregnancy.  A group of cells (Sinus Node) at the top-right of the heart has an innate ability to generate electrical impulses.  A circuit runs first through both Atria (upper chambers), to the A-V Node (between Atria & Ventricles), then down to the Ventricles (lower chambers), causing the heart muscle to constrict in a coordinated way, pumping blood.  See below; also Diagram:  The Heart – Anatomy.

The Heart’s Electrical Conduction Circuit




mayoclinic.org

The heart normally beats 60 – 100 times per minute.  Rates >100 are considered “Tachycardia”, rates <60 “Bradycardia” (from Ancient Greek words for “fast” and “slow”).  Normal exercise can raise the heart rate to 140; hearts of professional basketball players may be so well-conditioned that beating only 40 times per minute at rest pumps plenty of blood for the body.

The term “Arrhythmia” can mean either abnormal rate or rhythm. They’re diagnosed by an Electrocardiogram (EKG).  Usually in the office we don’t find the arrhythmia since the patient may not be having symptoms at the time, so we order an “Ambulatory EKG”; a portable patch for 1-2 days, or another kind for 2-4 weeks (showering is possible). If this doesn’t show anything, we consider an indefinite monitor implanted under the skin, usually only for patients who have fainting, spells where they feel about to faint, or infrequent but disabling symptoms like shortness of breath or chest pain.

The following are the most common Arrhythmias which clinicians mention and diagnose.  Asterisks denote what might be considered “diseases”; the more asterisks, the more potentially harmful.

Normal Variations in Rhythm

Sinus Arrythmia  —  Heart speeds up as we breathe in, slows as we breathe out.  It’s 100% normal, happens in 100% of people; not a disease.  Only relevant because when breathing is irregular, the heart rhythm can seem irregular, which it really isn’t.

Extra Beats  —  They can originate in the Atria (“Premature Atrial Contractions” – PACs) or the Ventricles (“Premature Ventricular Contractions” – PVCs).  They can occur very frequently, sometimes even every 2nd or 3rd beat; might feel like a “skip” in the heart.  There’s no danger at all; everyone might have some at some point.  But see “Skipped Beats” under Slow Arrhythmias” below.

Rapid Arrhythmias

The main symptom of all the conditions below is palpitations, perhaps lightheadedness.  If serious, there can be shortness of breath, chest pain, lightheadedness, fainting, rarely death.

Sinus Tachycardia  —  Heart rate speeds up, but not >140 beats/min.  The rhythm is regular (normal).  Can occur from Normal Exercise, Fever, Anxiety, Hyperthyroidism, Anemia, Shock, Low Oxygen, Hypoglycemia, & lots more.  Sometimes palpitations occur as well, especially with Anxiety.

Inappropriate Sinus Tachycardia  —  Simply a Sinus Tachycardia which happens for unexplained reasons.  Most common in young people (20s & 30s), more so in women than men.  No treatment seems useful at this time, it’s hard to know whether there’s a danger to the condition.  It’s newly-recognized, most clinicians won’t have heard of it.

* Paroxysmal Atrial Tachycardia  —  Now called “Supraventricular Tachycardia” (SVT) because the abnormal electrical impulse doesn’t come from the Sinus Node, but from elsewhere in either the Atria or from the A-V Node (but not the Ventricles).  It’s somewhat common, can be quite bothersome, and usually isn’t hard to control.

The Heart Rate is always >160, distinguishing it from other Tachycardias above which we don’t consider “diseases.”  The rhythm is completely regular.  An SVT begins abruptly out of nowhere, can be brief or ongoing, can occur every few days, every 10 years, or anything in between.  It’s only dangerous if it continues unstopped.

Ways to stop it abruptly include massaging the carotid pulse in our neck, or straining hard.  What works better is to turn the heart upside-down by bending over, or lying shoulders down and hips high.  Best of all and guaranteed to work is to thrust ones face into ice water (the “diving reflex”), though I’ve never heard of anybody doing so.

If nothing helps, paramedics & ER’s have medicine to give.  And in rare cases in which that doesn’t work, a controlled shock to the heart is always successful.  Ongoing daily medications may prevent future episodes.  There’s a procedure called ablation, done in cardiology laboratories, that can find the abnormal focus of cells and destroy them for good.

** Atrial Fibrillation (“A. Fib”)  —  This is a completely irregular rhythm, no pattern to it at all.  It’s easily diagnosed by an EKG.  There’s an immediate risk of stress to the heart if the rate is too fast (>100), and a long-term danger of Strokes.  See the link for more information.

