Recent blood work - need help

[Tohobo]

Hi all,

Last year I had some blood work done that showed very mild anemia for a few months. My doctor ran an absolute retic count which came back as 15 (ref range 25 - 80). She ran it again in the future, with the same results. Due to my red blood cells floating around low-normal, she decided it was likely just normal for me.

Recently at my annual checkup, she reran the tests. My results are below. She told me that my reticulocytes are almost none existant. Even though my HB and HC are not that low, they are still lower than normal and my retic should be higher to make up for it. She has referred me urgently to a Hematologist and requested I am seen before June. The only symptom I have is I have been really tired the last few months and I've lost 10lbs over last two months without trying. I am a slender male as it is, so the 10lbs should of been hard to lose. I am not too worried, but just wondered if everyone thinks my GP is right is requesting a BMB. She feels it is needed, but I don't know. Any help understanding this is appreciated! Thanks!!

Hemoglobin: 120 (range 140 - 170) LOW
Hematocrit: 0.34 (range 0.39 - 0.49) LOW
RBC: 3.9 (range 4.4 - 5.7) LOW
MCV: 86 (range 80 - 97)
MCH: 30 (range 27 - 32)
MCHC: 349 (range 320 - 360)
RDW: 12.7 (range 11.5 - 15.5)
Platelets: 177 (range 150 - 400)
MPV: 8.6 (range 7.4 - 11.3)

WBC: 3.8 (range 4.2 - 11.0) LOW
ABS Neutrophils: 2.24 (range 1.8 - 7.0)
ABS Lymphocytes: 0.9 (range 1.0 - 3.0) LOW
ABS Monocytes: 0.34 (range 0.0 - 0.80)
ABS Eosinophils: 0.23 (range 0.0 - 0.40)
ABS Basophils: 0.04 (range 0.0 - 0.20)
ABS Reticulocytes: 1 (range 25 - 80) VERY LOW

INR: 1.2 (range 0.8 - 1.2)

B12: 174 (Deficiency < 148, Insufficiency 148 - 220, Normal > 220) LOWISH
Ferritin: 54 (range 20 - 200)

Bilirubin Total: 4 (range < 23)
Albumin: 44 (range 34 - 48)
Alkaline Phos: 41 (range 40 - 130)
ALT: 28 (range < 46)
LDH: 160 (range 110 - 215)

[Marlene]

Did they start you on B12 shot or recommend you start taking B12. They should also check your MMA, Homocysteine, folate, iron, B6, copper and zinc? Your B12 is very low and you need B12 to make blood. It should be at least 500.

If you are not seeing the hematologist til June, then I would start supplementing with B12. There are good oral B12, methly form of B12, products that can help.

[tytd]

Hello Tohobo,
I certainly agree with what Marlene has advised. You could have B12, folate or iron deficiency. Also you don't mention your creatinine as significant kidney disease can give you anemia. You may have a mixed anemia with more than one cause. Even though your ferritin is within normal range you could have some iron deficiency as well as B12 deficiency. You don't mention your age. Have you had any stomach surgery or anything that would cause malabsorption of nutrients. Or could you be losing blood in the stool? Your weight loss is concerning. If you are in an older age group, have you had any colon cancer screening? Do you drink alcohol or are you on any medications which might be causing the problem? I would ask your GP to run a MMA (methylmalonic acid) level to check into the borderline B12 level, a creatinine if you haven't had it, folate level and do some home stool hemoccult checks to make sure you are not losing blood in the stool. Perhaps these could be done before your appointment with the hematologist or maybe they have already been done by your GP. If these don't shed light on the problem then it sounds like a BMB would be reasonable. Of course your GP is in a much better position to advise you than us. Good Luck tytd

[Tohobo]

Thanks for responding so fast!!! I appreciate this forum so much as I didn't know who to talk to. I will try to answer all the questions below.

To start off, I have Colitis, but it has been completely under control for the last two years without an diarrhea or problems recently.

I have been taking B12, Vitamin D and Multivitamins daily for the last couple years.

I have had my Iron checked, it was in the middle of normal. As you saw, my ferritin was normal to. My folate, B6 and copper were also all normal. My zinc was at the very bottom of low-normal. I have never had MMA or Homocysteine tested, but I will ask next time I see my GP.

I have had a Occult Fecal test and it showed no blood in my stool. I am not on any meds that would cause this issue and I do not drink alcohol at all. I have also had my kidneys checked out and they are good.

I am 25 years old and male, so I am very young. I went from 5'9" about 150 to 135lbs over a couple months.

