These are my sister's results and I'd appreciate advice please.
Despite low serum B12 she wouldn't supplement because GP said result was 'fine'. She forgot to request a retest in August. Do the results indicate B12 deficiency? She isn't symptomatic. Sis is hypothyroid post RAI for Graves and optimally medicated, eats a well balanced mediterranean diet but is awaiting a referral to gastroenterologist because of persistent diarrhoea. Our Aunt had pernicious anaemia, hence my concern.
Thank you.
Feb 14 Serum B12 285 (190-900)
Feb 14 Folate 8.6 (2-14.5)
Feb 14 Ferritin 127 (10-291)
MCV: Aug 96.7 and Feb 95.2 Range (76-96)
MCH: Aug 32.0 and Feb 33.5 Range (27-32)
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Clutter
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She has a high MCV and MCH so it would be worthwhile getting another B12 and folate checked. I take it all other bloods are OK? It would be more of a concern if she was symptomatic. Worth keeping an eye on though.
I would get better checks done on Iron (not just ferritin) Her MCH is just out of range. Just makes me think that there could be an iron deficiency hiding behind that.
If you have an iron deficiency and concomitant b12 deficiency, the iron deficiency masks it.
I know you are saying she isn't symptomtatic - but you are saying she has been diagnosed with other things. Maybe this needs closer examination in case it is a cause of the 'other things?'
The more I think about it the more I think there is a macrocytic anaemia there that could be masking other problems.
I'd like to bet that at the moment her hypersegmented neutrophils are within normal range but if she was treated for an iron deficiency they would then go out of range very quickly.
People always ignore the values on the MCH - I don't know why. Even doctors do it.
Did she get a Red Cell Distribution Width (RDW) result?
The classic of iron deficiency and PA can give normal-looking MCV as some cells are over-sized and some under-sized but average somewhere near "normal". The RDW shows how spread out the sizes are.
In this case, the high MCV is a concern. The MCH inevitably rises with MCV because it is a calculated value dependent on number of cells - the bigger they are the fewer there will be!
The MCH is still a stronger indication of an iron deficiency than the MCV (this post isn't as clear as my last) when the MCH should be a lower value. It now recommeds that the MCV is not used as a guide, or at least the only one, to being a reliable indicator of a macrocytic anaemia. Yet here we have a higher value but neither a sign of anaemia micro or macro in the blood results.
It isn't even a very high MCH - but the corresponding 'high' MCV would indicate it's a macro. Yet even those levels aren't high and in most instances today would be considered normal by most lab tests.
I had a 'normal' MCV (but higher than the figure of this patient, but consistently higher MCH - like this result. No iron or ferritin done. When I took iron supplements, my hypersegmented neutrophils immediately started to go out of range and the b12 deficiency identified.
One of my points being, the calculated value isn't as straightforward as that. You can have a normal MCV but a high MCH. If the MCH wasn't worth anything other than a confirmation of the MCV then there would be no point in doing it.
Hello. I have been having problems and Poppet is just so helpful! And others. I know very little, but it seems, more than my doctor ! I have to have my little say however. 285 for B12 is considered ok in the U.K. I forget about Europe and USA but I remember Japan considers anyone under 500 to be at risk. There may be no neurological symptoms (is that what you mean?) and the other complaints maybe mask the symptoms the B12 d would cause. Diarrhoea is a symptom of B12 d isn't it. I wish you luck and all you can do is be persistent. I have just started taking methylcobalamin that i got online because I suspected cyancobalamine didn't work for me, it just raised my serum reading but wasn't absorbed, my doc didn't agree and will prob say it's the placebo effect but it has made a difference to my symptoms, including diarrhoea, after 4 days, I don't know if that is possible? BLVD (Lynn )
I know you say your sister isn't symptomatic for b12 deficiency. The blood tests that you put up don't indicate a deficiency either.
So why would you be worried that she has a b12 deficiency?
They would be my first questions.
The other points to note are that
- a lot of people don't realise what the physical symptoms of a b12 deficiency are. They 'believe' that they know, but really they don't. If their doctor doesn't know either then they can end up being treated for other conditions that their blood tests indicate they have but which are really just symptoms of the underlying b12 deficiency.
Maybe someone can point you in the direction of Dr Chandy's checklist? I'm having a few problems with my server here today (and may well lose this post!)
The other fact in your sister's case is that her bloods do, slightly (and just because she has slight indications in her blood results doesn't mean she only has a slight functional b12 deficiency) that there is something wrong.
To me, the MCH would indicate a 'possible' corresponding macrocytic and microcytic anaemia. Treat one and then the other bloods may allow the remainder to reveal itself. It's only a suggestion - and I wouldn't go around telling anyone to treat with either iron (for microcytic) or folate (for macrocytic) without first being tested. She hasn't had the iron test only for ferritin. This test again is not a reflected of iron in the blood and it is also an acute phase reactant ie if your sister stresses the levels will go up.
Which brings me back to the start. Get an iron test - which her GP will, quite possibly, fight tooth and nail against.
If it's normal, I'm wrong - fair enough - I'll live. But common sense tells me to at least try and rule it out.
Thanks for your replies, Poppet. I'll advise her to get the iron test and retest B12 and folate.