** Atrial Flutter  —  Here the rhythm is regular, because the ventricles pump blood consistently.  But the Atria are beating extremely fast, only noticeable by an EKG (when we hear or feel a heartbeat, it’s what the ventricles pump out to the body).  It’s managed similarly to Atrial Fibrillation above.

***  Ventricular Tachycardia (“V. Tach”)  —  As opposed to the arrythmias discussed above, which originate in the Atria, V. Tach starts in the ventricles and is much more dangerous.  If too fast, the heart won’t pump blood adequately.  Treatment is by a electric shock automatically timed to protect the heart (“cardioversion”).  Otherwise, the arrythmia can degenerate into “V. Fib” below, which is fatal.

****  Ventricular Fibrillation (“V. Fib”)  —  Here the ventricles merely wiggle & flutter, unable to pump blood.  This is cardiac arrest, leading to death in 4-8 minutes.  The only treatment is immediate electrical shock (“defibrillation”), terminating the deadly arrhythmia in hopes that the Sinus Node will take over again with a regular rhythm.

**  Asymptomatic Arrhythmias  —  Two in particular may be found among patients who get EKGs for whatever reason.  The danger is that they can spontaneously change into very fast rhythms, including V. Tach which is potentially lethal.

  • Long Q-T Interval  —  A certain EKG measurement called the “QTc”, dangerous is >470 milliseconds for men and >480 msec for women.  Very dangerous is >500.  In some people the Long Q-T Interval is genetic, although they develop problems only rarely.  But certain drugs can make it long.  The most common ones (though not most dangerous) in use today are certain (not most) antibiotics, anti-psychotic medications, and cocaine.
  • Wolff-Parkinson-White Syndrome  —  A hereditary disease, such that anyone with a family member who died suddenly for unknown reasons should be tested for it.  The test is a simple EKG looking for a “delta wave.”  People with this who develop palpitations should get treatment.

Slow Arrhythmias

The main symptoms here are persistent senses of missed heart beats, maybe with lightheadedness.  If serious, they can include shortness of breath, maybe chest pain, and especially fainting.  The latter can lead to death if the heart rate is so slow that it stops (“flat line” on EKG).

**  Bradycardia  —  This simply means “slow heart rate.”  Reasons behind it can include any kind of heart disease (esp. heart attacks), abnormal electrolyte concentrations in the blood (potassium, magnesium, calcium), and especially medications (even certain eye drops for glaucoma).  Note that very-well-conditioned athletes have extremely efficient hearts which pump so much blood that they can beat quite slowly; there’s no danger at all here.

***  Heart Block  —  Third degree heart block prevents the atrial beats from stimulating ventricles, so the latter are left to find their own electrical source to pump blood.  That source (a group of cells somewhere) invariably discharges way too slowly (e.g. <40 times/min.).  Treatment mainly involves a pacemaker.

Myelodysplasia

A rare form of “pre-cancer” of the bone marrow, interfering with its ability to produce blood cells.  Sometimes it produces defective cells, sometimes it just doesn’t produce enough.  This can leave a patient at risk of infection, cause Anemia, or bruising; the danger is if it turns into Leukemia

Myelodysplasia is almost always a disease of the elderly. Patients may have no symptoms at all at first, just an abnormal result on a routine complete blood count (CBC) lab test.  Diagnosis is eventually made by a bone marrow biopsy — aspirating a sample from the pelvic bone.  There are lots of different forms of myelodysplasia, some mild and some severe.  Treatments vary enormously.

Folic Acid Deficiency

Folic acid is a nutrient necessary for making red blood cells (RBCs).  So people without enough develop Anemia.  As described in the link, hemoglobin is low, and RBCs are larger than normal. The latter is measured by a number “MCV”; large means >100, oftentimes around 110.

Fortunately, folic acid deficiency is very rare in the U.S., because since around the year 2000, it’s been added to flours and grains (“fortified”).  The only people still at risk, who should take folic acid supplements, are pregnant women, alcoholics, some elderly persons without access to enough food, and people taking certain uncommon medications.

Women who want to become pregnant should also take folic acid supplements, because studies have shown the vitamin prevents a common type of birth defect.  They should begin three months before they try to conceive.

Chronic Liver Diseases

Various chronic diseases can affect the liver.  We usually look for them if we find persistent elevations in liver function tests (LFTs), sometimes discovered by accident on a lab test done for other reasons.  We’ve all heard of Hepatitis B and Hep C; there’s also Hep D (Hep A and Hep E get better on their own and don’t persist chronically – see Differences Among Hepatitis Viruses). 

But there are other Liver Diseases as well; they’re all pretty rare, except for Fatty Liver at the end. The others are described here mainly FYI, if somebody is getting tests done because their LFTs were high. The blood tests we use to find them are in italics.

