Saturday, March 26, 2011

Chasing the ESR

We doctors order investigations when we are stumped as to what is wrong with the patient or some times to know the effect of treatment. Added to these, we also order teats to assess fitness levels. This last phenomenon which was exceptional when I began my career has now become routine. So common it is that patients themselves go to the lab and get tests done and then see us. Most often it is a sheer waste of money but occasionally it results in early diagnosis and effective management.

When tests are ordered a common one among them is called the ESR. This stands for erythrocyte sedimentation rate. In simple language it means speed with which the red cells of the blood drop when a column of blood is suspended in a glass tube. This simple screening test is very nonspecific. It tells us that there is something wrong but does not tell us where and what is wrong. A friend of mine once said you sneeze hard couple of times and then measure the ESR and sure it will be up.

Red cells are in large numbers compared to white cells. Their main purpose is to carry oxygen to the tissues and normally they circulate without clumping and when suspended they drop down ever so slowly. In disease conditions the rate of this fall is rapid. The higher the fall more serious is the disease. We accumulate willy nilly, lot of unwanted material in the blood during the course of our lives. These include among others bacterial and viral antigens against which the immune system produces antibodies, particulate materials which freely flow in our blood much in excess of the ability of our innate cleaning systems to scavenge. Some of these stick to the surface of the cells and make them not only heavy but also get them to stick to one another. Thus the cells which were once clean now become dirt laden and heavy and thus fall faster in suspension and the ESR goes up. In acute infections and in malignancies, the phenomenon is marked. And very high ESR levels are always worrying to the attending doctor.

Mrs. Y is a sixty year old woman and a true party animal. When she was with a group of friends, one of them told her that she was looking pale. Everyone looks pale in the artificial light and Mrs. Y did not attach any importance to the remark. Few days later at another party another friend remarked,’ what is the matter with you? You are looking very pale’. Remarks of similar nature on two successive days had her worried.

She took the decision to do the tests. Had she come to me I probably would have examined her and may and more likely not have got any tests done. She went to a well known lab and told at the reception to tests for her looking pale. Most labs are privately owned and clients like Mrs. Y are like a new lode of gold for them. All tests including the scans of her chest and abdomen were done. Here is something interesting. It is not difficult to find some trivial abnormality in most people and as they say half in jest, when you see a tail sticking out of a hole it is sometimes best not to pull it out, you don’t know whether you pull out a cat or leopard. The labs too have a funny way of reporting here. They put an asterisk against the slightest abnormality that is found or a value which even slightly abnormal. In madam Y’s case there were many such asterisks!

Thoroughly frightened, Mrs. Y landed in my clinic with a whole wad of papers. ‘I am very sick’ she said by the way of opening remark. She looked very fit and I said so. ‘No, no, you see these reports and then you will change your opinion’ she said. If she is insisting to be very sick, I felt I should first examine her before going through her papers. She agreed and a ten minutes physical found her in a fit condition with her basic parameters being normal. Now came the time to see her lab reports and scan reports and I could see her becoming visibly anxious. Almost all her reports including the ones marked with an asterisk were normal. There was however one major abnormality. Her ESR was very high. Normally in her age group it should not exceed 20mm of fall in an hour and in her it was 80.

This was indeed a surprise and a cause for worry. Surprise because she was fit and I found nothing which would explain this high ESR. In the absence of infection the only other cause would be occult [hidden cancer]. In women the most likely place is the breast where small tumors could easily missed. I felt her breasts once again. I could find no mass small or big. I found among her papers recent tests to exclude cervical [uterus] and ovarian cancer. Then where is it? Could this be in her blood forming bone marrow? Could this be in her colon? Lungs?

I had no option but to get a whole lot of expensive tests done. May be a better option would be to send her to an institution [an unsettling thought]. My brain was buzzing with all sorts of thoughts and idly I was sheafing through her papers and saw her liver function tests. There was a marginal increase in the globulin fraction of her blood protein. Globulins are very important componets of our immune system and special cells called plasma cells make these.

Here was a possible clue. Without telling her what I was thinking but all the same reassuring her, I ordered a test called serum protein electrophoresis in which the various fractions of blood proteins are studied, a non invasive test. She came back two days later with the report. She had a raised level of one particular fraction of her gamma globulin. I, at last, had the diagnosis. She has monoclonal gammopathy of uncertain cause. This condition is due to excessive production of gamma globulin of one variety by one clone of cells. This excess protein adheres to the surface of the red cells and thus making them heavy and drop faster in suspension. Monoclonal gammopathy is premalignant condition and in time a percentage of them go into a type of cancer called multiple myeloma. No one knows who will develop into this serious condition and who will not. I have had several patients who have carried MGUS [monoclonal gammopathy of uncertain significance] to their grave without suffering Multiple Myeloma.
I painted the picture highlighting the positive aspects. That was ten years ago. She is now seventy. The other day she had come for the usual follow up with her reports. They were all normal and she too will hopefully carry this to her grave without going into cancer when ever her time comes to go.

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