It was her low serum B12 that concerned me. She has explosive diarrhoea daily when she awakes (3 years now) which she ascribes to Levothyroxine. I wondered whether this may affect absorption of nutrients and cause B12 deficiency, particularly as our aunt had PA. Sis has been referred to a gastro for investigation.
I have the B12d signs and symptoms bookmarked but as I said she isn't symptomatic.
She'll have a problem getting the iron test because, if anything, her MCV and MCH indicate a macrocytic anaemia rather than a microcytic - which iron anaemia is.
She doesn't take any multivits,does she?
I just think all this is such a nonsense because doctors could simply do the iron test and it would stop all the conflicting information.
I was just very suprised that I was very, very, ill and my bloods basically showed nothing. The only thing was a consistently raised MCH (for about a year) - which no one acted upon. Yet within a fortnight of taking an iron supplement my bloods showed hypersegmented neutrophils. By rectifying the microcytic anaemia, the macrocytic responses became clearly visible. Then a b12 test was done...
Thanks, BLVD. I supplemented methylcobalamin spray and sublinguals which doubled my B12. Diarrhoea stopped too, but may also be due to adding T3 to T4 which had made me unwell.
In his book, 'Living with Pernicious Anaemia', Martyn Hooper says:
"Diarrhoea is an experience suffered by a great many members of the Pernicious Anaemia Society: Nearly 57.7 per cent reported that they experienced sudden and unaccountable bouts of diarrhoea, with 40.2 per cent experiencing this after a bout of constipation. Strangely thigh, it isn't widely recognised as an early indicator of B12 deficiency by medical professionals, despite being so common."
"When you remember that pernicious anaemia is caused by a malfunction in the digestive process it shouldn't come as a surprise that sudden bouts of diarrhoea are associated with the disease".
Thanks Polaris. Sis thinks the diarrhoea which is once daily on waking is caused by Levothyroxine. I wondered whether it would affect absorption of nutrients and be the reason for her low serum B12.
She already has a symptom Clutter, she has a low serum B12, but she may be able to sort that out
my taking sublinguals, IF she has no B12 deficiency symptoms.
Pernicious Anemia is in your family history,knowing this, allows you to be aware,when you are ill, to check this out.
One of the classic symptoms of B12 deficiency is the tingling or numbness.
I might be reading it wrong, but the b12 level is in the 'normal' range - it's not low. We know it's the range that isn't right, but in the eyes of the medical professionals she doesn't have a deficiency.
Also some people have been recorded as having a low b12 but are not symptomatic. That one generally throws a spanner in the works.
I'm still back to check the iron, treat it if needs be and see if that b12 level changes and the other bloods change. Also if she checks her symptoms against the checklist and she turns out to indicate a b12 deficiency as well as the conditions she has already been diagnosed with. Some are cross symptoms.
No, I know it's a nonsense too - but despite what the Japanese do, the doctors here will go on their knowledge of normal. So what you have to do is 'prove' that there is something wrong, get it rectified and hope the b12 levels adjust to their 'real' level.
I know we all go on about the Japanese - but it means nothing here. Nobody cares. We have to prove 'why' these ranges need to be raised and we have to do it scientifically. And if we can't do that (and we can't because we are not consider valid to have a medical or scientific opinion) then we have to figure out what is wrong, make them test for it and take it from there.
Bottom line is, the serum b12 level is in the normal range. For doctors - end of story.
Poppet, which is why I'm picking the brains of the members here I want things nipped in the bud before symptoms appear or become a problem and "it's your age" becomes the default response.
Surely, it all comes back to the fact that there is no gold standard test and, with the links between autoimmune hypothyroidism and PA in the family, I would not want to wait for more serious, irreversible manifestations, as has happened in my family.
Secondchance posted a few days ago - New BMJ article on B12 Deficiency - which summarises:
"Vitamin B12 deficiency is a common but serious condition
Clinical presentation may not be obvious thus leading to complex issues around diagnosis and treatment
There is no ideal test to define deficiency and therefore the clinical condition of patients is of the utmost importance
There is evidence that new techniques such as the measurement of holotranscobalamin and methylmalonic acid levels seem useful in more accurately defining deficiency.
If the clinical features suggest deficiency then it is important to treat patients to avoid neurological impairment even if there may be discordance between the results and clinical features.
Vitamin B12 (also referred to as cobalamin) deficiency is relatively common, with important and variable clinical consequences. This review presents a concise summary of the most up to date evidence on how to diagnose and manage vitamin B12 deficiency. "
I agree best test B12 and folate again. Ideally active B12 test if any symptoms are present.
High MCV and MCH can imply B12 and or folate def; see:
"Mean cell haemoglobin (MCH) - guideline normal values: 27.0-32.0 pg. High values are found in macrocytosis and low values are seen in iron deficiency."
Patient SE, an 87 year old man, presented with shortness of breath and anaemia.
Hb was low, MCV was normal and TSH was elevated indicating hypothyroidism.
Total B12 level was 170pmol/L indicating sufficiency.
Normal RBC folate and serum folate indicated that Iron status was normal and the anaemia was presumed to be due to the hypothyroidism.
However, the Active-B12 concentration was only 4pmol/L indicating severe B12 deficiency.
Conclusion:
Although the Total B12 level was normal, the Active-B12 level was severely low showing that the patient was B12 deficienct. Hypothyroidism patients can have this discrepancy between Total and Active B12 levels.
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