Hemochromatosis  Iron-overload, which can be caused by taking too much iron, but is usually a hereditary genetic condition.  It’s most common among Caucasian men >40 and post-menopausal women.  It affects mainly the liver, but later on other organs as well like the pancreas, heart, joints, and pituitary gland.

Once high LFTs are noted, we order blood tests for iron: ferritin, and the transferrin saturation (not just the transferrin, a common mistake).  If these are very high, we look for genetic mutations, or refer the patient to Hematology specialists.  Treatment involves removing a unit of blood every month or so; no problem, since the patient has way too much iron.  Otherwise, the liver will gradually develop cirrhosis with failure.

Wilson’s Disease  Copper overload, also a genetic condition.  It’s very rare, usually begins in childhood or by teenage years, but can occur later as well.  In addition to liver disease, which can flare suddenly and lethally, the disease can cause neurological symptoms (speech and coordination difficulty, tremors, awkward movements, and sometimes psychosis (without liver manifestations).

The initial diagnostic test is a blood test finding a low ceruloplasmin level; other tests include 24-hour urine collection for copper, images, and likely a liver biopsy.  Although rare, Wilson’s is worth looking for, as it’s 100% treatable, and 100% fatal otherwise (from either acute liver failure, or chronic cirrhosis).

Autoimmune Hepatitis (AIH)  —  Like other autoimmune diseases, our immune system mistakenly attacks the body itself, for reasons poorly understood.  Liver damage progresses gradually without symptoms, until Cirrhosis and chronic liver failure develop (acute liver failure can rarely occur).

When we find elevated LFTs, we do blood tests for an elevated Antinuclear Antibody (ANA), IgG level (gamma globulin), maybe an anti-Smooth Muscle antibody.  Hepatologists have many other labs to order.  Eventually, diagnosis is aided by liver biopsy.  Treatment includes a variety of medications to suppress the immune system.

Alpha-1 Antitrypsin Deficiency  —  Also a genetic condition which usually affects the lungs (causing COPD), but certain variants can damage the liver, either in early childhood, or adulthood.  Diagnosis is initially made by finding a low level of blood alpha-1 antitrypsin.  There’s no treatment for the liver disease, except liver transplant once liver failure progresses.  Transplantation of a genetically-unaffected liver can be curative.

Primary Biliary Cirrhosis (PBC)  —  An autoimmune disease that destroys the liver bit by bit, without any symptoms until cirrhosis and liver failure.  We usually suspect it by finding a very high blood level of Alkaline Phosphatase; the ALT and AST may even be normal.  The next step in diagnosis is to order a GGT enzyme to prove we’re dealing with the liver; a normal GGT means the Alkaline Phosphatase came from bone (or pregnancy, or not having been done fasting).

An Ultrasound or other imaging is usually done, not to find PBC, but to rule out cancers of the liver or gallbladder.  The main diagnostic blood test is then an Anti-Mitochondrial Antibody.  If that’s high, some specialists will do a liver biopsy.  But the blood test is probably so accurate that treatment can be given without biopsy.  Treatment is for life, but it works very well.

Primary Sclerosing Cholangitis (PSC)  —  A rare disease of the gallbladder (biliary) ducts, PSC is also an autoimmune disease of unknown cause.  Diagnosis is made by 1) finding an elevated Alkaline Phosphatase on a lab test, often with normal ALT and AST like PBC just above.  2) Again, a high GGT blood test proves the Alkaline Phosphatase is from the liver, not bone.  Ultrasound of the liver is usually normal.

But unlike PBC above, the Anti-Mitochondrial Antibody is negative, leading to special MRI tests of the bile ducts to make the diagnosis. Also, the various treatments don’t work, until liver transplantation becomes necessary once cirrhosis develops.  Since so many patients with PSC also have Ulcerative Colitis, there is a high risk of Colon Cancer, thus frequent colonoscopies are recommended.

Celiac Disease  —  Caused by sensitivity to gluten in foods, and more well-known for causing diarrhea, Celiac Disease can also cause ALT and AST to rise.  It’s a rare cause of elevated LFTs, but we might rule it out by ordering a blood test for tissue-Transglutaminase Enzyme IgA Antibody.

Liver Cancer  —  Many cancers can spread to the liver, causing LFTs to rise.  Ultrasound can find the metastases, and can also find primary liver cancer (one that starts in the liver itself).  The latter usually only occurs in persons with chronic Hepatitis B or C infection, or with Cirrhosis from any liver disease that has advanced.

However, the vast majority of people with elevated LFTs have NONE of the above illnesses.  But on ultrasound, many seem to have abnormal fat deposits, so we simply diagnose them as having “Fatty Liver”.  Most of the time, nothing will happen, although some will develop end-stage cirrhosis.  See the link for fuller explanation.

