Anemia CBC guidance. Low MCV, MCH, MCHC and Reticulocyte Count.

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Hey all!

Hoping some kind member can offer me some advice regarding my test results.

I seem to be suffering from anemia symptoms and/or pots(among other things)
My doctor said my blood work checks out but I don't believe that so would like to gain a bit more understanding for when I speak to a new doc

For context: I am 27. Not sure exactly how much I weigh, but I am pretty skinny and I could never put on any muscle mass. Only fat I could ever put on was around my waist when I was on medication, lost that after stopping and never gained it back no matter how much I consumed.

I eat very little protein daily(70-80g) as I have a terrible problem with sulfur/sulfites. I had to cut down my sulfur intake completely otherwise I'd have constant head pressure(tension migraines maybe?) almost constantly. After stopping all sulfur foods, finally some of my symptoms have reduced in intensity.
This week I am busy increasing my red meat intake to see just how sensitive I am with a slightly higher protein intake.

I am extremely sensitive to sulfite contaminated things, immediate brain fog(among other symptoms) from ingesting said contaminated items, eg Vitamin C, carbon filtered water. Even formaldehyde is a major problem, wet roller towel smell sets me off just as bad. I know Sulfite Oxidase and Aldehyde Oxidase are molybdenum enzymes but molybdenum supplementation barely improved my situation. I know that heme is a cofactor for those very same enzymes.
I am also sensitive to numerous smells, both organic and synthetic. Spices cause huge mood swings and brain fog. Foods are a big problem too, still struggling to find the right combination of foods.

I will list a few symptoms but there are just too many to even list:
  • My blood pressure is almost constantly 100/60+- sometimes /57.
  • Tachycardia after getting up. Have to wait a while before it calms down.
  • I get post meal fatigue around 30-45 minutes after eating, depending on meal size, currently my meals are tiny. Which makes me eat smaller meals more frequently. Again, depending on meal size I might get brain fogged, lose comprehension, concentration and motivation. Even lying down for an hour does nothing to help.
  • Dark circles under my eyes since I was 12, which won't ever go away. (I have no actual allergies)
  • Insanely heightened sense. Light, sound and smell sensitivity. So doesn't help that I react to smells but now I can smell them even better :/
  • My sleep cycle is completely messed up, sometimes end up going to bed 3am. I wake up fine, with some energy but after my first meal(small) and throughout the rest of the day(after every meal), I just get more and more fatigued.
  • I alternate between constipation, diarrhea and "normal stool shapes"
  • ***Likely most important clue, perhaps?*** - A few months ago my stools became completely yellow and I just can't get them brown again.I have tried Taurine supplementation and all it does is give me gallbladder pains after consumption which has never happened before or even after stopping it, not even with a very fatty meal.

Here are the links to my results.

CBC, Iron, ESR, Reticulocytes, Haemoglobin Electrophoresis:
https://drive.google.com/file/d/1p3J2FvHtPjoNnIQykxWcpnN8WjoNzaUe/view?usp=sharing
*The following are on or below the reference range:
MCV, MCH, MCHC and Absolute Reticulocyte Count.

Ammonia, Homocysteine:
https://drive.google.com/file/d/158Bazj18JBTqHYmIl8jcLxUnjNlaln5-/view?usp=sharing

B12/Folate:
https://drive.google.com/file/d/1SAvQ6evbEV-E1l1LlAcAe2Z240BaYn3B/view?usp=sharing

Electrolytes, Urate, Urea:
https://drive.google.com/file/d/1jaPRy6nzTv0G7BMDeIrXUKYztNLXdEZR/view?usp=sharing

Thyroid:
https://drive.google.com/file/d/1lqn6DZTSVepiUXeK5Pe-_mESCdUXggN1/view?usp=sharing

Lipogram, Cholesterol, C Reactive Protein, Glucose Fasting Blood, Liver Function Test:
https://drive.google.com/file/d/1Adgd5EQLkCRO9gUU9MytDz0-gMf-Nghv/view?usp=sharing

I had a more recent bilirubin test done, figures have risen somewhat:
https://drive.google.com/file/d/149l--MDMW6G0u_JhuIQ1V8K47n0Ah3fZ/view?usp=sharing

Does my liver function tests point out anything wrong with my bile flow? Maybe it's more of a heme issue only and nothing to do with bile salts themselves? That would line up with my anemia symptoms then if it's just heme related.

Soluble Transferrin Receptor:
https://drive.google.com/file/d/1q3X0iG43g_FNOMoyxOj3_LI7qRoj0Qqc/view?usp=sharing
Low

I already did an oxalate 24 hour urine test 3 months ago, I wasn't eating excessively high amounts of oxalate high foods at the time though. Here are the results:
https://drive.google.com/file/d/1RW4WTopzlz06D8OP_oUbdwW695y5eDhh/view?usp=sharing
This is a few months after my stools went yellow and I was still consuming 50g+- of fat daily(Mainly saturated fat from meat and ghee)

I have no idea what type of anemia I am suffering from or whether I could treat it. If I need to synthesis more heme, if so, how would I even go about that? I have been recommended B6 a few times for heme synthesis but I am a bit worried that the B6 will just increase my sulfur burden, as I have read it can induce CBS. Though I assume that's only really a problem if homocysteine is draining down your transsulfuration pathway?

