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Care During Chemotherapy and Beyond

Low Blood Counts



Includes: Low red blood cell count, Low white blood cell count, Low platelet count, Infection-prevention guidelines for immunosuppressed patients.

Other words you may hear:

  • Myelosuppression - a decrease in the production of blood cells, which may lead to low blood count.
  • Pancytopenia - a lowering of all three types of blood cells; red blood cells, platelets, and white blood cells, which may lead to low red blood cell count, low blood platlet count, and/or low white blood cell count.
  • Anemia - a decrease in the number of red blood cells (RBC), which may lead to low red blood count.
  • Thrombocytopenia - a decrease in the number of platelets (PLT), which may lead to low blood platlet count.
  • Leukopenia - a decrease in the total number of white blood cells (WBC), which may lead to low white blood cell count.
  • Neutropenia - a decrease in the number of neutrophils, one type of white blood cell, which may lead to low white blood cell count.
  • Granulocytopenia - a decrease in the number of granulocytes, the group of white blood cells that include neutrophils, basophils and eosinophils, which may lead to low white blood cell count.

What are low blood counts?

Many of the chemotherapy drugs temporarily stop cells from dividing, especially the cells that divide quickly.  Blood cells; red blood cells, white blood cells and platelets are made by the bone marrow.  These blood cells divide quickly.  Chemotherapy may lead to low blood counts, causing the possibility of a variety of symptoms.  The symptoms depend on the type of low blood cell count.

LOW RED BLOOD CELL COUNT (Anemia, low hemoglobin, low hematocrit)

Red blood cells carry oxygen and nutrients throughout the body.  A complete blood count (CBC) is a blood test used to check your blood count.  The RBC, hemoglobin, and hematocrit are tests to see if you have low red blood count.  

Normal Adult Values Male Female
RBC 4.5 - 6.0 M/ul 4.2 - 5.4 M/ul
Hemoglobin (HgB) 14 - 18 g/dL 12 - 16 g/dL
Hematocrit (Hct) 40 - 52% 37 - 47%
Note:  Normal values will vary from laboratory to laboratory.

When you have low red blood cell count you may feel:

  • Fatigued
  • Weak
  • Short of breath
  • Increase in your heart rate
  • Dizzy or lightheaded when you change positions quickly

If you suffer from low red blood cell count, you may experience:

  • Headaches
  • Chest Pain
  • Pale skin

Things you can do to help manage your low red blood count:

  • Rest between activities.
  • Plan ahead and save your energy for the most important activities.
  • Avoid or stop activities that make you short of breath or make your heart beat faster.
  • Ask others for help.
  • Eat a diet with adequate protein and vitamins.
  • Drink plenty of non-caffeinated and non-alcoholic fluids.

When to call your doctor or health care provider about low blood counts:

  • Severe weakness.
  • You feel dizzy or lightheaded.
  • Your heart is beating faster.
  • You feel short of breath or are having difficulty breathing.
  • Call immediately if you are having chest pain.

Your doctor or health care provider may prescribe or suggest to treat your low red blood count:

  • Epoetin alfa (PROCRIT®).
  • Darbepoetin (Aranesp®).
  • Iron supplement.
  • Multivitamin.
  • A diet high in protein.
  • A red blood cell transfusion.

LOW WHITE BLOOD CELL COUNT (low WBC)

Leukopenia - A decrease in the total number of white blood cells, which may lead to low white blood cell count.
Neutropenia - A decrease in the number of neutrophils, which may lead to low white blood count.
Granulocytopenia -  Some people use this term in place of Neutropenia.

White blood cells fight infection.  The white blood count (WBC) is part of a complete blood count (CBC) that is used to check your blood counts.  There are several types of white blood cells.  A differential test will show more detail about your white blood cell count:

Normal Adult Values
White Blood Cell Total 4-11 k/ul
     Lymphocytes 22-44%
     Monocytes 0-7%
     Granulocytes  
          Neutrophils 40-70%
          Eosinophils 0-4%
          Basophils 0-1%
Note:  Normal values will vary from laboratory to laboratory.


When you have a low white blood cell count there is an increased risk of infection.  The level of risk depends on several factors:

  • How low your white blood count falls
  • How long your white blood count is low
  • Which type of low white blood cell count you have 
  • Other medications you may be taking such as steroids or immunosuppressive agents (cyclosporin).

One measure of risk is the absolute neutrophil count (ANC).  The ANC is calculated by multiplying the total white blood count by the percent of neutrophils (also called segmented neutrophils, segs, polymorphoneucleated cells or PMNs, polys)

Total white blood count  x % neutrophils* = ANC

* Neutrophils may be reported as segs & bands (a band is slightly less mature form of a seg).  In this case add the % of segs to the % of bands then multiply by the total number of white blood cells. 

