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What Causes Normocytic Normochromic Anemia?
Question: Good evening,
I am a 30 year old, 6'1", 190 lbs. white male with diagnoses of PTSD, migraine without aura, ADHD, and now anemia. I am currently prescribed hydrocodone, 5 mg twice daily; dextroamphetamine, 10 mg twice daily, and androgel 1.62%, two applications once daily. I receive my healthcare at the V.A., so it is typically a 3 month wait for any follow-up with my Dr.
At the beginning of January I started experiencing sleep maintenance insomnia, extreme fatigue, lethargy, clouded consciousness, apathy, bilateral parasthesia of the legs, facial hot flashes, supine nasal congestion, recurring sinusitis, and anxiety. CBC and thyroid panel came back unremarkable. My P.C. ran a testosterone level that showed a value of 339 ng/dl and a vitamin assay that showed a low level of Calcidiol at 22.6 ng/ml. On his advice I began supplementing vitamin D3 and my level raised to 45.5 by May. During the same lab, my total testosterone had dropped to 323 ng/dl. My symptoms continued unabated, so i was evaluated for depression, which was ruled out. Do to increasing anxiety that failed to respond to benzodiazepines and buspirone, I was given chatecholamine serum and urine tests that proved unremarkable. I was given another thyroid panel (all in range) that showed TSH at 1.08, free T4 at 1.29, and Total T3 95.23. MRI showed small, left frontal lobe gliosis. ENT found no cause for my daily sinus congestion.
Since September I have normocytic, normochromic anemia with Hemoglobin at 12.7, RBC at 4.48, and a hematocrit of 37.5. Reticulocytes were at 1.6% and the rdw was low. My ferritin was at 249.6, serum iron at 59, TIBC at 291 and LDH at 137. FOB test was negative.
Suspecting AOCD, my sed rate was 6, Rhuematoid factor negative, Nuclear AB negative, my Doctor exhaustively ruled out multiple myeloma and heavy metal poisoning. We decided to try Testosterone because I suggested that a 30 y.o. male should have a level higher than 323, and that we had ruled out every other cause of the anemia. 3 weeks into my new treatment, my initial symptoms have not improved. Is any diagnosis consistent with my initial symptoms which are all still current, development of normocytic anemia, and my previous lab findings?
Thank you for your time Doctor.
I am a 30 year old, 6'1", 190 lbs. white male with diagnoses of PTSD, migraine without aura, ADHD, and now anemia. I am currently prescribed hydrocodone, 5 mg twice daily; dextroamphetamine, 10 mg twice daily, and androgel 1.62%, two applications once daily. I receive my healthcare at the V.A., so it is typically a 3 month wait for any follow-up with my Dr.
At the beginning of January I started experiencing sleep maintenance insomnia, extreme fatigue, lethargy, clouded consciousness, apathy, bilateral parasthesia of the legs, facial hot flashes, supine nasal congestion, recurring sinusitis, and anxiety. CBC and thyroid panel came back unremarkable. My P.C. ran a testosterone level that showed a value of 339 ng/dl and a vitamin assay that showed a low level of Calcidiol at 22.6 ng/ml. On his advice I began supplementing vitamin D3 and my level raised to 45.5 by May. During the same lab, my total testosterone had dropped to 323 ng/dl. My symptoms continued unabated, so i was evaluated for depression, which was ruled out. Do to increasing anxiety that failed to respond to benzodiazepines and buspirone, I was given chatecholamine serum and urine tests that proved unremarkable. I was given another thyroid panel (all in range) that showed TSH at 1.08, free T4 at 1.29, and Total T3 95.23. MRI showed small, left frontal lobe gliosis. ENT found no cause for my daily sinus congestion.
Since September I have normocytic, normochromic anemia with Hemoglobin at 12.7, RBC at 4.48, and a hematocrit of 37.5. Reticulocytes were at 1.6% and the rdw was low. My ferritin was at 249.6, serum iron at 59, TIBC at 291 and LDH at 137. FOB test was negative.
