Low Reticulocyte count?

[Harpssss]

I've been having symptoms for a while now and a few months ago they led me to believe I may have had a B12 deficiency. I was tested and my B12 levels were 270 which my doctor said was fine. My doctor also issued a B12 Deficiency autoimmune profile, which again came back fine. Although, my symptoms continued so I saw a Rheumatologist who discovered I have higher than normal Bilirubin levels which could indicate something called Gilbert's Syndrome, so we waited a few months and i was issued a retest. I've just had my results back and I can't see anything about Bilirubin (I'm not sure whether the test name might be something different?) but I do have a note on my file saying a need to contact a doctor as my Reticulocyte count is a bit low. I've obviously googled (mistake I know) and it keeps coming up with different types of anaemia as possible causes, including Pernicious Anemia. Could this still be related, or is the Reticulocyte count related to Bilirubin? I can't get a doctors appointment for a while at my surgery so would be good to get some insight.

Also just a last note my haemoglobin count, levels and concentration all came back normal, as did my red and white blood cell counts.

Thanks

[fbirder]

Low reticulocytes can be associated with lots of different causes - labtestsonline.org.uk/tests...

Decreased reticulocyte percentages may be seen, for example, with:

Iron deficiency anaemia

Pernicious anaemia or folic acid deficiency

Aplastic anaemia

Radiation therapy

Bone marrow failure caused by infection or cancer

The reticulocyte count gives an indication of what may be happening but cannot diagnose of any one particular disease. Reticulocyte count can show whether further investigations may be necessary and can help monitor the effectiveness of therapy.

[Harpssss in reply to fbirder]

Thank you, I understand this. But is it related to Bilirubin in anyway and also if my haemoglobin etc is fine does that not rule out iron deficiency anaemia?

[fbirder in reply to Harpssss]

Bilirubin is related to liver problems. I can't think how it might affect reticulocyte number.

Yes, you would expect low haemaglobin in IDA.

[FlipperTD]

I'm a scientist, not a medic. Please excuse me if I'm teaching my grannie to suck eggs, but here goes:

Reticulocytes are red cells recently released by the bone marrow. They remain as retics for a day or two before maturing. Red cells remain in the circulation for around 4 months [110-120 days or thereabouts], and it's reasonable to assume that the oldest ones are removed at that point, so at any one point in time there will be around 1% to 2% retics in circulation. The body is remarkeably efficient at maintaining the haemoglobin level, and can cope with very much more than 1% to 2% replacement each day, providing that there are sufficient nutrients to keep the process 'stoked up'.

What happens to the old red cells? The body dismantles them and recycles virtually everything. The Haemoglobin is broken down into Haem and Globin. The iron from Haem is stored for re-use. The Globin chains are broken down and recycled. The remains of the Haem however are broken down and excreted. The breakdown of Haem goes through a complex process, and Bilirubin is generated during this process. Virtually all the Bilirubin in circulation is related to red cell breakdown, and the processes take place in the liver. When Bilirubin is raised, it's either due increased red cell breakdown, or reduced excretion, or a combination of both.

If the retic count is 'reduced' but the rest of the FBC profile is 'normal' it's interesting and that's where your doctor comes in useful.

Good luck.

[fbirder in reply to FlipperTD]

Nice summary.

Can I just add one bit -

If you've been suffering from macrocytic anaemia which is now being treated (or if you've had a large blood loss) then your body will go on a spree of making new red cells. So your reticulocyte count will go up.

[FlipperTD in reply to fbirder]

Thanks for that. You're absolutely right.

Recovery from any sort of anaemia will result in a reticulocytosis, and it can happen very quickly.

In untreated PA, mild jaundice is sometimes seen, and that's typically due to 'ineffective erythropoiesis'. The red cell production process is faulty, and there's breakdown of red cell precursors in the bone marrow as well as the normal breakdown of mature cells.

[Harpssss in reply to FlipperTD]

Thank you for your help. I went to a GP who said they I have Gilbert's Syndrome as apparently my Bilirubin has been elevated on all the blood tests I've had for at least four years (and despite complaining of severe tiredness and gastro-related issues none of the doctors at my surgery thought to tell me). The doctor kind of just ignored my low reticulocytes despite the doctor who checked my test result stating that I needed to come in to discuss them. I was also told I had a slightly elevated Eosinophil count but again she wrote it off. I'm not sure how I feel about just ignoring these things, am I just overreacting or are these things I should be looking futher into?

[FlipperTD in reply to Harpssss]

Gilbert's Syndrome seems to be quite a common condition. If it's been there four years it's probably been there a lot longer.

The retic issue? Well, if your Haemoglobin level is being maintained then clearly you've got enough retics being produced to maintain your Haemoglobin. It's worth noting that the 'reference range' is almost certainly a 95% interval, so 95% of the normal population is within that range. Meaning that 5% of normals will be outside the range, but still normal. The same applies to the Eosinophil count. Your dovtor writing it off is probably being entirely sensible. One approach with anything 'abnormal' is simply to repeat it, and see if anything changes, and if needed, consider what's going on then, once you've all had time to think. Viruses can cause all sorts of transient problems, so some 'thinking time' is always worth it.

If your doctor wants to write it off, that's probably sensible!