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Early Coronavirus Detection Through Blood Tests

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Published on June 30, 2020

Are there early signs of COVID-19 in your regular bloodwork? Clinical laboratory scientist Dr. Susan Leclair explains what red flags to look for in your CBC test results that may be an indication of infection. 

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Transcript | Early Coronavirus Detection Through Blood Tests

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrea Hutton:

Hello. I'm Andrea Hutton, a patient advocate with Patient Power. And I'm here today with Dr. Susan Leclair, who is the Chancellor Professor Emerita from the University of Massachusetts. She's a clinical laboratory scientist specializing in hematology and she's been with us on Patient Power before. Welcome Dr. Leclair.

Dr. Leclair:

Thanks to be back.

Andrea Hutton:

Dr. Leclair, I understand that you have sort of developed a series of laboratory testing results that you think might indicate to ER docs or other providers when a patient might have COVID-19 or be at risk for having severe reactions to the virus aside from the COVID test itself. That there are lab tests, blood tests that come up during other kinds of exams that might have some indication that might be helpful to doctors and patients as they're trying to figure out what's going on with someone. Can you explain kind of what the tests are, why you think this would be helpful and how patients might be able to have these conversations if they're able to with their doctor.

Dr. Leclair:

This originally started - and I'll just go off onto a slight tangent here. This originally started when obviously the pandemic became the only thing on the news. And I started to hear from colleagues, I started to read in preprints, Those are not yet ready for publication materials and from peer reviewed articles, there were certain things that I noticed that everybody talked about. They talked about this test always being increased or that test always being decreased. And so I started a kind of a cheat sheet over time to make them up, to see if there was a pattern that people could have. And it turns out that there are certain tests that give you information that suggests this could be the coronavirus or maybe not. This could be something that's going to become more important for you or maybe not. These are not black and white things they're like all the other laboratory results that we deal with, they're suggestions, they're indications of what's going on.

But they will come back from the laboratory probably within the same day that that specimen is collected, which is a big difference between both the traditional PCR and even some of the more rapid COVID testings that are out there. They're just a little bit of a heads up, a little bit of a thing to talk about when you speak to your physicians and over time with Patient Power, I have learned that there are several things that you all have in common. The first and most important is you get your laboratory tests done and then you sit by the computer until you can get those answers as fast as possible. And then you have something to deal with. Did they change? Are they different? What's going on? And it frames your discussions with your physicians. Well this is kind of the same thing. Something to frame a discussion.

Andrea Hutton:

First of all, how many tests are we talking about? And what are they?

Dr. Leclair:

Wait a minute. I'm counting eight, nine, 10, 11, 12, about 20. We're not going to get to all of them, but I can group them together.

Andrea Hutton:

Are these 20 tests that an ER physician or another physician is going to do automatically? Or are these things that, are there ones that everyone's going to do that come up right away that might be a red flag?

Dr. Leclair:

There is, I suppose, in a sense, tier one and tier two testing in this. Pretty much every ER physician on the planet, the minute somebody walks in is going to do a CBC and everybody again on Patient Power knows that that's going to be the case. What we notice within the CBC, and that's a bunch of smaller tests linked together, is that the white count is almost always decreased. Now for the CLL folks, you're going to have to figure out what that means in terms of the numbers that you normally carry. If you've got a chronic lymphocytic leukemia and your white count is always, oh I don't know, 40,000, then you're going to have to see does this decrease by maybe 10 or 15,000? It's a significant decrease in what you usually have as a white cell count.

For the other folks, particularly those who are on chemotherapy of any type, there's always a mess with these numbers. You would want to see again, your white count maybe runs around a four or a five, because it is suppressed. And now all of a sudden you're coming in with one that's a two or a 2.5. You're looking for a significant, in that sense, enough for you to say, "That's not what I normally do." That's kind of what you want. Actually, that's what you don't want to see, but that's what you should be looking for.

Andrea Hutton:

And is that something that would be an unusual flag for a doc? Or is an ER doc always going to notice if someone's white count is super low?

