Question About My Father's Abnormal MCV, MCH and RBC

[zent1000]

Hello,

Thank you for your time!

This is a question regarding my father. He is 79 years old. Every three months, he gets routine blood tests done by his Primary Care Physician(PCP). He has been having slightly elevated MCV values (around 98) for 3 years and the last MCV on May 5, 2016 was 102.26.

He saw a Hematologist on May 15, 2016 and a follow-up visit on June 18, 2016 (details of the visit are mentioned after the next paragraph).

Following is a listing of his values for MCV, MCH, RBC and Hemoglobin for the last eight test periods. His values for WBC and Platelets have been normal for all the tests:

MCV - (Reference Range : 80-96) measured with PCP
Dec 2013 : 98.2
March 2014 : 98.6
June 2014 : 98
Feb 2015 : (Less than 100)
Feb 2016 : 101.94
May 5,2016 : 102.26

MCV - (Reference Range : 80-98) measured with Hematologist (different lab)
May 15,2016 : 98.3
June 18, 2016 : 97.6


MCH - (Reference Range : 27-31) measured with PCP
Dec 2013 : 33.7
March 2014 : 33.6
June 2014 : 34.7
Feb 2015 : (Don't have the value : possibly around 34)
Feb 2016 : 34.4
May 5,2016 : 33.58

MCH - measured with Hematologist (different lab)
(Reference Range : 26-34)
May 15, 2016 : (Don't have the value handy but it was less than 34)
June 18, 2016 : 33.8


RBC - (Reference Range : 4.5 to 6.2)
Dec 2013 : 4.42
March 2014 : 4.32
June 2014 : 4.5
Feb 2015 : (Don't have the value : possibly around 4.5)
Feb 2016 : 4.37
May 5, 2016 : 4.65

RBC- measured with Hematologist (different lab)
(Reference Range : 4.5 - 6.5)
May 15, 2016 : (Don't have the value handy but it was slightly more than 4.5)
June 18, 2016 : 4.55

Hemoglobin- (Reference Range : 14-18)
Dec 2013 : 14.9
March 2014 : 14.5
June 2014 : 15.6
Feb 2015 : (Don't have the value but it was normal)
Feb 2016 : 15.05
May 5, 2016 : 15.74

Hemoglobin- measured with Hematologist (different lab)
(Reference Range : 13.5 - 18)
May 15, 2016 : 15.5
June 18, 2016 : 15.4


During my father's last visit with his PCP in Feb 2016, his PCP told him that he has Vitamin B12 deficiency and he was prescribed the following:

OPTINEURON INJECTIONS (Vitamin B1 + B12 + B2 + B3 + B5 and B6)

Alternate Days (for one week)
Twice a week (4 weeks)
Once a month (1 year)


During his first visit to the Hematologist on May 15, 2016, my father was given the following report:
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Patient does not show any abnormal cells. Physical examination is within normal limits.

The patient has a normal CBC. Also, probably a normal MCV after taking Vitamin injections.However Vit B12 deficiency is usually associated with Pancytopenia and a higher MCV.

Therefore we will see the patient and repeat CBC on June 18, 2016. If there is rise in MCV again, then we should rule out Myelodysplastac syndrome (MVS) and also perform a thyroid test and I agree with continuing OPTINEURON injections once a month for six more months

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The thyroid test (T3, T4 and TSH) for my father was done in the second week of June 2016 and was normal. My father followed-up with the Hematalogist on June 18, 2016. After that visit, I spoke to the Hematologist by phone. He told me that even after taking Vitamin B12 injections for some months now, my father's MCV (97.6) and Hemoglobin (15.4) have not responded as well as it should have even though they are within normal limits. Given that my father is 79, the Hematologist told me that my father probably has MDS and advised us to get a bone marrow biopsy in July 2016 for confirmation. We have postponed the biopsy for September 2016 as he had a throat infection for almost a month and also had pain in his knee/hips from which he as not fully recovered yet. He is otherwise fine without any other symptoms.

