Q: I am 44 years old. I have low haemoglobin and new blood cells are not getting generated. What is the cause and treatment for this?

A:The problem of low blood counts (called pancytopaenia) could be due to several causes including hypoplastic / aplastic anaemia, myelodysplastic syndrome, etc. Aplastic anaemia is a condition in which there is bone-marrow failure, which is characterised by anaemia (low haemoglobin), leukopaenia (low white cell count) and thrombocytopaenia (low platelet count). The bone marrow shows large fat cells with marked reduction in normal blood forming cells. The problems due to this disease relate to infection (due to low white cell count) and bleeding (because of thrombocytopaenia). It is postulated that the disease arises due to a defect in or damage to bone marrow stem cell, the cell which gives rise to all other blood cells. The condition is usually acquired and is presumed to be an autoimmune disease but it may also be secondary to some infections or exposure to drugs and chemicals. Myelodysplastic syndromes (MDS) are a varied group of haematologic disorders arising from a problem in the stem cells. They are characterised by ineffective blood cell production resulting in varying degrees of anaemia, leukopaenia and thrombocytopaenia. The bone marrow and peripheral blood examination shows cells with abnormal features. The postulated causes include prior chemotherapy, exposure to radiation or chemicals, viral infection or genetic predisposition. The condition is considered to be a premalignant one as some forms of MDS may transform to leukaemia. Treatment of aplastic anaemia includes transfusions, treatment of infections and immunosuppressive therapy. The definitive treatment is a bone marrow transplant (BMT) from a HLA-matched sibling but this too has a rejection rate of about 10%. Immunosuppressive therapy is planned if BMT is not possible. This includes the use of steroids, anti-thymocyte globulin (ATG) and cyclosporine (CSA). The response to treatment is slow and may take upto 3 months after initiating therapy. Following this initial response, there is slow improvement. About 50% patients respond by 3 months after ATG administration, and about 75% respond by 6 months. Most patients improve and become transfusion independent, but bone marrow changes may persist. Relapse is common and patients often need continued immune suppression. Several studies have shown that the addition of cytokines (e.g. G-CSF, GM-CSF) may hasten the white cell count recovery. Most treatment of MDS is not standard and is considered experimental and is constantly changing. It is based on the stage and mechanism of the disease that predominates. In the early phases of ineffective haematopoiesis, retinoids and haematopoietic growth factors are indicated. In late stages, with inevitable leukemic transformation, cytotoxic chemotherapy and bone marrow transplantation may be necessary. All of these modes of therapy are undergoing clinical trials to determine the overall benefit to quality of life and survival. Supportive therapy like transfusions of the cells that are low (red cells or platelets), and treatment of infections form the cornerstone. Symptomatic therapy improves quality of life but these measures are temporary and more long-term measures are necessary to stimulate the patient's bone marrow. These include erythropoietin for anaemia and granulocyte colony-stimulating factor for neutropaenia. Transition to acute leukaemia is prevented by administration of the newly approved demethylating agent azacitidine. New promising drugs such as Revimid are completing clinical trials. You need to be investigated: complete blood count with reticulocyte count, peripheral smear examination, a bone marrow examination (both aspiration & trephine biopsy) and if indicated, cytogenetic studies. Please contact the Department of Haematology in any government or private hospital so that you can be examined by a clinical haematologist and appropriately advised.