I just have a question of my own. My GP thinks while my B12 is on the low side, she doesn't think it is low enough to have caused my retic to be almost 0. She feels regardless of if my HB, HCT and RBC being only mildly low, that a bone marrow test should be done just to be on the safe side with such a low retic count. I would really appreciate an honest answer as I'm not a panic type person, I just want to go into my appt with a realistic approach.

Am I possibly dealing with a bone marrow suppression problem hear or is it very unlikely? I know you aren't doctors, just wondering if you've seen others like my case.

Thanks a million!!!

[Marlene]

I still feel you need to address the B12. How much are you taking and what form? Have you been checked for gluten sensitivities? Too much of the bad bacteria in your gut will get in the way also. H-pyloria is another culprit. It really appears you have some absorption issues and are not getting what you need out of your food. Having colitis is a red flag. IMO, multi-vitamins don't provide enough. Regarding Vitamin D....did you have your levels checked.

You are young and should have a higher B12. There is no reason for you or your doctor not to try to get the B12 up to an optimal range. It will not hurt you and in fact, if there is something more serious going on, it's best to have an optimal level.

Low zinc can impact WBC.

Here's a link on B12.

http://www.aafp.org/afp/2003/0301/p979.html

The other thing you doctor can check is your EPO levels. This is made by your kidneys and is a red cell growth factor. It stimulates the growth of red cell.

[mausmish]

I'm no expert but I think you should get a bone marrow biopsy instead of trying to guess whether there's something going on there. I've had six of them over the past 16 months with just local anaesthesia. I was terrified of the procedure the first time but it wasn't bad for me at all on any of them.

[Tohobo]

Thank you all for the help.

I agree my B12 should be looked after regardless if something else underlying is wrong. My doctor feels I am not in the B12 shot category yet, so she said to continue with my B12 tablets. I have a feeling the hematologist will just dismiss me and say that I should have B12 shots and I don't need to see a hematologist about this. Before I go into my appointment, does anybody have experience or knowledge to know what this possibly could be other than a B12 issue? I just want to make sure I know what to ask the doctor to make sure I rule out everything. I prefer not to google about this as I know 99% of the info wont apply to me. Any info is appreciated, thanks! :-)

[Marlene]

Please know this is just my opinion and not meant to replace the advice of your doc. It’s intended to give you some things to consider when working with your doctor.


Here’s my list of things to consider. They usually start with some standard tests to rule out the easy/most likely possibilities. It’s usually a process of elimination.

Nutritional:
Re-check B12, folate, iron, B6, D, copper and zinc. You can ask the doc to include an MMA & homocycteine to further assess B12 status, but at this point it’s pretty apparent you have a B12 issue. Regarding iron, I would request they run more than ferritin to get a good assessment of iron. Ask for Transferrin, TIBC, UIBC and serum iron in addition to FE.

Heavy Metals:
You may want to ask them to check for lead and other heavy metals.

Other diseases and reasons:
Anemia can be a result of other chronic diseases like auto-immune diseases; digestive disorder like....crohns, h.pylori bacteria, celiac disease, malabsorption issues; Kidney and liver problems; blood loss; heavy use of antacids; metabolic issues where your body does not convert nutrients to a usable form....like B12, most supplement require the liver to convert it to a usable form; medications.

Bone marrow disorders:
SAA, MDS, blood caners, PNH

Genetic:
There are genetic reasons for anemia that should be tested for if they suspect a bone marrow disorder.

Hormones:
Low testosterone levels.


Finally, at this point, if were me and my appointment with the hematologist isn’t till June, I would address the B12 with at least 5000 mcg of oral Methycolbalamin B12. I would take it by itself 1/2 hour before eating or 2 hours after eating. And I would start off with 1000 mcg for the first two days, up it to 2000 mcg for two more days, etc, until I got to 5000 mcg. Once I got to 5000 mcg, I would add in a good B complex. The B vitamins need each other to be effective. I would also consider a good probiotic to help balance the gut environment. Or, push B12 shots with my doc. There’s no good reason not to. If you do increase your B12, let them know you are supplementing because it will show up as an increase in B12 serum reading and can throw them off. What’s good is that you have a baseline of your B12 now and will be able to assess effectiveness of supplementation. I would also consider stopping all supplements about one week before the appointment.

I know I sound like a broken record but B12 is vital to blood production, mental health, central and peripheral nervous system, and most importantly, to healthy RNA/DNA production and gene expression. It can take a while to restore B12 and then to correct the problems created by it.

Hope this helps,
Marlene

[mausmish]

I think you underestimate the hematologist. It has been my experience that they are more diligent in isolating and treating the cause than in simply treating the symptom. After all, blood is their specialty and they are interested in its finer details.

[Greg H]

Wow!

Marlene's got a great list going there. I second all of that, and also Karen's advice not to underestimate the hematologist. I have three: my local heme, a university-based doc, and a researcher at NIH. They are all extremely interested in understanding what's going on with their patients.

