[Michellevalea]

Post liver treatment 20 month old - confusing labs - help?

by Michellevalea on Wed Dec 18, 2013 7:47 pm

My son is a 20 month old post liver transplant child. His blood work has been off for a while, showing ANC dropping off and rising quickly, and iron deficiency anemia. any one know what's going on here? The stars are what were unusual/out of range. His IgG is currently 2387 (normal range is 453-916).. Here is more of his recent blood work.

I'm very concerned and was looking for someone who could point us in a direction. He is treated at Boston children's, but they've admitted at the moment they have no idea what to think. No one has a diagnosis, and I came here after doing a little looking around of my own (I'm no doctor by any means, but the high IgG is mostly what did it)..

**Hypochromasia, RBC (2+)
Microcytosis, RBC (1+)
Anisocytosis, RBC (1+)
Absolute Eosinophil Count: 0.2 K cells/uL (0.03–0.29)
**Absolute Lymphocyte Count: 7.37 K cells/uL (2.32–5.49)
**Absolute Neutrophil Count: 0.2 K cells/uL (2.47–6.41)
RBC Morphology (Yes)
**Neutrophil/Band: 2% (23–69)
**Lymphocyte: 73% (15–67)
**Monocyte: 18% (4–10)
Eosinophil: 2% (1–5)
**Atypical Lymphocyte: 5% (0–4)
**Morphology Comment: (Yes)
Poikilocytosis, RBC (1+)
Ovalocytes, RBC (1+)
**Target Cells, RBC (1+)
**Tear Drop Cells, RBC (Rare)
Helmet Cells, RBC (Rare to 1+)
Stomatocytes, RBC (Rare to 1+)
Acanthocytes, RBC (Rare to 1+)

And I know these basically mean he's anemic.. But not sure if they're at all helpful with the above results.
WBC: 10.1 K cells/uL (7.73–13.12)
**Hemoglobin: 8.3 g/dL (10.4–12.5)
** Hematocrit: 27.7% (30.5–36.4)
**Platelet: 512 K cells/uL (223–461)
**MPV: 9.1 fL (7.3–8.1)
RBC: 3.82 M cells/uL (3.81–4.74)
**MCV: 72.5 fL (75.6–83.1)
**MCH: 21.8 pg (26–29)
**MCHC: 30.1 g/dL (33.6–35.2)
**RDW: 20% (13.6–15.5)
HDW: 2.98 g/dL (2.76–3.36)

Also
**Sodium: 134 mmol/L (135–148)
**Potassium: 5.12 mmol/L (3.2–4.5)
Chloride: 107 mmol/L (99–111)
**CO2: 15 mmol/L (22–30)
Anion Gap: 12 mmol/L (7–14)
Glucose: Level 77 mg/dL (61–199)
**BUN: 36 mg/dL (5–18)
Creatinine: 0.3 mg/dL (0.2–0.4)

Anyone have experience or opinions about these labs? Thanks in advance..

[Multibilly]

Re: Post liver treatment 20 month old - confusing labs - help?

by Multibilly on Wed Dec 18, 2013 10:42 pm

I'm not a doc by any stretch of the imagination, but some great docs monitor this site.

I'm only responding to your comment about a high IgG. Liver disease can cause high IgG. I assume since your child had a liver transplant that all the usual liver function tests and/or biopsy have already been run?

http://www.mayoclinic.com/health/liver-function-tests/MY00093

http://www.mayoclinic.com/health/liver-function-tests/MY00093/DSECTION=why-its-done

[Michellevalea]

Re: Post liver treatment 20 month old - confusing labs - help?

by Michellevalea on Thu Dec 19, 2013 2:10 am

He has had three liver biopsies and biweekly liver function tests since transplant. His liver disease was a congenital type, dealing with the formation, not because of an immune issue, therefore, it shouldn't effect his new liver, and he no longer has the liver disease he had. Liver biopsy looked great, liver functions tend to run a little high, but not concerning. And IgG's this high aren't typical of liver disease either from my understanding. His immunologist is very concerned about the IgG levels, and his transplant team at BCH says they've never seen IgG's this high either... Usually only low in transplant children.

[Multibilly]

Re: Post liver treatment 20 month old - confusing labs - help?

by Multibilly on Thu Dec 19, 2013 8:32 am

I'm so sorry to hear that you are dealing with this situation with such a young child. Again, some great docs do monitor this site and chime in every few days regarding these posts. Perhaps one of them will have some ideas of what to pursue.

[Anonymous]

Re: Post liver treatment 20 month old - confusing labs - help?

by Anonymous on Thu Dec 19, 2013 1:19 pm

IGG is an immune cell, have they searched diligently to rule out infection? A family friend had a liver transplant and the transplant iself worked great but she has not been able to get rid of infection, but is doing much better now (if was to do with her abdominal cavity/incision area). She is much older an has different health issues, but infection can strike anyone so I would make sure to rule that out.

[Michellevalea]

Re: Post liver treatment 20 month old - confusing labs - help?

by Michellevalea on Thu Dec 19, 2013 4:42 pm

He's has two scopes, and a lot of blood work to rule out infections, and different viruses.. All have been negative.. On December 31 he will be one year post treatment. He is also monitored closely for infection due to him being born without a spleen among other structural issues.. Just wasn't sure if coming here I'd find someone who had dealt with this issue or had seen the same thing! Thank you to you both!

[Dr. Adam Cohen]

Re: Post liver treatment 20 month old - confusing labs - help?

by Dr. Adam Cohen on Fri Dec 20, 2013 12:30 am

A high IgG level can be a non-specific reaction to some other process going on in the body (such as infection, inflammation, autoimmune disease, chronic liver disease, viruses), or it can be a reflection of an underlying cancer of the marrow or lymph nodes (such as multiple myeloma or lymphoma). In the first case the IgG is polyclonal (i.e. there are multiple different IgG's being overproduced by the reacting immune system, all adding up to cause the high level), and in the latter the IgG is monoclonal (ie. there is one specific IgG being made in high amounts by the malignant cells). The way to differentiate this is by doing blood tests called serum protein electrophoresis (SPEP) and serum immunofixation. If these show that the IgG is monoclonal, I would be concerned about a possible post-transplant lymphoma (since myeloma is unheard of in this age group), and the work-up would usually include a bone marrow biopsy and CT or PET scans to look for this. I suspect however that this is going to be polyclonal/reactive, in which case there just needs to be a continued search by the transplant team for one of the potential underlying causes listed above. Unfortunately, since I'm not a pediatrician or transplant surgeon I can't really comment on what additional work-up should be done at this point, though Boston Children's is one of the best in the country so I'm sure they are exploring all options. Sorry I can't be more helpful. I wish you and your son the best of luck.

[Michellevalea]

Re: Post liver treatment 20 month old - confusing labs - help?

by Michellevalea on Fri Dec 20, 2013 12:48 am

Thank you very much! This was actually very helpful!