Dr. Leclair:

They'll probably notice the super low, but in the case of the CLL patients, if they drop say into the almost, but not quite normal range, they might not be thinking of a viral disorder at all, because usually increased white cell counts come more often than not with bacterial infections. Yes, there are others that will do it. But when a physician's in an emergency situation, they're going to look and say, "Oh, high white count. It's got to be bacteria." And that would be wrong. The other thing you would be looking for other are the amounts of the different cells. There are five different white cells that normally are found in your bloodstream. Increases in granulocytes, neutrophils, they go by two different names, usually again means more of a bacterial problem. Where an increase in lymphocytes tends to be more of a viral problem, except in this instance is many more of those neutrophils present than lymphocytes.

Andrea Hutton:

That's specific to this coronavirus, there are more neutrophils than lymphocytes. And is this something that again, I'm sort of questioning is my ER physician or my doctor necessarily going to know this? Is this part of their normal thing to check? Or is this something that it's slowly becoming known, but maybe isn't the standard of people to notice these kinds of things yet?

Dr. Leclair:

It is slowly becoming known because it takes time for those peer reviewed articles to come out. It's also problematic and occasionally I will blame the laboratory and this is one of those circumstances. There were two ways to report out the presence of these white cells. The original one that's been around for oh, about a 125 years now, is to do it in a percentage. The problem with percentage is in order for me to have an increase in one percentage in one cell, I must because it's a percentage, have a decrease in another. This relative increase is what most physicians look at. It's up at the top of the CBC. It's the first thing they're going to look at. The absolute numbers that interpret those percentages, that's further down in the list. And if I'm an ER physician, I might not read to the bottom of the page because I've got this white count and I'm going to increase this and off I go. Without thinking about, is this relative neutrophilia that I've got because it's a percentage, real or not?

For the past, I don't know, however many years now I've been doing this, I've been yelling at patients, "Don't look at the percentage, look at the absolutes." Now I'm going to tell you, in this instance, look at the percentages, because again, in an emergency situation or in a situation in which you might want some decisions to occur in a surprisingly rapid, you thought you were going in for your monthly test and this happened, then you might want to speak the same language as your physician. And most of them still use the percentage differential, the percentage neutrophil count.

Andrea Hutton:

As a cancer patient, if I'm having my regular blood work drawn and I have, because we do before we have treatments, there's always blood work that's being done. Before, I may be, because we first started saying, "Okay, in an emergency room situation," but now just thinking about it before a routine chemotherapy appointment or something like that, where they're doing my tests, then these are flags that might show up before I'm feeling sick.

Dr. Leclair:

That's right.

Andrea Hutton:

Do these tests also indicate whether somebody might be at risk for having more severe complications from coronavirus? Or is it just that these are early indicators that this patient might have the virus and is asymptomatic currently?

Dr. Leclair:

The numbers are early indicators. As you progress through this disorder, these cells become, they become shabby. Neutrophils, small moment of tears here. Neutrophils will give up their lives for you. That's what they do. And so they start off of a certain size and a certain shape and they have tons of granules, that was the original name was granulocytes. Because all of these granules are ways to phagocytize and kill and degrade organisms, bacterial or viral. And they will do that until there's no more granules left. Until there's no more material for them to kill or neutralize this organism. And as that happens, they develop certain morphologic, they're not numbers, they're the way they look, qualitative changes.

Hopefully tomorrow after the hairdresser's, I will look pretty good, but right now I look a little bit less than put together. And that's how those cells look, they look like they've got holes in them and not granules anymore. The nucleus isn't sharp and crisp the way you normally see it. It looks like it's gotten beaten up and it's out of shape and the colors are changing. These are things that laboratory people will report. In the CBC usually at the bottom of the form, there'll be a place for comments. And you will see comments about lack of granulation or abnormal nucleus or something. Some places will do this, not many will say something about the cells having burst and ruptured because they were trying to give you their all. And so those morphologic changes that occur, suggest a bigger fight, a harder fight, a more dangerous fight than you would ordinarily want to see in your peripheral blood. It's not just the numbers, we also want to now look at the comments. See what the comments say about the quality of the cells.

Andrea Hutton:

If I see that in my report, assuming I can access the comments in my report.

Dr. Leclair:

Oh well, yeah.

Andrea Hutton:

And if I can't, but now that I'm an informed patient, I can say, "Were there any comments in my report that talked about the state or the degradation of the cells, et cetera." And what would be the action after that?

