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Fatigue and AnemiaFatigue and Anemia
           
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Broaching the subject with Dr.
Apr 17, 2005

Hi Dr. Bob,

I'm a 31yo man, have been HIV+ for several years and have been on HAART for the last 16 months. My regimen includes Atazanavir/r and Truvada along with 1gm daily Valtrex suppressive therapy. I am currently undetectable and have an average cd4 count of ~400 (nadir 204).

For the past several months I've been feeling run down, often finding I am tired and "blah" for lack of a better description. I've considered depression and have discussed seeing a therapist with my doctor but before doing so, I feel inclined to rule out any physiological source(s) of the problem.

I guess my question is how to exactly do that tactfully and when is it appropriate to request certain tests. I consider myself an informed patient who has a great 2 way-street relationship with his doctor, but I don't want to overstep my knowledge and jeopardize that working relationship by seemingly questioning my Dr.'s attention to the matter.

Here's what I am aware of, but which hasn't been explored or explained to me... I consistently have a lower than average RBC - usually about 3.6 or lower, and I consistentaly have a high MCV, usually 110+. Does height and weight value into these numbers? And if so could that be why its never been mentioned to me that these numbers are a little off...I'm 5'7", 135lbs so maybe these numbers are not too clinically signifigant? I'm aware of the numbers because I usually always request a copy of my labs and my Dr. is great about reviewing the other screenings like V.L, Lipids and lymphocyte subset but usually skips over the routine CBC stuff.

I guess my concern is, if my Dr. doesn't think anything of it and passes over it, should I? I've also never had a hormone test and find I am apprehensive to request further investivation of either anemia or hormone screenings because again, I don't want to risk offending my Dr's opinion. Incedentally I routinely have little to no sex drive and am aware this can also indicate depression. Is there a tactful way to broach the subject from your point of view?

I think I know what you'll say... If its such a good relationship with your Dr., there is little chance requesting the tests will offend him. But its been a rough 1st year dealing with everything and its in that light that I am slow to open any new cans of worms... Over the last year I've had an upper endoscopy showing Barrets, serious GERD and some other minor problems, a colonoscopy showing some kind of spirocitosis with still unresolved episodic diarrhea, 3 staph infections (2 of which were MRSA) and a couple episodes of fainting/vasovagal syncopse (it seems I tend to get dizzy, nausea, and fainty after excersize or eating breakfast...) with all in all, probably a dozen trips to the dr. this past year. So part of my apprehension is seeming like the pesky patient, although each visit was certainly warranted I think and each resulted in a very thorough search for the cause. We even explored Celiac at one point because there is a family history of it and although I had slightly elevated antiendomysial and antigliadin levels the biopsy of the small bowel during the upper endoscopy was clean.

So whatcha think? Just ask for the tests, consult a therapist or both? Either way a therapist certainly couldn't hurt!

Kind regards and many thanks for your generous time and thought,

- Sleepy in NYC

Response from Dr. Frascino

Hi Sleepy in NYC,

Let me address your specific questions first.

1. Height and weight do not change the normal-values range for RBC or MCV.

2. You should not pass over abnormal laboratory test results without an explanation of what's going on and knowing whether the abnormality should be further evaluated, treated or merely monitored for the time being.

3. Any physician who gets "offended" if you ask for additional information is not a physician you want to be taking care of you.

4. You don't need a tactful way to broach any topic you're concerned about. I suggest you make a list of all your concerns decreased sex drive, possible depression, fatigue, feeling "blah," etc. and show the list to your HIV specialist.

Regarding your general fatigue, you don't need to ask for specific tests, but rather just advise your HIV specialist that you were reading the information in this expert forum that mentioned common causes for HIV-related fatigue anemia, hormonal imbalances, opportunistic infections, drug side effects/toxicities, depression, etc. and that you were concerned that your fatigue might be related to one or several of these underlying problems. This does not make you a "pesky patient," but rather one who is informed and involved.

Regarding the therapist, yes, I agree: "either way it certainly couldn't hurt!"

Finally, you live in NYC and that is the city that never sleeps, right? So being "sleepy in NYC' should not be an option!

Good luck!

Dr. Bob


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