(% segs + % bands) x Total white blood count = ANC 

Risk of Infection based on Absolute Neutrophil Count (ANC)
ANC greater than 1500 No increased risk of infection
ANC 1000-1500 Slight increase in risk of infection
ANC 500-1000 Moderate increase in risk of infection
ANC 100-500 High risk of infection
ANC less than 100 Extremely high risk of infection


Things you can do to reduce your risk of infection when you have low white blood count:

  • Frequent hand washing of both you and those coming in contact with you.
  • Avoid contact with anyone who is sick.  If someone in the home is sick limit contact and consult your doctor or nurse.
  • Do not have dental work done while your white blood cell count is low.

When your white blood cell count is low you may NOT have the usual signs and symptoms when developing an infection such as:

  • Redness
  • Swelling
  • Pus formation  (at the site of an injury or incision)
  • Cough
  • Sputum
  • Nasal drainage (from a sinus or respiratory infection) 

Therefore, it is extremely important to be alert to any change in how you feel and report and discuss what you are feeling with your doctor or nurse.

When to call your doctor or health care provider about low blood count:

Call immediately if you have: 

  • A temperature greater than or equal to 100.5°F.  (Check with your health care provider, you may be instructed to call for temperature greater than or equal to 100°F)
  • Chills (rigors) or shakes
  • Sudden onset of a new unexplained pain.

Call within 24 hours if you experience the following:

  • Sore throat
  • Sores in your mouth
  • A white coating in your mouth, especially your tongue
  • Signs of a bladder infection
    • Burning with urination
    • Blood in your urine
    • Needing to urinate more frequently than normal
    • Having to urinate in hurry and possibly not making it to the bathroom in time. 

Your doctor or health care provider may prescribe or suggest to treat low white blood cell count:

  • The following medications may be given after each cycle of chemotherapy to prevent your white blood cells from falling too low and/or for too long.
    • Filgrastim (Neupogen®)
    • Peg - Filgrastim (Neulasta®)
    • Sargramostim (Leukine®)
  • The following are antimicrobial medications that may be prescribed to prevent specific infections that are common when the immune system is suppressed by chemotherapy and/or other medications.
    • Sulfamethoxazole - trimethoprim
    • Acycolovir
    • Flucanozole
    • Intraconazole
  • Other antiobiotics or antimicrobials are used to treat specific infections as needed.

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LOW BLOOD PLATELET COUNT (Thrombocytopenia, low PLT) 

Platelets help blood to clot.  They are found in the blood flowing through the blood vessels.  Platelets also line the inside of the blood vessel.  When low blood platelet count is present, this layer thins and tiny drops of blood can leak through the spaces made when this layer thins, causing red dots on the skin called petechiae (pa-TEE-kee-eye). 

Normal Platelet Count 150,000 - 400,000 cells/mm3
Note:  Normal values will vary from laboratory to laboratory.

When low blood platelet count present a person is at an increased risk of bleeding.

Risk of Bleeding is based on the Platelet Count
100,000 - 149,000 cells/mm3 Little to no risk of bleeding
50,000 - 99,000 cells/mm3 Increased risk of bleeding with injury
20,000 - 49,000 cells/mm3 Risk of bleeding increased without injury
10,000 - 19,000 cells/mm3 Risk of bleeding greatly increased
Less than 10,000 Spontaneous bleeding likely

When you suffer from low blood platlet count you may notice:

  • Increased bruising
  • Petechiae (red dots on your skin described above)
  • Bleeding from nose, gums, rectum

Call your doctor immediately if you have sudden, severe unexplained pain.

Things you may do to decrease your risk of bleeding if you have low blood platlet count:

  • Do not take medications that interfere with the platelets being able to form a clot.
    • Aspirin
    • Ibuprofen (Advil®, Motrin®)
    • Naproxen (Aleeve®)
  • If you are not sure about taking any medication, check with your doctor, nurse or pharmacist.
  • Do not use rectal suppositories or take your temperature rectally.
  • Use caution or avoid flossing your teeth.
  • Use a very soft bristle toothbrush or oral swabs as recommended by your doctor or health care provider.
  • If your gums bleed, rinse with cold water.  If bleeding does not stop call your doctor or health care provider.
  • Avoid activities that increase your risk of bleeding when you have low blood platlet count:
    • Contact sports
    • Amusement park rides that involve fast or quick motion.
    • Strenuous exercise.
    • Avoid or limit the use of sharp objects such as knives, razors.
    • Hold pressure on any cut or scrape for at least 5 minutes. 

