need help please with (liver) blood test results

[charlie1]

I've been ill for about 3 yrs ... dx with POTS thru TTT'ing and also fit the CFS criteria (although not dx ) I've had blood work done numerous times during that period and am always flagged with LO WBC & Lo neutrophils but never had results showing liver issues. Even six months ago while in the hospital ER, I had a liver panel done which came back in the normal range.

Then, last month I had more bloodwork done which was more inclusive. The results still show the chronic neutropenia but this time I had some liver/kidney enzymes flagged (sorry don't know the units)-

ALT 47 (Hi) ref range: 10-44
AST 38 (Hi) rr 7-31
GGT <10 (Lo) rr 12-43

uric acid 178 (Lo) rr 210-450 (for post-menopausal)

I have not spoken to my doctor about these results b/c she often dismisses my issues such as when I was continuously being flagged LO for DHEA ('undetectable' amounts) and she fought tooth and nail against giving me T4 (finally relented) which has now helped my vitals.(was tachy/brady& hypotensive) So now I get bloodwork done through a naturopath and I will likely go back to him but before doing so, I was hoping someone on PR is knowledgeable in liver/kidney issues.(when I google my bloodwork, Wilsons Disease keeps coming up but there are many symptoms of that disorder that I don't fit and so many of CFS that do fit)

Note- The reason I was in ER 6 mths ago was due to a very sudden and strange episode of short term memory loss lasting 10hrs. The ER attendant ended up dx'ing me with either 1)Global Transient Amnesiac which is supposedly quite rare or 2) O2 deprivation which is very unlikely b/c I was very coherent while talking in the hospital. I was even able to get up and down from the gurney to the CAT scan machine which I have zero memory of. I'm just mentioning this weird episode in case anyone thinks it has any relation to my CFS symptoms or the recent liver enzyme changes.

Thanks!!

 

[halcyon]

Dr. Ramsay published a paper back in the day with some clinical findings in 10 ME patients. A large number of them had elevated liver enzymes as you do. None of them had low GGT though. The findings are listed as GOT (AST), GPT (ALT), and y-GTP (GGT) in the paper.

Note- The reason I was in ER 6 mths ago was due to a very sudden and strange episode of short term memory loss lasting 10hrs. The ER attendant ended up dx'ing me with either 1)Global Transient Amnesiac which is supposedly quite rare or 2) O2 deprivation which is very unlikely b/c I was very coherent while talking in the hospital. I was even able to get up and down from the gurney to the CAT scan machine which I have zero memory of. I'm just mentioning this weird episode in case anyone thinks it has any relation to my CFS symptoms or the recent liver enzyme changes.

Were any of your labs at the ER out of range? Did they mention the possibility of hepatic encephalopathy?

 

[charlie1]

Were any of your labs at the ER out of range? Did they mention the possibility of hepatic encephalopathy?

I didn't have any liver tests out of range and there was no mention of Hepatic E.

There were a few other things that were flagged although they were ok on last blood results.

TSH was @ 9.6 and free thyroxine was 11.8 (the only reason my doc prescribed T4)

Platelets 142 RR 150-450
lymph:1 and lymphs abs# were both low

thanks for posting

 

[halcyon]

Lymphs were low at the hospital but normal now? What was the actual number when they were low?

 

[Eeyore]

The elevations in the transaminases (ALT/AST) are really very small. I've seen people with values >20x yours from taking fluconazole for a few weeks. What you have would generally be considered a very mild transaminase elevation. Most doctors, unless there were other symptoms, would not be alarmed, but might test for hepatitis viruses (b/c) and repeat the tests in a few weeks or so. The low GGT doesn't usually mean there is a problem - elevation would be concerning, but reduced or normal levels are usually not a big issue - or at least not through any mechanism/disease I know. I am guessing that bilirubin and alkaline phosphatase are normal or you would have listed them. Usually GGT is run to help interpret an abnormal alkaline phosphatase result.