And all three, I have found, really value a patient that is interested in understanding the details of their disease.

For a local heme, those kinds of patients might be 20 or 30% of the total. The rest just want the doc to fix them. So the docs can get a little lulled into complacency. But, if you express a strong interest in understanding the details of what's going on, I bet you'll get a great response. If not, you should find another doc.

Take care!

Greg

[Tohobo]

Wow, thanks for the great detail Marlene!

Thanks to everyone for there advice, it all has helped.

I actually just spoke to my GP. She said the Hematologist wants me to repeat all the blood workout to ensure the Retic count wasn't a lab error due to it being extremely low.

I will let you know the results when I get them (likely next week sometime). Hopefully the results are normal and it was an error of some kind.

Thanks again everyone!

[Marlene]

That's a great next step.....good luck and let us know the outcome.

[cathybee1]

Thanks, Marlene, for the great summary of what you've posted elsewhere. This is really a great check off list, should be put in a sticky post somewhere.

[Marlene]

Hi Catherine,

I'm sure there are many more reasons since anemia is a symptom of some other disease process or imbalance.

I think I missed the toxic exposure of chemicals and radiation, both low and high levels of exposure.

Yesterday I was listening to a book review on plastics and was reminded about the phthalates, specifically DEHP, and how they disrupt the endocrine system and can cause cancer. But the most disturbing was to hear about the use of plastics containing these chemicals in medical devices. Apparently, IV tubing and the bags blood is stored in are effected. DEHP leaches out of the plastic and into the blood product. It makes me sick to think of all the blood products John got over two year were basically contaminated with DEHP. So I wanted to find out the timeline on the discovery of this and to see if anything has changed. It appears they've know about this for quite some time and the FDA suggests hospital switch over to safer plastics. Is it happening? On some level it is but it's not mandatory. Here we are fighting to regain our health, only to get exposed to hidden toxins.

So who's at the highest risk of adverse effect to DEHP....infants, pre-pubescent boys, premature infants in the neo-natal units, and anyone needing multiple transfusions or the very ill.

Here are some links I came across in case you are interested in reading about this. What I haven't come across yet is whether or not they've changed the types of plastic for blood storage. I would like to think some action has been taken since many of the reports are from 2006 and earlier. Unfortunately, John's major exposure was in 2002 - 2004. BTW, he stopped producing testosterone during that time and had to go on hormone replacement therapy eventually.

http://www.fda.gov/MedicalDevices/Sa.../ucm062182.htm

http://www.mindfully.org/Pesticide/D...C-Toxicity.htm

http://www.noharm.org/us_canada/issu...vc_phthalates/

If anyone has current knowledge of this, please share.

Marlene

[Tohobo]

Hi everybody,

I have received my latest blood work. I will be speaking to my doctor on Friday about it. I have put my lab results side by side for ease. It appears my levels are all a bit higher. I was very sick the day of the test, so that likely explains my higher WBC. My retic is still a lot lower than I would expect though. Do I still need to see a hematologist or is the improvement in the other numbers mean I don't need to? Thanks a lot!!


------------------------------- April 11 -------- April 20

ABS Retic: (range 25 - 80) ---- 1 --------------- 7
HB (range 140 - 170) ---------- 120 ------------- 128
HCT (range 0.39 - 0.49) ------- 0.34 ------------ 0.37
RBC (range 4.4 - 5.7) --------- 3.99 ------------ 4.27
MCV (range 80 - 97) ----------- 87 -------------- 86
MCH (range 27 - 32) ----------- 30 -------------- 30
MCHC (range 320 - 360) -------- 349 ------------- 342
RDW (range 11.5 - 15.5) ------- 12.7------------- 12.9
Plat (range 150 - 400) -------- 185-------------- 177
MPV (range 7.4 - 11.3) -------- 9.0-------------- 8.6

WBC (range 4.2 - 11.0) -------- 3.8 ------------- 5.9
ABS Neut (range 1.8 - 7.0) ---- 2.24 ------------ 4.48
ABS Lymph (range 1.0 - 3.0) --- 0.99 ------------ 0.53
ABS Mono (range 0.0 - 0.80) --- 0.34 ------------ 0.59
ABS Eosin (range 0.0 - 0.40) -- 0.23 ------------ 0.24
ABS Baso (range 0.0 - 0.20) --- 0.04 ------------ 0.06

[Neil Cuadra]

Tohobo,

It's nice to see improvement, even if it's slight. But there's still something wrong so I would definitely recommend seeing the hematologist.