Many thanks. Any and all advice is welcome!
 
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CFS_for_19_years

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  • You are NOT anemic. Your hemoglobin and hematocrit are fine.
  • Your Mean Cell Volume (MCV) is 81 with a reference range of 81-95. This indicates borderline microcytosis (small red cells). Typically microcytosis is due to low iron, but your iron level is fine.
  • The low Mean Cell Hemoglobin (MCH) is due to the small size of your red cells. Your result was 27 with a ref. range of 28-35.
The following article might be helpful:
Evaluation of Microcytosis
https://www.aafp.org/afp/2010/1101/p1117.html

First check Table 4 to see if any of the suggested diagnoses make sense.

Then follow this algorithm. You've had all of the diagnostic tests.
Laboratory Tests in the Differential Diagnosis of Microcytosis

Another article that could help you:
http://www.irondisorders.org/tests-to-determine-iron-levels/

The chart at the bottom of this page may be helpful:
http://www.irondisorders.org/Websites/idi/files/Content/854256/HowdoIknow_Anemia__Converted_.pdf

The results from your CBC show that:
  • your Red Blood Cell color is Normochromic [normal Mean Cell Hemoglobin Concentration (MCHC)] and
  • your Red Blood Cell size is Microcytic to Normocytic (borderline Microcytic) 81 (81-95)
  • you are not anemic (normal hemoglobin and hematocrit)
My brain has fizzled out and I can't make an interpretation (seems to be above my pay grade). @valentinelynx do you want to take a shot at this?
 
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Thank you for the response @CFS_for_19_years

I will give the articles a look.

I would love to hear @valentinelynx thought's about this too.

I will only be able to see a hemeotologist in the new year so all the advice is welcome while I do some research to discuss with them.

Thanks again.
 

CFS_for_19_years

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I will only be able to see a hemeotologist in the new year so all the advice is welcome while I do some research to discuss with them.
I'm glad you're seeing a hematologist. I couldn't say "Ah ha, that's what you've got" by checking off any of the boxes. Now you can impress them with your vocabulary of normochromic microcytosis.

Spleenpoker is an interesting name considering your red cells are being investigated. The spleen is where old red cells go to die. The blood vessels in the spleen are the smallest of any place in the body so if they don't survive being squished there, their membranes break up. Keep in mind that a red cell lives about 120 days, so it survives a lot of trips through the spleen before giving up. People missing their spleens have a lot of odd looking red cells that the spleen would normally cull. (A spleen can be given up during surgery.)
 
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Thanks for the bit of spleen trivia, quite funny in hindsight. Username I've been using online since I was 10, less funny now though :p

I will definitely be seeing both a gastroenterologist and hematologist in the new year.

Though the yellow stools seem to have a connection with Oxalates, which have a connection with Sulphation and B1 deficiency which can cause low adrenals. Very interesting reads!

Hopefully it's as "simple" as that. I will do some research here on PR about B1. I will probably start low and slow with that in the mean time while I wait till the new year. All I can do really.

Thanks again, been extremely helpful :)
 

valentinelynx

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Sorry, I've been working, which leaves no time/energy for anything else. It does, however, pay the bills... :D

Regarding your results, please be aware that I'm not a hematologist, and the intricacies of diagnosing the various types of anemias sometimes boggles my mind. I had to look up causes of microcytosis without anemia (which gave me flashbacks to medical school...). What comes up are: various traits of abnormal hemoglobins (hemoglobinopathies) such as thalassemia trait (alpha or beta), or the old standard, Anemia of Chronic Disease. Then there's this sentence from a good review article in American Family Physician Evaluation of Microcytosis: "Microcytosis is typically an incidental finding in asymptomatic patients who received a complete blood count for other reasons."

It is worth noting that your MCV is still low normal, so you don't yet qualify for microcytosis. Yours could be a normal variant.

Here's a good algorithm for diagnosing the etiology of microcytosis.

That your soluble transferring receptor level is low (just barely) is intriguing. This suggests that your marrow is not making red cells at the usual rate. This is supported by your low level of absolute reticulocytes (reticulocytes are just made red blood cells that haven't matured yet). According to LabCorp's description of the use of the soluble transferring receptor test, "sTfR is elevated in subjects with hyperplastic erythropoiesis (eg, hemolytic anemia, beta-thalassemia, polycythemia, etc) and depressed in subjects with hypoplastic erythropoiesis (eg, chronic renal failure, aplastic anemia, or post-transplant anemia)." I do not suspect your have renal failure (your eGFR is just fine!), or aplastic anemia or post-transplant anemia—in fact you don't have anemia. However, I suspect you are male, and men tend to have higher hemoglobin levels than women. The normal range includes both men and women. Depending on the lab, normal Hgb for men can be as high as 14 g/dl, in which case you'd be on the low normal side.

I'd like to point out that the majority of your labs are normal. These red blood cell related labs are slightly abnormal, but whether it is a significant abnormality I don't know. Maybe follow up with repeat labs in 6 months to a year and see if things have changed. A hematologist can give you a much better assessment than I, although they might just say it's not abnormal enough to be worried about.

I don't know if any of that is helpful. Best of luck!