Dr. Leclair:

There should be some discussion about which of these tests am I going to do? Am I going to do the rapid one, or am I going to do the PCR one? Or are we going to do both? Two for the price of one at this point. And how should I live my life until we get those answers? Should I go into more of a protective cocoon than one that I'm already in? Should I get things ready just in case so that I have the list of all of my medications ready to go and all the rest of that stuff? Because it is possible, more possible than somebody who doesn't have any of these things, that there might be an issue here. Now, maybe you're just going to stay home and quarantine for 14 days, but that of course also means you're going to have to find out about food. There are those kinds of things you might start thinking about.

One of the other ones is a platelet count. Now, pretty much everybody who's been on any kind of hematologic therapy knows that platelet counts are usually something we think of as important and have a tendency to bounce around a lot. Again, how much more decreased are they than usual? If you always been around a 100,000 for your platelets and now all of a sudden you're at 60 or 50, it's not going to be a big drop, but it's going to be a drop. There might later on in life also be discussions about the quality of them as well. Because they're participating in your defense. But in the beginning, they're just going to drop down and you don't want them to go very low because one of the standard aspects, I almost wanted to call it a complication and it's not, is that you become more hyper clotting through, this is part of the problem with this virus. Is it causes more clotting, inappropriate clotting.

And if you already start out with a very small number of platelets and platelets are used in your clotting process, what happens when you run out? Or you get to a point where you really don't have enough of them? You would like to keep, you would like that number to be as close to what you normally do as reasonable and you don't want it to drop down into the fifties or lower. Again, that would be something just to look at. My platelets are okay in the fact that they've always been in the seventies. Okay, then nothing has changed. My platelets were always pretty good or on the high side of low and now they've dropped down by a half. No, I want to talk about that. What happened?

Andrea Hutton:

It sounds like all of your indicators are important for patients to understand what their baseline is or if it's not an actual straight line, but what their normal variance is and then be attuned to any kind of change. And that any kind of change in these kinds of specific ways could indicate a more complicated recovery or that you're on the precipice of a decline in some way or just that it requires more attention and watch. I'm hopeful that what you're sharing with us is also being shared with clinicians and that this is something that is happening in doctor's offices and hospitals, is that happening?

Dr. Leclair:

I think it is. I did send copies of this to a fair number of people that I think of as at least colleagues and maybe even some friends who are physicians under the title of, I think you have enough to memorize right now or to be aware of, why don't you just stick this up in an office or on a wall somewhere in the emergency room or the clinic and say, "That's one less thing for me to remember. I can just look at this form and go, yes, yes, no, no, no, no. I like this better. No, no." And be able to then say, "Oh okay, I've got that one. Then it's easy in my head."

Andrea Hutton:

Well, thank you so much for sharing this information with patients and also with doctors. I know that part of a patient's journey is understanding their own test results at a more grant granular level. And I think what you're saying really underscores the importance of knowing what our bodies are normally doing and what our baselines are and then paying attention to any kind of variation within that. And being our own advocates to have a conversation with our physicians if something seems off in those test results and always read to the bottom. I always tell people, especially same thing for like the side effect box, read down to the bottom because those side effects that are listed for a reason. This is kind of the same thing.

Dr. Leclair:

Yes, it is. And it's important because at the worst case scenario, you walk in and you say to your physician, "So I have an increase in this and a decrease in this and a decrease. What do you think? Do you think it could be COVID?" The worst case scenario is for that physician to go, "I'll have to check that out and get back to you." And that's maybe not the thing that you want to hear, but at least you'll be getting a follow up from that physician. If you don't say anything, or you say, "I noticed a few of these were," and then all of a sudden they're going to say, "Oh, well, no, you don't have to worry about that."

Well, now you're saying, "I am worried about that. Explain these to me." And hopefully what will happen, because these have gone around to, I did give them to folks who are in teaching hospitals who said they made photocopies of it and shunted them around to various people. That there are more and more as we speak, looking at this thing and going, "Oh okay that makes sense, actually, with what's going on physiologically with my patient, I either don't have to rote memory it anymore because it makes sense. Or I have this piece of paper with me and I'll just look it up." And that means everybody wins, which is kind of what I'm hoping is going to happen.

Andrea Hutton:

Absolutely. Well, thank you again for helping us navigate through some very complicated information about this virus and our own test results. Thank you, Dr. Susan Leclair. I'm Andrea Hutton for Patient Power. And remember, knowledge is the very best medicine of all.

Dr. Leclair:

Thank you for inviting me.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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