Mild elevations in liver enzymes have been found in ME. I have not personally experienced that, but I have read about it from many sources. I think it's a subset that gets it - I'm not sure why. Were your past levels borderline, near the top of the normal range? If so, it's probably just a subtle variation. If not, I think at the very least the test should be repeated to see if there is a trend. If there is an increasing trend that could be concerning.

Uric acid can be low for a number of reasons, and generally the greater concern is elevation (which can lead to gout). It could be that there is increased oxidative stress and peroxynitrite production, which can reduce uric acid - but that's speculation. Dr. Cheney has mentioned that he has observed very low levels of uric acid in his patients. In and of itself, I would not worry about a low uric acid.

Have you changed any medications or supplements, and do you drink at all? What meds do you take regularly? A lot of the time, liver enzymes are elevated from drugs (prescription or otc), supplements, or alcohol.

Do you have any other unusual symptoms that are not part of your normal pattern? Any abnormal fatigue, easy bruising, excessive bleeding that doesn't stop normally, digestive symptoms, itching, yellow color to your skin or the whites of the eyes, or anything else out of the ordinary?

A thorough evaluation would include a repeat testing as well as an antibody test for hep a, b, and c.

What were your albumin and globulin levels, and were they in normal range?

I don't see a lot of evidence for wilson's disease, and docs tend to catch it because they teach it a lot in med school. Do you see orange/yellow colored rings in your eyes? (These are called Kayser-Fleischer rings and are around the outside of the iris near the sclera, which is the white part of the eye.) I doubt it's wilson's disease - it's one of those diseases that is mentioned far more often than it is actually found. If you had a family history of it that would raise more suspicion.

You mentioned abnormal "kidney enzymes" - but you didn't list any measures of kidney function (creatinine or BUN). Are these normal or abnormal?

The platelets are a bit low - not dangerously so in and of itself, but still lowish. That combined with other low blood counts may represent a pattern. This would be less likely tied to the liver and more likely tied to the bone marrow and blood cell production. A serum protein electrophoresis might be justified. It measures both antibodies as well as proteins made by the liver for various purposes.

Did you have any abnormal markers of inflammation (e.g. sed rate or ESR, ferritin, CRP)?

This could be nothing - but I'm trying to give as thorough an answer as I can.

 

[charlie1]

After an absence of POTS for 18 months, I'm now dealing with it again (2-3 wks) and was unable to respond to your posts. Thanks for taking the time to write!
I'll post the results. Sorry but don't know how to make the margins line up nor how to scan and post the actual results.

Lymphs were low at the hospital but normal now? What was the actual number when they were low?

In October 2014 -

NEUT:1 (Auto) .810 (H) RR .4 -.75
Lymph:1 .14 (L) RR .2 -.45
Lymph ABS# .8 (L) RR 1.5 - 3.5

April 2015 -

WBC 3.5 (L) 4. - 11.
Neutrophils (A) 1.2 (L) 2. - 7.5
Basophils 0. 0 .- 0.

Mild elevations in liver enzymes have been found in ME. I have not personally experienced that, but I have read about it from many sources. I think it's a subset that gets it - I'm not sure why. Were your past levels borderline, near the top of the normal range? If so, it's probably just a subtle variation.

October / 2014

Albumin 45 (35 - 590)
Total Bilirubin 14
ALK. PHOS 44
AST (SGOT) 22
ALT (SGPT) 124
Free thyroxine 11.8

Flagged tests were:
ultra s-TSH 9.6 mIU/L (H)
CBC listed in halcyon's insert above

April 2015
UA 178 (L) RR 210-450
T3 Total 1.1 (L) RR 1.2 - 2.8
Flagged liver tests are in original post
Albumin 43
Total biliruben 9
Fibrinogen 2.45 RR 2 - 3.9
Platelets 190 RR 150 - 400 ( improved for some reason since Oct)
TSH .76 (improved with Synthroid)
DHEAS 1.5 RR <6.7 (self supplementing after a decade of non-detectable amts'. Still low?
Vit D (25 hydroxy) 82 RR 75 - 250 (supplementing for yrs with drops. Still low?)
1.24-Dihydroxy Vit D 125 RR 60 - 206 (what's the dif in D tests?)
Globulin was not tested.
By kidney tests I meant UA

Have you changed any medications or supplements, and do you drink at all? What meds do you take regularly? A lot of the time, liver enzymes are elevated from drugs (prescription or otc), supplements, or alcohol.

