Re: Re: Help with persistent megaloblastic anemia case

[Guest guest]

Hi Fine Folks!  I am in need of help working up a case of persistent megaloblastic anemia.  Specifically I'm wondering about what tests to run next.  The doc that has been ordering her tests so far wants to refer her to a hematologist but I'm not certain that is necessary without at least looking for folate deficiency.

She is female, 30 years old, eats a vegetarian diet that includes fish.  Her chief complaint in October of last year was rosacea and initial consult revealed significant gi distress with variable stools in which she noticed whole foods and mucus, sometimes passed just mucus.  We've been treating with drainage since October 2010 with improvements in skin and digestion though both still flare from time to time.

May 11, 2010 - Anemic with low WBC (3.6) and RBC = 3.69; Neutrophils were low and Lymph were high and globulins were low norm                 serum methlymalonic acid was normal at 264nmol/L (range is 73 to 376) and this would seem to rule out B12 deficiency      anemia

May 25, 2010  - WBC = 3.3; RBC = 3.69; neutrophils still low and lymphs still high She brought the labs above from another doctor.Sept. 2010  - WBC = 4.3 (low normal); RBC = 3.53 L; MCV = 100.5 H (range is 80 - 100); MCH = 34.2 H (range is 27 - 33); neutrophils and lymphocytes were normal

When she came to see me in October 2010 she was taking B vitamins (Orti and Vitamin DJan 2010 - WBC = 4.0 (low normal); RBC = 3.73 L (range is 3.8 to 5.10); MCV = 99; MCH = 34.8 H (range is 27 - 33); borderline low neutrophils

GI Health Panel Jan 2011 - low SIgA (152); chymotrypsin was less than 3 suggesting decreased pancreatic output and negative gliadin antibody.  Pretty unremarkable considering her significant GI symptoms. 

Digestion and skin had improved but was still up and down.  She had been avoiding egg and dairy in her diet since October of 2010.  I had used mostly gi undas along with ficus and juglans (and BTGs of course).  Recommened pancreatinum but she didn't take it.  She talks about doing a trial w/ digestive enzymes but hasn't done it yet.  Overall she doesn't really taking much except the Undas and she wants to be able to eat dairy though she knows it causes her rosacea to flare.

May 2011  Alk Phos was pretty low at  35 (range is 33 to 115) and makes me question zinc deficiencyAlbumin top of normal while globulins were bottom of normal with normal total protein (getting enough protein in her diet)

WBC = 3.0 (range is 3.8 to 10.8); RBC is low at 3.69; MCV = 100.9 H; MCH = 34.1 H; low neutrophils (absolute); total iron = 234 H (range is 40-175); iron binding capacity = 372 (range is 250 - 450); % saturation = 63 H (range is 15 to 50%)

Vitamin B6 = 20 (range is 2.1 to 21.7)Obviously my question is re: the persistent low WBC and RBC with high MCV and MCH.  She is very close to fitting the pattern for B12/Folic acid deficiency but the meththymalonic acid was normal last may so that seems to rule out B12 deficiency.  Obviously her iron is high.  So folic acid deficiency is the next likely reason for the megaloblastic anemia, right?  I actually haven't ordered any of these labs b/c she does them through another doc for insurance reasons.  Seems like I should recommend homocysteine levels.  Do I need to also repeat serum methylmalonic acid and should I include the MTHFR as part of the look at folate metabolism or is that overkill at this point?  She's been supplementing with B complex at least since October 2010.

Any input is appreciated - I just don't want to order labs that aren't necessary but it seems definitely time to find out why she continues to be anemic despite supplementation.  I don't want to just assume it's due to malabsorption forever. 

-- Kathy Sweeney, NDVital Health & Wellness6018 SE Stark St, Ste 103Portland, OR 97215p: vm: f: