My anemia from last year felt better when I started taking iron
twice a day, but my latest test indicates it's not iron-deficient
anemia.  I was thinking pernicious anemia because I have some
chronic symptoms of B vitamin deficiency, thin hair, split nails,
mouth and tongue sores and skin problems.  Also, I've never
handled stress well.

So, I did start taking B complex twice a day also.

But when I got results of latest test, it said my Red {*filter*} Count
was high, whereas pernicious anemia would have a low RBC.  Also my
Mean Corpuscle Volume and Mean Corpuscle Hemaglobin are lower than
last year, even though my hemoglobin and hemocrit are now in
normal range.

Since I won't hear results of latest test (to rule out Thalassemia
trait) until Saturday, I'm curious (ok, also nervous) since I
couldn't find anything in my medical books that had low MCV and MCH.

I feel fine, better than usual, except with disgust at self for
gaining 12 pounds in 4 months.  (I'm compulsively eating
chocolate, though I suspect it may be allergic to me and also
over-eating other stuff until I get a stomach ache from being so
full.  Then I finally stop.)  My usual chronic problems are
depression, allergies and fibromyalgia.  Recently I got a badly
sprained ankle and am clumsy in other ways, too, but am healing
better than usual.  I'm a bit tired and weak, but less so than
usual.

I've suspended taking anti-depressants, though I was taking an
extremely low dose because I metabolize imipramine unusually
slowly, but I will have to resume taking my {*filter*}contraceptive,
Demulan next week.  (I still feel fine, without the meds.)

What could my {*filter*} count mean?  Could it be due to cooking.net">food intolerance?
Could it be "normal for me" and nothing to worry about?

If it means that I have lots of little red {*filter*} cells instead of
fewer bigger ones, then so what, why should it matter?

Thanks!

You didn't give any numbers, but the classic picture for thalassemia
minor is mild anemia, low MCV, low MCH, and an elevated RBC count.

What test has been ordered on you for thalassemia? To my knowledge
there is no readily available diagnostic test, although a hemoglobin A2
level may be elevated in some cases and can be helpful.

In my opinion, the best way to diagnose thal minor is to rule out iron
deficiency and establish that one parent has microcytosis (assuming
both parents are available for testing). This can be done very
inexpensively without any esoteric testing.

Ed Uthman, MD
Pathologist
Houston/Richmond, TX, USA

Ed was nice enough to respond to my question.  Thanks!

Ok, I got the results of my last test which was a Hemoglobin
Electrophoresis.  I don't have the Thalassemia trait, but I do
have elevated hemoglobin E.  70% of my hemoglobin is normal.  My
doctor (an internist and gynecologist) already consulted a
hemotologist and is planning to consult a pathologist and I'm
going to have 2 more tests.

However, she and I are both convinced that my {*filter*} is ok for me,
but we want to get to the bottom of its strangeness so that I
don't fool future doctors into thinking it's strange in a worse
way.

I found out some things about {*filter*} in my physiology book and
genetics book to supplement what I found in my nursing book,
though none talk much about hemoglobin E.

Hemoglobin is a protein comprised of 4 polypeptide chains, each
containing 1 heme group which has 1 iron atom.  The sub-chains are
generally 2 of 4 types.

Normal {*filter*}s have 98% hemoglobin A (Hb A) which is 2 alpha chains
and 2 beta chains, and 2% of Hb A2 which is 2 alphas and 2 deltas.

Embryos start out with hemoglobin that has 4 epsilon chains.
Fetal hemoglobin, Hb F, has 2 alpha chains and 2 gamma chains.
Thalassemia results in Hb F.  When a person is homozygous, they
get Thalassemia major or intermediate, which can be serious or
fatal.  When the person is heterozygous for the gene, they may
have no symptoms or may just be mildly anemic.

There are many abnormalities in the alpha and beta chains, mostly
named for places.  Sickle-cell, for example, has a mutation in the
alpha chain.  If a person is homozygous for the gene, the
hemoglobin is almost all Hb S with some Hb F.  If the person is
heterozygous, the hemoglobin is about half Hb S and half Hb A, and
the person may have no symptoms, except, of course, a resistance
to malaria.

What I'm hypothesizing about my {*filter*} is:
1. Hb E is the embryonic epsilon type
2. If a person can do ok with 50% Hb S and 50% Hb A, then a person
   could probably do ok with 50% Hb F and 50% Hb A.
3. Maybe I have something like a Thalassemia trait, but with Hb E
   instead of Hb F and it's at a low enough level (30%) that it
   really doesn't matter.