When to call your doctor or health care provider about low blood count:

  • Bleeding that will not stop after 5 minutes of pressure.
  • Bleeding that occurs spontaneously (by itself), without injury.
  • New or unexplained pain
  • Fall or experience trauma or injury
  • Feel dizzy or lightheaded
  • Have difficulty seeing or double vision

Your doctor or health care provider may prescribe or suggest for low blood platlet counts:

  • Oprelvekin (Neumega®)
  • A platelet transfusion 

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COMMON SENSE INFECTION-PREVENTION FOR EVERY-DAY LIFE FOR IMMUNOSUPPRESSED PATIENTS AND POST-TRANSPLANT PATIENTS 

These precautions are intended for people with absolute neutrophil count (ANC) less than 500 or for people with prolonged neutropenia.  Consult your physician to discuss precautions specific to your low blood count.

The basic holistic tenets of good hygiene, a well-balanced nutritious diet, stress avoidance, sufficient sleep and moderate exercise are more important than ever for a person with llow white blood cell count and a recovering immune system.  Any activity or practice that enhances the body's basic immune structure or does not stress it will help to prevent endogenous (from within yourself) and exogenous (from outside yourself) infections.

Food selection and preparation

  • Do not eat raw or undercooked eggs, or foods that may contain raw egg.  (some hollandaise sauce, Caesar or other salad dressings and mayonnaise.)
  • Do not eat raw or undercooked poultry, meat, or seafood or unpasteurized dairy products.  (Well-cooked means no pink in the middle or with the internal temperature higher than 165F.)
  • Produce should be thoroughly washed before being eaten.  (See Travel section if leaving the U.S.A)
  • Take care to avoid cross contamination of food.  For example, uncooked meats should not come into contact with other foods.  Hands, cutting boards, counters, and knives and other utensils should be washed thoroughly after contact with uncooked foods.
  • Do not share food, eating or drinking utensils with others if you have low white blood cell count.  A dishwasher is not necessary as long as soap, friction, a hot rinse and a clean towel are used for utensils.  Avoid using "communal" dips with vegetables, crackers etc. where others redip items that have been in their mouths or do not wash their hands. 

Immunizations:Influenza vaccine is recommended annually before the influenza season.

  • Pneumococcal vaccine is recommended for all patients. 
  • All adults who have not had chickenpox should discuss the value of Varicella vaccine with their physician.
  • Babies and children in the household should receive inactivated (injection form) of polio vaccine rather than the oral (live virus) vaccine.  Consult the child's pediatrician. 

Prophylaxis (prevention):

  • Depending on the level of immunosuppression some patients should receive medication to prevent PCP (Pneumocystis carinii) pneumonia.
  • If a person with low blood count is exposed to another person with an infectious disease (sexual contact or intimate contact) consult the physician as soon as possible for possible preventative medication.   Some of the diseases of concern are pulmonary tuberculosis, sexually transmitted diseases (e.g. gonorrhea, syphilis, chlamydia), or hepatitis A, B, or C.
  • Many patients also receive medications such as a acyclovir or ganciclovir for prevention of certain viral infections.  Some patients receive medications to prevent fungal infections.  These preventative programs vary depending on the type of transplant received as well as other factors.

Infants, babies and children:

  • Contact with human feces (diaper changing) can potentially expose people to a variety of infections.  It is preferable that another family member be the principal diaper changer when you suffer from low blood count.  But if it becomes necessary, wash hands thoroughly after changing diapers, and avoid caring for babies with diarrhea.  Wear gloves if at all possible. 
  • Avoid contact (kissing, hugging) children who have been exposed to childhood diseases or "who do not feel well."  This is especially applicable for children exposed to chickenpox and have not been vaccinated, or had the disease.  If the immunosuppressed person has not had chickenpox, discuss the possibility of vaccination with your physician.
  • Most of the time however, hugging and kissing your family members and close friends is fine!

Pets:

  • Wash hands after handling pets (especially before eating) if you have low white blood count.  Avoid contact with pets feces, especially if the animal has diarrhea.  Seek veterinary care for animals with diarrheal illness and a fecal sample from such animals should be examined for Cryptosporidium, Salmonella, and Campylobacter.
  • Those who elect to acquire a cat should adopt or purchase one that is over one year of age.  People who are severely immunosuppressed are at an unusually high risk of developing a disease caused by Bartonella species (cat-scratch fever).  Unfortunately routine testing of a cat for the organism is not beneficial and declawing is not generally advised.  To avoid infection with Toxoplasma gondii that may be found in cat feces, have the litter box changed daily, preferably by a nonimmunosuppressed, nonpregnant person; alternatively the person should wash their hands thoroughly after changing the litter box.  People need not be advised to part with their cats or have them tested for toxoplasmosis (encephalitis).
  • Avoid contact with reptiles such as snakes, lizards, and turtles because of the risk of salmonellosis. 
  • Avoid cleaning fish tanks because of possible exposure to Mycobacterium marinum.
  • Birds, especially if imported from other countries, should receive a clean bill of health from a veterinarian.
  • Special care should be taken in a farm, barnyard, or other outdoor environment.  Persons with low blood counts should avoid situations where hay or other fodder is being "pitched."  Inhalation of environmental fungal spores, particularly from moist, dark areas (e.g. compost piles) should be avoided at all costs especially if the white blood count is low or if extra immunosuppressive medication is being administered. 

