Treat the patient, not the lab test result

I SOMETIMES have to remind patients, that the most important thing is how they feel in general, as a whole person, rather than an abnormal blood test result in isolation.

Occasionally I get a referral in clinic to see a patient with an increased white blood cell (WBC) count. WBCs are those cells that form a part of the immune system and assist in fighting infections. When the WBC count is increased, the first concern, is that a patient may have an infection. Understandably, an infection, especially a bacterial one, is something that we would want to eradicate quickly.

However, infection is not the only cause of an increased WBC count. Sometimes the WBCs are increased because of some general stress to the body; we call that a stress response. Also, some medications, particularly steroids, can cause the WBC count to be increased. Another feared cause is some sort of malignancy, especially one of the blood cancers.

BUT SOMETIMES, there is no real cause for a slightly elevated WBC. In the average laboratory, the normal WBC count ranges from about 4 to 11. However, as I often tell patients, that normal range is the average for most people. There will sometimes be persons who fall outside this “normal” range, with counts that are a bit lower, or a bit higher. But in the absence of actual symptoms of disease, there is usually nothing to worry about. Severely abnormal WBC counts are a different story, and definitely warrant further investigation, even in someone who feels perfectly fine.

AN EXAMPLE of a case that I felt needed no further investigation, is a middle aged diabetic woman who was sent to me because her WBC count was fluctuating between 12 and 15. She was treated for a bone infection involving one of her toes about 6 months ago. The ulcer on her toe had completely healed and there was no more redness. However, with the mildly increased WBC count, there was concern that the infection in her toe came back, and was the cause of her elevated WBCs. She was started on antibiotics and sent to me.

When I saw this patient and her pristine looking toe, and the fact that she generally seemed completely ok, with no fever, malaise, or symptoms or signs of anything new going on, I told her to stop the antibiotics. I said to her, “we are going to treat you, the patient, and not your abnormal test result.” A mildly elevated WBC count in an otherwise normal patient, can be monitored over time and the patient reassured.

ANOTHER EXAMPLE was a woman with a WBC of about 15. She was actually totally fine until she went for her routine gynecology check up. Her urine came back “abnormal” and she was told that she had a urinary tract infection (UTI). Now, the patient had absolutely no symptoms of a UTI, and as outlined in this post, antibiotics are generally not needed for abnormal looking urine in the absence of symptoms.

Anyway, this patient got antibiotics for her “UTI” and from there her problems started. She started having cramps in her legs, and chills, and wondered if she was having fever. She continued to feel unwell and ended up going to the emergency room (ER). There her WBC was high so it was felt the “UTI” was still there and she was given another antibiotic. But she continued to feel unwell, went back to the ER, and was admitted.

The patient still had an increased WBC count, though by this time, the urine culture was negative thus it was felt that she no longer had the “UTI.” But, alas, there must be an infection somewhere! So she went on the have a “million dollar workup.” The more tests were done, the more they came back normal. The more she heard she had normal results, the more unwell she felt. The vicious cycle continued every day for over a week.

The WBC count had been as high as 20 but now hovered at about 15. I got asked to see her and admittedly had the benefit of all the negative test results to review. Examining her there was nothing to indicate infection anywhere. I felt that she could probably go home and be monitored. The team agreed. It so happened, that at the time of discharge, the WBC suddenly dropped down within the normal range.

Retrospectively, it turned out to be much ado about nothing for this patient. I think she experienced side effects from the antibiotics she was given for the “UTI.” These side effects cause stress to her body, and in response, her WBCs went up.

She told me that every time she did a new test, she kept hoping that it would be the one to tell her why her WBCs were high. It was as if she was waiting with baited breath for an answer, and that perpetuated the stress. Not to mention, laying around in a hospital bed for over a week is enough to make anyone lack energy.

I SHARED these two examples to illustrate the point that sometimes we as doctors have to step back, and take a good look at the patient in front of us, rather than focus on the blood test results on the computer.

Obviously, there are situations where a patient feels completely fine, but has a life threatening lab abnormality, such as a very high potsssium level, or very low sodium, for example. These cases will be acted upon emergently because by the time symptoms arise, it may be too late to save the patient.

IN CONCLUSION, the examples I gave are common scenarios I come across as an infectious diseases specialist. I shared them to remind you, the readers, that sometimes we should focus on how we feel in our bodies, rather than on what a result on paper says. If you feel fine (except for worry!), and everything else looks ok apart from that one abnormal test result, that is not life threatening, it is often not wrong to hold off on taking a medication and monitoring what happens with time.

I like the idea of intermittent monitoring, because sometimes, a medical condition may evolve over a period, declaring itself with time. Otherwise, the sole lab abnormality reverts to normal, which is most often the outcome.

HAVE YOU ever been worried sick over an abnormal lab result? Even though you felt totally fine before finding out about it? Please share in the comments below!