Suspecting AOCD, my sed rate was 6, Rhuematoid factor negative, Nuclear AB negative, my Doctor exhaustively ruled out multiple myeloma and heavy metal poisoning. We decided to try Testosterone because I suggested that a 30 y.o. male should have a level higher than 323, and that we had ruled out every other cause of the anemia. 3 weeks into my new treatment, my initial symptoms have not improved. Is any diagnosis consistent with my initial symptoms which are all still current, development of normocytic anemia, and my previous lab findings?
Thank you for your time Doctor.
Brief Answer:
None of the diagnosis are consistent with symptoms
Detailed Answer:
Hi,
Thanks for asking.
I am Dr. Jyothi BL and I will be answering your query.
Looking at your clinical history and query, my opinion is as follows:
1. Normocytic normochromic anemia is commonly due to blood loss, hemolysis, malignancies or chronic inflammation.
2. ESR of 6 virtually rules out chronic inflammation or malignancies. Reticulocyte count of 1.6% rules out hemolysis. FOB test rules out bleeding in GIT. Your hemoglobin is only mildly reduced i.e. 12.7g%. Around 13g% would be considered normal and a mild reduction could not cause these symptoms.
3. Iron levels are good. However, Vit B12 or folic acid assay is not done. Early deficiency stages of these vitamins can cause normocytic normochromic which later on progresses to macrocytic normochromic. Most of your symptoms are neural related and I strongly suspect vitamin deficiencies, particularly B12 and folic acid.
4. You can start yourself on nutritional supplements - multivitamin with minerals and specifically also add B12 and folic acid. Also improve your diet with fish, egg white, red meat, green leafy vegetables.
Difficult to identify trace vitamin or mineral deficiencies. Load yourself with B12 and folic acid. They are water soluble and have no toxicity.
All other medications to be continued as usual. Hydrate well and have a good balanced diet with moderate exercises.
At present, I am not seeing any specific diagnosis being made.
Testosterone - mild reduction cannot cause so many symptoms.
Nutritional deficiencies could be a possible cause, which has led to mild anemia and other symptoms.
Anemia of 12.7g% does not cause any of the symptoms you are suffering from.
Improve your diet. If possible attach your whole reports. I will try to help you more.
Hope it helps.
Any further queries, happy to help again.
None of the diagnosis are consistent with symptoms
Detailed Answer:
Hi,
Thanks for asking.
I am Dr. Jyothi BL and I will be answering your query.
Looking at your clinical history and query, my opinion is as follows:
1. Normocytic normochromic anemia is commonly due to blood loss, hemolysis, malignancies or chronic inflammation.
2. ESR of 6 virtually rules out chronic inflammation or malignancies. Reticulocyte count of 1.6% rules out hemolysis. FOB test rules out bleeding in GIT. Your hemoglobin is only mildly reduced i.e. 12.7g%. Around 13g% would be considered normal and a mild reduction could not cause these symptoms.
3. Iron levels are good. However, Vit B12 or folic acid assay is not done. Early deficiency stages of these vitamins can cause normocytic normochromic which later on progresses to macrocytic normochromic. Most of your symptoms are neural related and I strongly suspect vitamin deficiencies, particularly B12 and folic acid.
4. You can start yourself on nutritional supplements - multivitamin with minerals and specifically also add B12 and folic acid. Also improve your diet with fish, egg white, red meat, green leafy vegetables.
Difficult to identify trace vitamin or mineral deficiencies. Load yourself with B12 and folic acid. They are water soluble and have no toxicity.
All other medications to be continued as usual. Hydrate well and have a good balanced diet with moderate exercises.
At present, I am not seeing any specific diagnosis being made.
Testosterone - mild reduction cannot cause so many symptoms.
Nutritional deficiencies could be a possible cause, which has led to mild anemia and other symptoms.
Anemia of 12.7g% does not cause any of the symptoms you are suffering from.
Improve your diet. If possible attach your whole reports. I will try to help you more.
Hope it helps.
Any further queries, happy to help again.
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Thank you for your prompt reply Dr.