My father is a vegetarian and has never consumed any alcohol all his life. He has been taking the "Calcium Citrate Malate Vitamin D3 and Folic Acid Tablet Supplement" once per day for over 7 years. His diet is brown rice, wheat bread, fruits, nuts and vegetables. He is 5 ft 3 inches in height and weighs 119 lbs with a waist size of 35 inches.


Questions:
1) Given this background (I realize its limited), what do you think are the chances of my father having MDS?

2)
During his CBC on May 5, 2016, his WBC Differential Count had the following abnormal values:
a) Eosinophils (7.9, Ref Range: 1-6)
b) Basophils (1.1, Ref Range : 0-1)

On his CBC on June 18, the WBC Differential Count had abnormal values for Monocyte (01, Ref Range - 2 to 8 %) and all other values were normal.

Any concerns?


Thank you!!
Zent

[Neil Cuadra]

Zent,

I'm a caregiver, not someone with medical training, but I can share my impression with you. Your father's test results don't strike me as typical of MDS. I can't really second-guess a physician who has all the facts at hand, but I suggest asking him to explain more about what he thinks needs to be done and why.

You didn't mention symptoms your father might be having. Has he experienced any symptoms of blood or bone marrow problems, like fatigue? From your description, he sounds pretty healthy, so congratulations for that.

Some of his counts are just within the normal range or just outside of the normal range, and at 79 I think that's pretty good news. His health also sounds very stable (i.e., not changing at a fast pace), and I hope that means that there is no major cause for concern.

Have the doctors pointed out that B12 deficiency is common for vegetarians (see this article)? That connection seems stronger to me than the connection between B12 and pancytopenia from MDS.

Perhaps you should ask for more of an explanation from the hematologist about why he thinks that the discomfort and expense (and tiny risk) of a bone marrow biopsy is warranted. Also, before considering any invasive medical test, your family and the hematologist should discuss what good the information would do you. If your father was found to have MDS, what would you do about it? If he's age 79 and symptom-free then the risks of treatment might be too high to be worth it.

[zent1000]

Hello Neil,

Thanks a lot for such a detailed reply!!

The following happened to my father in the last two months:

1) In early July, my father had pain in his left hip and knee and lower leg and it made him limp when he walked. The Orthopedist did an X-ray of pelvis and both of his hips and it was normal. The treatment with painkillers worked and the pain went away in about 4 weeks.

2) In July he also had a throat infection/cough/cold and after recovering from that, his Respiratory Specialist, gave him a Penumonia vaccine in early August. Right away after that, the pain returned on his left legs and knee and this time it also was in his left buttocks. The Orthopedist gave more pain killers and it was effective in bringing the pain down but he still had it and he felt it when he walked.

3) We sought another Orthopedist who said the pain is nerve related and is probably sciatica, but we will know next month when a MRI of the spine will be done. In the meantimne, anti-neruopathy pain medication was prescribed to see if the pain would go away.


Are any of the above related to MDS? He's had elevated MVC (98-102) and low RBC between(4.25 -4.55) for almost 2 years and 9 months without any symptoms. He typically would go for morning/evening walks and also use his exercise bike every day. Since his pain from the last two months, he is only able to take smaller walks and has not used his bike.He is able to do his daily activities and has not complained about fatigue.

Thanks for the link of Vitamin B12 and vegetarianism. My father's Vitamin B12 in Dec 2013 was > 2000 and it was subsequently measured in June 2014 and it was 1608 pg/ml (Reference Range : 211-940).It has not been measured after that. When I talked to his PCP in Feb 2016 about why he is been given Vitamin injections when his Vitamin B12 has not been measured recently, he told me that measuring MCV and MCH (along with CBC) is an adequate to check for low Vitamin B12 and there is no need to measure Vitamin B12 directly.

When I asked the Hematologist for his reasons for suspecting MDS (with borderline normal values of RBC and MCV) and ordering a bone marrow test, he mentioned that my father's age of 79 was a risk factor and that other reasons were eliminated. He also said that it would provide a good baseline.

As you said, if my father has MDS and he is symptom free, would treatment make sense without any symptoms? Isn't "wait and watch" the standard treatment strategy?

I would appreciate any comments from you with the above information.