I don't drink alcohol at all and have not changed meds other than supplementing with T4, DHEA and started 1/4 of the suggested daily dose of KPAX energy. (w caffeine)

Do you have any other unusual symptoms that are not part of your normal pattern? Any abnormal fatigue, easy bruising, excessive bleeding that doesn't stop normally, digestive symptoms, itching, yellow color to your skin or the whites of the eyes, or anything else out of the ordinary?

Daily routine has not changed but I have for some reason experienced a return of POTS ( started @ end of April...not sure why but might be related to the death of my companion dog. I don't think so though...
No abnormal fatigue or other things you asked.

Uric acid can be low for a number of reasons,

I don't see a lot of evidence for wilson's disease,

That's good to know. Searches with my lab # combination kept bringing up Wilsons but I agree I don't think I fit

The platelets are a bit low - not dangerously so in and of itself, but still lowish. That combined with other low blood counts may represent a pattern. This would be less likely tied to the liver and more likely tied to the bone marrow and blood cell production. A serum protein electrophoresis might be justified. It measures both antibodies as well as proteins made by the liver for various purposes.
The platelets were in normal range in April/15 but not so 6 months earlier. In Canada, the doctors rule...I can't even make suggestions with mine but if you think it's appropriate, I will ask for the serum protein electrophoresis.

Did you have any abnormal markers of inflammation (e.g. sed rate or ESR, ferritin, CRP)?

normal (not flagged) -
CRP .2mg/L (no values given)
Ferritin 34 RR 10-291

This could be nothing - but I'm trying to give as thorough an answer as I can.

My doctor is not approachable so I really appreciate you are taking time to look into these details!






.

 

[halcyon]

In October 2014 -

NEUT:1 (Auto) .810 (H) RR .4 -.75
Lymph:1 .14 (L) RR .2 -.45
Lymph ABS# .8 (L) RR 1.5 - 3.5

April 2015 -

WBC 3.5 (L) 4. - 11.
Neutrophils (A) 1.2 (L) 2. - 7.5
Basophils 0. 0 .- 0.

Lymphocytes were normal in April 2015 though? It's possible you could have picked up a viral infection back in October, that can cause a transient drop in lymphocyte count. It's probably unlikely, but as Eeyore mentioned, it may not be a bad idea to have a hepatitis A/B/C virus panel done. Your liver enzymes are so minimally elevated, it could have just been a transient elevation for any number of reasons. I'd have this test done again to see if anything has changed.

 

[Eeyore]

By total bilirubin, do you mean .9 or 9? If 9, what units? Some of your units appear to be different from what I'm used to seeing. e.g. your albumin is 43, whereas I would normally see something around 4.3 (which would be normal). So I'm guessing these tests are normal, also because you didn't flag them.

In general I'm not sure what to make of it all - what does your doctor think?

The only liver test that looks much out of the ordinary is the elevated ALT in 2014. It appears to have come way down from there towards normal, but remains slightly elevated.

The fluctuating pattern of lymphocytes/neutrophils being high and low is a bit odd. I don't know how to interpret that either. These pools do fluctuate, and during acute infection they can be very abnormal, but I'm not sure why they are abnormal in you.

I'm surprised they did not check globulins - I've never seen them measure albumin in serum but not globulins...

You definitely look like you were hypothyroid and needed treatment, but it looks good with the tsh at .75, so that seems good.

Don't worry too much about the basophils, it's not at all uncommon to see a 0 for basophil count.