I developed the same theory as you, and began supplementing B-complex on the off chance I had developed Beriberi. I neglected to mention in March my folate and B12 were both in the top 2/3 range. All of my nutritional values have been normal, except a decrease in HDL from 41 to 30. At the onset of my symptoms, my CBC was wholly unremarkable so the anemia was and still is asymptomatic.
My MCV has actually dropped from 91.1 in XXXXXXX to 83.7 at present, so megaloblastic anemia seems rather unlikely to me. Are there any micronutrient deficiencies that you know of that display this type of pattern or could an endocrine issue cause hypoproliferation anemia? I was following a differential algorithm from the NIH which said that if the corrected RI is below 2.5%, to suspect hypoproliferation. I calculated mine at 2%.
I developed the same theory as you, and began supplementing B-complex on the off chance I had developed Beriberi. I neglected to mention in March my folate and B12 were both in the top 2/3 range. All of my nutritional values have been normal, except a decrease in HDL from 41 to 30. At the onset of my symptoms, my CBC was wholly unremarkable so the anemia was and still is asymptomatic.
My MCV has actually dropped from 91.1 in XXXXXXX to 83.7 at present, so megaloblastic anemia seems rather unlikely to me. Are there any micronutrient deficiencies that you know of that display this type of pattern or could an endocrine issue cause hypoproliferation anemia? I was following a differential algorithm from the NIH which said that if the corrected RI is below 2.5%, to suspect hypoproliferation. I calculated mine at 2%.
Brief Answer:
Not hypoproliferative anemia
Detailed Answer:
Hi,
Thanks for asking again.
You are not having hypoproliferative anemias, even though your reticulocyte count is 1.6%. Normal range is between 0.5-2%.
If it is more, we can think of hemolytic anemias. It is within normal range.
Good to know, your Vit B12 is within the normal range. 12.7% is good and anemia is not the present cause for any of your symptoms.
There are multiple micronutrients like selenium, copper and also vitamins like B1, B6 which influence blood cells. You can improve your nutrtion with diet rich in fish, egg white, red meat, green leafy vegetables. Take a multivitmain supplement, as many times, difficult to identify micronutrient deficiency.
This will also improve your immunity. Try to maintain a active life, with moderate exercises. It improves circulation.
Also avoid alcohol, smoking and irregular sleep schedule.
Do you have any back pain? If only parasthesia of legs and no arms are involved, a neural compression and early lumbar spondylosis also needs to be thought of. Would require an X-ray or MRI for evaluation.
Hope your WBC count is normal. Any eosinophilia is seen? suggest recurrent allergy leading to nasal congestion? Is it still present?
You can try to stop androgel for a few days, and see if any of the symptoms are reduced or whether it will get exacerbated. You testosterone is only mildly reduced.
Hope it helps.
Any further queries, happy to help again.
Dr. Jyothi BL
Not hypoproliferative anemia
Detailed Answer:
Hi,
Thanks for asking again.
You are not having hypoproliferative anemias, even though your reticulocyte count is 1.6%. Normal range is between 0.5-2%.
If it is more, we can think of hemolytic anemias. It is within normal range.
Good to know, your Vit B12 is within the normal range. 12.7% is good and anemia is not the present cause for any of your symptoms.
There are multiple micronutrients like selenium, copper and also vitamins like B1, B6 which influence blood cells. You can improve your nutrtion with diet rich in fish, egg white, red meat, green leafy vegetables. Take a multivitmain supplement, as many times, difficult to identify micronutrient deficiency.
This will also improve your immunity. Try to maintain a active life, with moderate exercises. It improves circulation.
Also avoid alcohol, smoking and irregular sleep schedule.
Do you have any back pain? If only parasthesia of legs and no arms are involved, a neural compression and early lumbar spondylosis also needs to be thought of. Would require an X-ray or MRI for evaluation.
Hope your WBC count is normal. Any eosinophilia is seen? suggest recurrent allergy leading to nasal congestion? Is it still present?
You can try to stop androgel for a few days, and see if any of the symptoms are reduced or whether it will get exacerbated. You testosterone is only mildly reduced.
Hope it helps.
Any further queries, happy to help again.
Dr. Jyothi BL
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Answered by
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