Thanks a lot!!
Zent

[bailie]

I would really doubt MDS without more information. Always good to be aware, but I doubt any connection of the hip pain with MDS.

[zent1000]

Thanks for your reply, bailie!!

What additional information would be needed?

I hope you are feeling good.

Take Care,
Zent

[bailie]

If you and your Dad really want a definitive answer concerning MDS he will need a bone marrow biopsy. I wouldn't think that would be necessary unless the CBC results start deteriorating, but that would satisfy your curiosity about this. I will be having my 18th bone marrow biopsy next month. They are entertaining. I am feeling very well at this time, thank you.

[zent1000]

Hello Bailie,

Thanks again for your answer!

Glad to know that you are doing well!!

Regards,
Zent

[tytd]

hello Zent, I wholeheartedly agree with what Neil has said. It appears that your father's MCV corrected with B12 therapy so why go looking for trouble. Your father could live another 20+ years and even if he had MDS with normal blood counts what would they do about it? They would watch his blood counts(CBC) for any decline and follow him for symptoms or signs of any anemia, low WBC or low platelet count. As far as I know there is no advantage to diagnosing MDS in the early stages unless one is having symptoms from the disease which need support. Granted I do not know all the details of your father's medical history but I would not subject him to a bone marrow unless the information obtained from it would benefit your father or change his treatment. I do not find bone marrow taps entertaining as Baillie does. Good luck to your father and you.

[bailie]

tytd, I agree with you that "entertaining" is probably not the best description. I meant "entertaining" in that the BMBs would get and hold your attention for a few seconds. A BMB would give more clarity to the situation, but again, in this situation a BMB does not seem to be necessary. It does call into question why the hematologist had "reasons for suspecting MDS"? For me, I had two BMBs within a week of being diagnosed with MDS when my platelets were at 48 for my routine CBC.

[zent1000]

Hello Tytd and Bailie,

I cannot thank you enough for your replies!! They are very helpful! We are planning on getting a second opinion from another Hematologist. I will let you know how it goes.

Thanks again!
Zent

[zent1000]

Hello Neil, Tytd and Bailie,

My father saw another Hematologist for a second opinion last week regarding the need for a bone marrow test.

The Hematologist advised that a bone marrow test was not needed at this time as his recent CBC from Oct 4 was borderline/normal. My father was asked to take an injection of (Folic Acid + Vit B12 + Vit B3 + Vit C) once every three months for life as he is a strict vegetarian. He will see the Hematologist again in three months.

The following are his values from latest CBC (done two weeks ago):

RBC : 4.35 (4.5 - 6.5)
MCV : 99.94 (80-96)
MCH : 32.6 (27-31)
Hemoglobin: 14.18 (14 - 18)
WBC: 5680 (4400-11000)
Platelets: 243690 (150000 - 450000)

WBC Differential:
Neutrophillis 43.5 (50-70)
Lymphocites : 40.4 (20-40)
Eisonophillis 6.6 (1-6)
Basophilis 1.2 (0-1)


Compared to his CBC from three months ago, in his latest CBC:
a) Neutrophilis has decreased to 43 from 53
b) Hemoglobin has decreased to 14.18 from 15.4
c) MCV has increased to 99.94 from 97.6
d) RBC has decreased to 4.35 from 4.55.


Any comments regarding the above values and the plan of action from the Hematologist?

I cannot thank you enough for your detailed and informative answers!!

I hope all of you are doing well!

Regards,
Zent

[bailie]

Zent, those numbers do not seem to sound an alarm. I have been tracking my CBCs for three years now. I have CBCs every two weeks and sometimes every three weeks. There are variations that are greater than what your father is showing and for no particular (or ominous) reasons. I would suggest making sure that you set up a chart and look for trends rather than comparing individual CBCs. Hopefully this doesn't amount to anything significant or anything at all. It is great that you are paying close attention. Being educated about his health will be rewarding no matter what happens.

[Neil Cuadra]

Zent,

Those recommendations sound quite appropriate to me. His absolute neutrophil count, which you can compute from his WBC and white count differential, comes out to 2471, which puts him well into the normal (safe) range.