Multiple Myeloma

Multiple Myeloma (MM) is a type of blood cancer, less common than others (Leukemias and Lymphomas).  It mostly affects people over 65 years-old, very rarely under 50.  It’s a disease of Plasma Cells, a kind of white blood cell lymphocyte that makes antibody.  The abnormal plasma cells multiply rapidly to invade various organs, especially bones and the kidneys.

Most of the time the disease evolves slowly, although occasionally it erupts rapidly as an emergency (the worst being Sepsis, or paralysis from an unstable spinal vertebra).  The most common symptoms are fatigue (perhaps some shortness of breath with exertion), bone pain, and weight loss.  We consider MM if a person has recurrent bacterial pneumonias or sinusitis (we consider HIV then as well).  Sometimes we make come to suspect the diagnosis based on abnormal blood tests ordered for other reasons.

Diagnosis usually proceeds stepwise:

1. Common lab tests, the Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP):

  • Low hemoglobin with normal-sized red blood cells (Anemia of Chronic Disease)
  • Elevated creatinine (Kidney Injury)
  • Elevated Calcium
  • Elevated Globulin
  • If ordered, the ESR and CRP may be extremely high

2.  We then order both Serum and Urine Protein Electrophoresis (SPEP and UPEP), looking for any abnormal protein (a “monoclonal spike” among normal proteins).

3.  If all of the above are positive, the traditional exam is a “Skeletal Survey,” meaning Plain X-Rays of many bones in the body (skull, entire spine, ribs, pelvis, long bones in arms & legs [humerus & femur]).  We look for “lytic” spots: punched-out areas of bone loss.  Nowadays, clinicians find it easier to order whole-body CT scans.

4.  We then biopsy any abnormal findings.  If the Skeletal Survey is normal, we may refer to a Hematologist for a bone marrow biopsy.

Treatment of MM is very complex.  New chemotherapy is constantly being developed, new studies appear all the time.  The only cure would be an “allogenic” stem cell (bone marrow) transplant from a genetically-matched compatible donor.  Another option, not as curative but which can add years of life, is an “autologous” transplant of one’s own bone marrow.  The problem with bone marrow transplants, however, is the procedure itself are risky.  Any excellent website explaining differences is the American Cancer Society’s cancer.org, search for “Types of Stem Cell Transplants”.

Polycythemia Vera

Polycythemia Vera (PV) is an uncommon condition in which the body makes too many Red Blood Cells (RBCs).  Most cases occur over 50-years-old, and are discovered accidentally when a Complete Blood Count (CBC) is drawn for other reasons.  Some patients with PV have vague symptoms like fatigue.  Others may have unusual symptoms, like unbearably intense itching after a hot shower, burning hands or feet along with color changes in the skin there, or weird visual changes like flashing lights or floaters.

The danger is that the too many RBCs cause stagnant blood flow, which in the brain can cause Strokes.  Diagnosis begins with a CBC.  We may suspect PV if the hemoglobin is >16.5 gm and hematocrit >50% on two or more tests, and no other conditions exist that would cause such numbers.  We’d especially suspect it if WBC’s & Platelets are also very high, if the patient has any of the above symptoms, or if we find an enlarged spleen.  In such cases, we refer to a Hematologist for special testing.

The main dangers of Polycythemia are Strokes on the one hand, and the eventual development of Leukemia or other blood diseases.  In the past, most patients died by 2 years after diagnosis, but today’s treatments help them live much longer.

Colonizing Bacteria

There’s a difference between bacteria that colonize a part of the body, and those that infect it.  For example, we have lots of bacteria living harmlessly in our noses, mouths, and throats.  But if they work their way into tissue like roots of teeth, the ear, the lungs, etc., then they cause infection.  Our bowel is full of the bacteria E. coli, but if it gets into the bladder, we have a Urinary Tract Infection (UTI).

This can occasionally confuse us.  For example, up to 10% of people may be colonized with Streptococcus pyogenes, the bacteria that causes Strep Throat.  So if a patient has a sore throat caused by a virus, we do a test, and find Strep, we wind up with a wrong diagnosis and give unnecessary treatment.  In this case, it’s impossible to know; but if a person gets “Strep Throat” repeatedly, we might test for the bacteria at a time they don’t have symptoms to see if it’s there.

Older people may have their bladders colonized with E. coli, without it causing disease.  Here we can tell by looking for white blood cells in the urine (Urinalysis).  White blood cells occur with infection, so if there aren’t any, we say they have “aysmptomatic bacteruria,” and not a UTI.

Diagnosis can be tricky.