Gardening/Farming:

  • Routine flower and vegetable gardening is permissible using some precautions for your low white blood count.  Strictly avoid an environment where mulch, hay, topsoil, etc. is being "pitched" or spread.  Inhalation of environmental spores, particularly from moist, dark areas (e.g. compost piles) should be completely avoided.  (Aspergillus spores that are abundant in these areas and if they are inhaled can cause serious disease in the immunosuppressed person.)
  • Gloves should be worn for contact with dirt and soil and good hand washing after the gloves are removed is essential.  If walking through areas where soil, dust and fungal spores may be found in the air cannot be avoided, wearing a mask is preferred.

Camping/Fishing/Swimming:

  • Immunosuppressed people should not drink water directly from lakes or rivers.  If necessary boil water for 1 full minute to avoid Cryptosporidium and other waterborne organisms.  Use of a submicron personal-use water filter may reduce the risk.  Be advised that swimming can cause accidental ingestion of water and may increase the possibility of acquiring Cryptosporidium, even in public swimming pools.  Avoid situations that would permit the inhalation of environmental spores, particularly from moist, dark areas (e.g. compost piles, rotting leaves etc.).  Again these are areas where Aspergillus spores are abundant and if they are inhaled can cause serious disease in the Immunosuppressed person.
  • Hot tubs, saunas, and other communal baths are generally not recommended.  Bacteria and other microorganisms thrive in warm water.  However, if the immunosuppressed person is aware that the tub is adequately disinfected regularly as recommended then there is no contraindication their use. 
  • Spelunking or cave exploration should not be done during periods of low white blood cell count because of the risks associated with bat guano exposure.

Travel:

  • The risk of food and waterborne infections among immunosuppressed persons is magnified during travel to developing countries.  Those who elect to travel should avoid foods and beverages that may be contaminated, particular raw fruits and vegetables, raw or undercooked seafood or meat, tap water, ice made with tap water, unpasteurized milk and dairy products, and items sold by street vendors.  Foods and beverages that are generally safe for those with low white blood cell count include steaming-hot foods, fruits that are peeled by the traveler, bottled (especially carbonated) beverages, hot coffee and tea, beer, wine, and water brought to a rolling boil for 1 minute.  Treatment of water with iodine or chlorine may not be as effective as boiling but can be used when boiling is not practical.
  • Prophylactic (preventive) antimicrobial agents are not generally recommended for travelers, but your doctor may advise carrying certain medications with you.  The effectiveness of these agents depends upon local antimicrobial-resistance patterns, which are seldom known.  Check with your physician for decisions based upon your low blood counts and the region and duration of travel.
  • Check with your doctor or health care provider well before the planned travel date is advised. 

Housekeeping:

  • Regular dusting, sweeping, windows, floor washing, bathrooms are okay to clean if you feel well.  However, avoid cleaning or dusting areas where a lot of sediment can be aerosolized.  Use common sense and avoid cleaning areas that have been untouched for years.  (Aspergillus lives in dust, especially in old building).  Wear gloves for washing heavily soiled areas and commodes. 

Construction/Renovation:

  • In general, it is wise to avoid construction/renovation areas if you  have low white blood count because of the possibility of aerosolized yeast or mold in the dust.  If it is unavoidable an immunosuppressed  person can reduce the risk by wearing a particulate respirator (mask - NIOSH approved N95 respirator) and fitting it tightly to his face.

Public Places (Restaurants, Shopping, Sporting Events, Church):

  • On the whole, it is fine to go to public places.  Avoid, if possible tightly crowded places during the height of the cold/flu season.  Generally a mask will not offer much protection from viruses, so it is better to avoid close contact with people coughing and sneezing.  Hand washing is always advisable, especially after frequent handshaking.

Masks:

  • There are a few occasions when a mask (NIOSH approved N95 particulate respirator) is appropriate, such as if a person suffering from low white blood cell count must go into a construction/renovation area, or when exposed to heavy "puffs" of dust or debris.  Additionally if required to have close contact with another (children, adults, etc.) who is ill with a respiratory infection (common cold, flu, childhood illness) a mask will reduce the risk of acquiring the infection. 


These guidelines for persons with low white blood count are based on the following:
USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus:  A Summary.  MMWR, Vol 44, No. RR-8-1995.

Note:  We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website about low blood count and other medical conditions is meant to be helpful and educational, but is not a substitute for medical advice.