Let's hope the vitamin supplements put a stop to his dropping blood counts.

A high eosinophil count might still be of concern to the hematologist, so that's worth watching. Some treatment centers consider the normal range to be up to 7, not up to 6, but you'd still consider it borderline high.

[zent1000]

Hello Neil and Bailie,

Bailie: Thank you for the advise on setting up a chart and looking for trends and not just individual CBC's. I will do that.

Neil: Thank you for explaining about the absolute neutrophil count. I will certainly ask his Hematologist about his high eosinophil count next time.

If there are any other suggestions/advise, please let me know. Your replies have been invaluable.

I am glad you both are doing well!

Regards,
Zent

[zent1000]

Hello again,

Thanks again to all your replies from July-Oct 2016!! That was very helpful.


My father has been seeing the same Hematologist every three months as described in Message#11. A CBC is done before the visit and he examines my father with the results.

Since Oct 2016, once every three months, he has been taking an injection (2500 micrograms) of Vitamin B12 + Folic acid as prescribed by his Hematologist. So far, he has no symptoms and is doing fine.


My father saw his Hematologist in January 2017 and again today, July 9 (he could not see him April 2017 as he was visiting us in US).

Following is a summary of the abnormal/borderline values from his CBC and other tests (abnormal values are bolded):

RBC (Reference Range : 4.5 - 6.5):
January 2017 : 4.35
July 2017 : 4.24

Hemoglobin (Reference Range : 14-18)
January 2017 : 14.41
July 2017 : 14

MCV (Reference Range : 80-96)
January 2017 : 99.9
July 2017 : 94.55

MCH (Reference Range : 27-31)
January 2017 : 33.11
July 2017 : 33.03

Packed Cell Volume (Reference Range - 42-54)
January 2017 : 43.16
July 2017 : 40.09


Vitamin B12 (Reference Range : 211-940)
July 2017 : 1788

Folic Acid (Reference Range : 2.34-17.56 ng/ml)
July 2017 : > 20.0 ng/ml

Reticulocyte count
July 2017 : 0.5
(No reference range was given in the report, but I found it to be 0.5-1.5 online)


The Hematologist told me that my father is doing well and he should see him again in Oct 2017 with the results of a CBC. My father should continue the Vitamin B12 injections (once every 3 months). No further testing of Vitamin B12 or Folic Acid were needed.

My father is 80 years old and lives alone in India. He is 5 ft 3 inches in height and weighs 119 lbs with a waist size of 35.5 inches. He is socially and physically active (walks and exercise bike).

Questions:
1) A RBC of 4.24 and a Hemoglobin of 14 is the lowest he has ever had. Also, for the first time his MCV is nromal, but his MCH is still elevated. The Reticulocyte count is at 0.5 %, which is the lower limit of normal. The Packed Cell Volume has been low the first time. Your comments?

2) I am unable to understand why my father needs the Vitamin B12 injections if his value is so high at 1788. When I asked the Hematologist about it, he told me this was because my father is a strict vegetarian (for all his life). Does this make sense? Just worried about the downsides of taking too much Vitamin B12.

3) Does my father need an Iron Profile and other tests like Urine FIGLU, Peripheral blood smear, Serum methylmelonic acid and serum homocystiene at this time for further investigation?

Thank you!!
Zent

[Hopeful]

Hi zent1000,

It sounds like your father is living a happy, healthy life

Having counts at the low end of normal is not a concern. The ranges are statistically based. Normal is normal.

A slightly elevated MCH is probably okay, given that everything else is normal.

B12 is usually obtained in the diet through dairy and meat. As a person ages, their ability to absorb B12 from food decreases. So, if your elderly father is a strict vegetarian, it probably make sense to continue the B12 injections. Excess B12 is eliminated through the urine.

I am not a doctor but don't think your father needs extra tests at this time. I can imagine that it is hard to manage his health from so far away, but it sounds like he is doing well!

[zent1000]

Hello Hopeful,

Thank you so much for your informative and kind reply!!

Nice to know that there are no toxicities with excess Vitamin B12.