There are 2 kinds of vitamin D tested for - 25-d3 is the kind you take as a supplement or make from sun. 1,25-d3 is the active form (aka calcitriol) - this is modified in the body by the liver and kidneys. It looks like you have the same amount of each but look at the units - they're not the same! You have much more of the former. Your D levels look fine.

So ultimately, I don't really know what to make of it. I think I'd be continuing to check liver function to make sure it returns to normal range, and get serology for viruses that affect the liver (hep a, b, c). A lymphocyte subpanel might be useful, as well as an SPEP / IFE to check the proteins (immunoglobulins and other things) produced by your body. I think it should be followed up to make sure blood counts are normal and liver function is normal, and also to try to figure out why they were/are abnormal.

Your inflammatory markers look pretty normal, so that's good.

Wish I could help you more - but you do really need to talk to your doc about this and try to figure it out. It would require more testing.

 

[charlie1]

@halcyon , @Eeyore I appreciate your input. I will book an app't with the doctor although she never takes me seriously, even with bloodwork to back up my signs and symptoms. She has no use for CFS but good drs are few and far between here.
My other option is booking with the Naturopath who may prove to me more worthwhile
Best wishes for good health to you both

 

[Eeyore]

If the doc is really bad, get another one. I know lots suck when you have a hard to define illness, but they don't all suck. Mine current PCP is really great. Most of my life, I had another one, who was also very good - a kind, intelligent man who always listened and never dismissed me as crazy (he knew me as a kid before I ever got sick and was my pediatrician - family practice, so he treated both children and adults - he recently retired). In between those 2 I had some really bad experiences, one in particular was nightmarish... I really think that doc should have been banned from practicing medicine. I've also had some excellent and some horrible specialists over the years.

Doctors generally hate to be in a position where they can't understand what is wrong (since no one can yet) and they can't make you feel better. The few good ones are persistent though, and understanding, and at least keep trying, and rule out other conditions. You also need to understand how hard the insurance companies make it for them. They can't practice as they want - they have to see a ton of patients per hour just to keep the lights on. PCP's especially really get screwed by insurance companies who have tried to make them into mindless drones who follow flow charts designed to save the insurance companies money.

So it's not always the doctor's fault - although yes, some doctors are terrible. I know some kids I went to high school with - and even college - who were really not very bright and never understood a tenth of what I did, and who later became doctors. I also know some brilliant doctors, including my college best friend / college roommate who is a specialist at a top academic medical center, and is both brilliant and kind. It's a mix.

 

[charlie1]

If the doc is really bad, get another one

We have a dr. shortage here so it's not easy to find a local dr. especially with my lack of energy and brutal PEM. When I finally did have an 'interview' app't with a new one about 5 yrs ago, first thing he said was " I don't like using drugs unless absolutely necessary so if you go with me, I'll be taking away your sleeping medication". I didn't like him nor the fact I wouldn't be able to have sleep aids.

I think I'll have better luck with the naturopath who has a clinic an hour from me. He does listen and is licensed as an MD so can prescribe blood work. I'm just not happy that he also uses 'muscle testing' for dx a'ing me and is big on homeopathy for treatments.(but has allowed me to use Cortef in the past.) Some people may not have any problem with those therapies...that's just my personal opinion!

 

[charlie1]

Some of your units appear to be different from what I'm used to seeing

Ya, I"m in Canada and our units are different than in USA. When they were listed, I included them. ONe test noted the units, the other testing date did not. Weird.
Doesn't matter....I'll go to the naturopath when I'm able (POTS has returned )
Thank-you!

 

[Rlman]

@charlie1 it might be worthwhile to do a Free T3 test to make sure you are not hypothyroid. Total T3 is apparently not that helpful. Your TSH is much lower which is a good sign, but Ft3 is the active thyroid hormone tht goes into the ceels so having enough of it is the main way to determine that one is no longer hypothyroid. Could low WBC be from mono or not enough nutrition?

 

[charlie1]

Thanks @Riman. I've since seen a functional med dr in London who said I'm not hypothryoid so I'll see about getting the flagged blood results rechecked in a few months.