I feel fine, especially since I started taking extra B complex
every single day and also from getting more exercise with our
recently acquired enormous puppy.  :-)   (55 pounds and only
half-grown, Bouvier des Flandres)

However, a lot of people think I'm weird and this is the second
medical thing that even MDs think is weird.  Oh, and my
fingerprints are weird, too, type "other", found in Australian
Aborigines and descendents of Frisian Islanders (off the coast of
Germany).  Or could it be space aliens......   :-)

-krista

The problem is that hemoglobin electrophoresis cannot determine the
presence or absence of thalassemia. Hemoglobin E is incredibly rare in
people who are not of Southeast Asian racial background. Hemoglobin E can
also be confused with several other hemoglobins, including hemoglobin A2,
which is elevated in thalassemia. Hopefully they did some sort of
confirmatory study before they called hemoglobin E on a Caucasian (which
you are, right?)

Not necessarily. Hemoglobin F is elevated in only a minority of
thalassemics.

Actually, sickle cell is a beta chain mutation.  

Hb E is not an embryonic hemoglobin. It is a beta chain mutation and is
thus a variant of the {*filter*} Hb A. It has nothing to do with epsilon
chains.

Possibly, but I'm still leery of calling Hb E in someone not of SE Asian
background.

Ed Uthman, MD
Pathologist
Houston/Richmond, TX, USA

Thanks for correcting and clarifying what I tried to find out
about hemoglobin.  One more fact I learned today was that Hb E is
fairly common in Thailand, Cambodia and Burma.  My ethnic background
is northern and central European, so it does seem unlikely that
I'd have Hb E, but there is the possibility.  As you said, it's
probably more likely to turn out to be a Thalassemia trait.

Either way, it sounds like I'm stuck with a mild anemia that will
never go away completely.

The next tests are for quantitative A2 and F.  It's really hard to
find out much about this subject.  I greatly appreciate the emotional
and informational support.

Thanks!

I'm running slightly behind - per usual - in reading sci.med, so
I hope someone hasn't already asked this...  In the face of an
elevated RBC count, is the anemia defined by a low hematocrit?
Perhaps an silly question...

- Cecilia De Blasi

--

Yes, I agree with getting those tests. I would also check with the lab
which made the Hb E call and ask what kind of confirmation they did, if
any.

This whole thal thing has become something of a crusade of mine. I
continually see people misdiagnosed as iron-deficient when all they have
is thal minor, which rarely needs intervention of any kind. Thal is very
common in black people, but it seems that few physicians realize this.
Also, it seems that many physicians think that a hemoglobin
electrophoresis will diagnose any hemoglobinopathy or thalassemia.
Actually it rarely is abnormal in thalassemia, and it picks up only a few
types of hemoglobinopathy (sickle cell being the most important).

Good luck, Krista. Let us know how it turns out.

Ed Uthman, MD
Pathologist
Houston/Richmond, TX, USA

Unless you have some Mediterranean or thereabouts (Spanish/Greek
etc) ancestory somewhere....
There are some Irish folk with Thalassaemia brought there by
the Spanish for instance.

--
          Some things have got to be believed to be seen.
-------------------------------------------------------------------
Alan Teh                        | Fax:603-7562253    Ph:603-7502316

                [PGP Public Key available on request]

the sickle mutation is in the beta chain.. but you're forgiven :) (b6 glu  
-> val)
no....HbE is 2 normal alpha chains with 2 abnormal beta chains...

True  - HbE trait (which it sounds like) has pretty normal oxygen  
transport function

You are closer than you think..:-)
HbE is a splice mutation abnormality... without checking my text books I  
think its at beta 26 (glu-lys?) which is the join where some of the DNA  
is transcribed and some is redundant...this leads to a reduction in  
production of the chain (hence the small red cells and the comparison  
with thalassaemia)

regards
rogerds

writes:

For practical purposes, anemia is defined as an abnormally low hematocrit
or hemoglobin. In some cases, notably thalassemia minor and
therapeutically bled polycythemia, the individual can be anemic but have
a high red cell count. The red cells are just smaller than normal in such
a case.

Ed Uthman, MD
Pathologist
Houston/Richmond, TX, USA

I agree. Beta thal (minor) is very common and the electrophoresis looks
OK. Do A2 to confirm. Hemoglobin E, even EE is pretty mild. As I recall,
E-thal is common in SE Asia too. Remember that Thalassemia is primarily a
Chinese disease--if one looks at incidence. But, what the hell, we are all
one species and I see sickle trait in caucasians sometimes, ad infinitum.
If we think managed care will ever do any of this we are beyond hope.
Incidentally, sickle is a beta chain single amino acid difference!...from
one codon. Bill Palmer

--
William Palmer
Anatomic Pathology Institute
Oakland, CA 94618

        According to my notes from Med Tech school (usual disclaimer),
thal is suspected when the RBC for men is > 6.0, and > 5.0 for women.

Pete Womack, MT(ASCP).
--
______________________________________________________________________________
You know I hate to ask, but are friends electric? Mine's broken down, and now

______________________________________________________________________________

Basically I agree. One also looks for a low MCV. And remember to check
the history -- someone with p. vera who has become secondarily
iron-deficient due to therapeutic phlebotomy can look just like a thal
minor.

Ed Uthman, MD
Pathologist
Houston/Richmond, TX, USA