I hope all is well at your end and that you are doing great!!

Thank you,
Zent

[zent1000]

Hello,

Thanks again for all your answers over the course of a year regarding my father's abnormal values on the CBC report. Your advice has been invaluable!!

Background:
My father is 80 and lives alone in India. His see his primary care physician every 3/6 months. A CBC has been done every time he sees his PCP since 2014. He started seeing a Hematologist in May 2016 as his MCV was elevated during two consecutive CBC's. My father has no symptoms so far and is able to do his daily activities : morning and evening walks, exercise bike and participate in social events. He is 5 ft 3 inches in height and weighs 119 lbs with a waist size of 35.5 inches.

The Hematolgist orders a CBC before each visit. He will be seeing my father tomorrow. A CBC was done yesterday and the following values were abnormal (in bold):

RBC (Reference Range : 4.5 - 6.5):
January 2017 : 4.35
July 2017 : 4.24
October 2017 : 4.00

Hemoglobin (Reference Range : 14-18)
January 2017 : 14.41
July 2017 : 14
October 2017 : 13.4

MCV (Reference Range : 80-96)
January 2017 : 99.9
July 2017 : 94.55
October 2017 : 100.5

MCH (Reference Range : 27-31)
January 2017 : 33.11
July 2017 : 33.03
October 2017 : 33.3

Packed Cell Volume (Reference Range - 42-54)
January 2017 : 43.16
July 2017 : 40.09
October 2017 : 40.2

The rest of his values in his CBC are normal.

His RBC of 4.0 and Hemoglobin of 13.4 are the lowest values in his 4 years of CBC testing. His Hematologist has always told me that even if my father has elevated MCV (97-103) and low RBC (4.25-4.5), he will not order a bone marrow test if my father's Hemoglobin is normal (equal or more than 14). My father's Vitamin B12 and Folic acid were normal when measured in July as mentioned in my previous post #15). His Iron (and Ferritin) were never measured.

Questions:
1) All the reasons for his low Hemoglobin seem to be pointing towards MDS at this time. Your comments?

2) His primary care physician recommended my father ask for a peripheral blood smear with his Hematologist before a bone marrow test is used to confirm MDS. Your comments?

3) Any other advice or questions my father should be asking his Hematologist when he sees him tomorrow? I will update you after the visit.

Thank you again,
Zent

[Hopeful]

Hi zent,

I think it is great that your father is continuing to live a healthy and active lifestyle!

Originally Posted by zent1000

His RBC of 4.0 and Hemoglobin of 13.4 are the lowest values in his 4 years of CBC testing. His Hematologist has always told me that even if my father has elevated MCV (97-103) and low RBC (4.25-4.5), he will not order a bone marrow test if my father's Hemoglobin is normal (equal or more than 14). My father's Vitamin B12 and Folic acid were normal when measured in July as mentioned in my previous post #15). His Iron (and Ferritin) were never measured.

Questions:
1) All the reasons for his low Hemoglobin seem to be pointing towards MDS at this time. Your comments?

You can't make an MDS diagnosis without a BMB.

Even if they did a BMB, and he was diagnosed with MDS, if he has stable counts and no other symptoms, the doctors would probably just watch and wait. That's probably why they don't see the need to do a BMB at the point.

Originally Posted by zent1000

2) His primary care physician recommended my father ask for a peripheral blood smear with his Hematologist before a bone marrow test is used to confirm MDS. Your comments?

This sounds like a good idea. They could look for abnormal shapes in his cells or for the presence of blasts. Depending on what they saw (or didn't see) they could determine whether more testing was needed.

Hope his appointment went well!

[zent1000]

Hello Hopeful,

Thank you again for your insightful reply!!

I spoke with my father's Hematologist after my father's visit on Sunday. He told me that my father's elevated/low values are normal for his age. Since he is doing fine without any symptoms, he will not be doing a peripheral blood smear. If his values drop further and he has worsening symptoms, he will take up the peripheral blood smear and bone marrow test at that time. My father was asked to see him after 6 months. The Hematologist's advice was exactly the same as your answer.

Hope you are doing great!!

Take Care,
Zent