[Tohobo]

Thanks for the response Neil. My GP is going to call me Friday to talk about the results and I'm assuming my hematologist visit will continue as scheduled. Since my blood levels show very very mild anemia (25 year old male), is the retic important or is it only important when you are extremely anemic? I would assume I should at least be in the reference range, not 1 -7 even if my red blood cells were on the higher of normal. Just curious as to how it all works together, thanks a lot!

[Neil Cuadra]

The way I see it, your reticulocyte count isn't the most important direct measure of how you are doing but it's one of the keys to identifying the causes of your other chronically low counts. You might live perfectly well with counts hovering near the low end of the normal range, but if they dropped any more I'd be worried that the appropriate treatment couldn't be determined without a specific diagnosis. In the same way, losing 10 pounds isn't a critical problem by itself but it's a clue, and I'd really want to know what these clues mean!

[Marlene]

I second that. Do keep your appointment with the hematologist. It appears your GP feels it's beyond her expertise and getting a second opinion is always a good idea.

[Tohobo]

Thanks again to you both for your responses, it helps.

I completely agree with what you said, I really just want to know why my numbers are chronically low. Every single one of my counts has hovered around the low-normal range to the mildly/moderately low at times. It just seems to go up and down, but I am never higher than the bottom of normal. I know some people might be like this naturally, but I think the combination of this and the low retic count would be enough for a BMB just to be safe. That way if the BMB is clean, I can forget about it and if they find something, I can deal with it while I am still healthy.

My real concern is I saw a hematologist last year. She dismissed me because she said my RBC/HB/HCT were not low enough to be worried about it and my retic count is likely just naturally lower than normal. At that time last year my numbers were:

HB: 141
HCT: 0.42
RBC: 4.6
Retic: 16

this time they were

HB: 120 & 128
HCT: 0.34 & 0.37
RBC: 3.9 & 4.2
Retic: 1 & 7

At don't think the red blood cell counts have changed enough for my hematologist to care anymore this time than she did last time. The only thing I will be sure to ask her is if my normal before was 14-16 (had three tests in this range), then why is my normal now 1-7? Sorry for rambling, just concerned I will be pushed off without a BMB again. We will see I guess.

Thanks again...you are all great!

[Marlene]

Unfortunately, they don't look at subtle changes. John, as far as we know, always had low normal platelets and borderline anemia. We too were told that it was probably normal for him. I don't think a BMB at that time would have shed any light on what was going on though. Nine months prior to John ending up in the hospital, he had a physical and was told he was healthy. We noticed a shift in labs from the past year and thought it odd. However, we were dismissed because it was still in a normal range. Those lab results which were odd, had no direct connection to SAA, but it was a indicator that something was going on. In hindsight, he should of had labs run again in 3 month but we didn't push it. Would it have changed anything? Probably not. Except that we wouldn't have been in crisis 9 month later.

Moral of the story: look for trends and don't let them dismiss them. They may not be able to treat because your counts are OK, but at least you can keep a close watch on everything.

If you can, put together a spreadsheet of all your lab work over the past 3 or 4 years and take it with you.

[mausmish]

You might try a different hematologist if you aren't comfortable with the current. It never hurts to get more opinions. Everyone, including doctors, looks at things differently.

[Tohobo]

Thanks a lot for the responses. I appreciate the information Marlene.

Do you think I am wrong in wanting a BMB just to see if everything is ok. I'm just worried about why my retic count which was low last year, is very low this year. I would like to make sure nothing is wrong. Should I ask the hematologist to consider a BMB or does this sound like something I should just monitor. Just curious if I am overreacting as an outside view is helpful.

Thanks a lot.

[Neil Cuadra]

Originally Posted by Tohobo

Do you think I am wrong in wanting a BMB just to see if everything is ok. I'm just worried about why my retic count which was low last year, is very low this year. I would like to make sure nothing is wrong. Should I ask the hematologist to consider a BMB or does this sound like something I should just monitor. Just curious if I am overreacting as an outside view is helpful.

Thanks a lot.

Tohobo,

I would certainly ask for an explanation of why a bone marrow biopsy would or wouldn't be worth the expense and the tiny risk of the procedure, based on the information it could potentially provide. If the hematologist recommends against it, you should be clear exactly why.

[Marlene]

Like Neil says, do address whether or not BMB, as well as other tests, are warranted at this time. You may want to go in with clear goal/objective in mind and let the doc know what that is. We would make a list of all the things we wanted to discuss and then prioritize it. If our list was long, we knew we would only get to the top three in any detail. Both the doctor and you can be overwhelmed by long lists and it's better to get a few things answered clearly and save the rest for the subsequent appointments.

I don't think you are over-reacting. It is normal to want to understand why you're experiencing less than optimal counts. Just know that a BMB is not the only thing a doc looks at and is not usually the first thing they do to assess reasons for anemia.