2

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Can you have inflammation and not know about it? (and how it relates to ferritin levels)

Answered on September 12, 2014
Created July 02, 2012 at 2:22 AM

I have been reading about inflammation raising ferritin levels.
Which made me think, even if your tested ferritin level comes back as a good number, could it still be possible that it is actually at a ???good??? level due to it being raised by inflammation...and without the inflammation the real ferritin level would be below optimal (inflammation may be raising tested ferritin levels, from sub-optimal to optimal).

So, let???s say that as far as you can tell, you are well, your body fat levels are good, you have no pain or any other symptoms;
Can you still have inflammation somewhere (raising ferritin levels) without any symptoms?
I guess this would be called asymptomatic inflammation, does it exist?

Edit:
Here is one example of some of the info 'out there' that prompted my question, this particular text is from stopthethyroidmadness http://www.stopthethyroidmadness.com/ferritin/;
"...Can my ferritin look great, but my iron levels are not? Do I need other iron labs done along with ferritin?
You betcha. Because as mentioned above, ferritin can look optimal, yet your other iron labs reveal you have poor iron levels. Why would the ferritin look good when the others don???t? Because ferritin can rise in the presence of inflammation (very common), infection or even cancer. TIBC will also tend to go high in the presence of low iron. Inflammation of any kind is especially common with some thyroid patients and needs to be discovered and treated, such as using flavonoid-rich foods like krill oil, as well as turmeric (containing curcumin), Lauricidin or ginger capsules.
Ferritin rises to counter the normal binding of tissue iron due to the infection or inflammation..."

Another example from http://labtestsonline.org/understanding/analytes/ferritin/tab/test "...Ferritin is an acute phase reactant and thus may be increased in people with inflammation, liver disease, chronic infection, autoimmune disorders, and some types of cancer. Ferritin is not typically used to detect or monitor these conditions..."

121a16aded2bed8dca492d3c9662ef4c

(1327)

on July 05, 2012
at 12:51 PM

I think the way to think about is: the likelihood of an iron deficiency declines with increasing ferritin. People with chronic disease can be functionally iron-deficient even with high ferritin levels (people on dialysis come to mind). Those are special cases, though, and require a totally different treatment strategy.

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 05, 2012
at 06:56 AM

epic, thanks for taking the time to post. With regards to serum Ferritin and iron, it seems you could say that if ferritin is low, then you may (likely?) have an iron deficiency. But if it is normal or high....it is still possible that that you may have an iron deficiency. Normal ferritin by itself cannot rule out iron deficiency. Which kinda answers my question, inflammation &/or infection can raise ferritin so it 'looks' normal. & it may be hard to tell if/when you have inflammation &/or infection

4ef079c57d2140bba4dbf4e30240a645

(4413)

on July 02, 2012
at 04:39 AM

Very interesting Daz and as with most things I think it doesnt always happen. "Ferritin... thus may be increased with..." Fro me when I had chronic infection and allergies and inflammation and an auto immune thyroid disease, my ferritin was LOW. As digestion and diet has improved & I no longer have an active autoimmune disease (my tpo is now in the negative range), my ferritin is now better than ever. Still too low but better and I do not take Iron!

4ef079c57d2140bba4dbf4e30240a645

(4413)

on July 02, 2012
at 04:35 AM

Yes. Get a full iron study and also ask for the high sensitivity CPR or Cardiac CRP. 1.00 or below is Ideal/Optimal but you definitely want it no higher than 1.5. Best of luck.

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 02, 2012
at 04:29 AM

so, as i say, it may be better to get a full iron panel done, rather than rely soley of ferritin as a marker for iron. Where i live doctors generally just do a ferritin test (for iron). getting a full iron panel can cost or take some persuasion.

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 02, 2012
at 04:27 AM

thx Crowlover. actually i am not at all concerned with my ferritin level. its been right where i like it over my last three tests (between 40 & 75). But after reading that inflammation/infection could raise ferritin, i was wondering if even low levels of ferritin could be misleading with regards to iron stores, & better to get a full iron panel done. eg. inflammation/infection has raised ferritn level to say 35 ng/ml, when without the inflammation/infection it may be too low. But may be none of this applies to low level ferritin (eg sub 200 ng/ml).

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 02, 2012
at 04:11 AM

after your comments, been doing some more googling on "ferritin inflammation" & also "ferritin infection". there is quite a bit of info out there. but may be it is more/only applicable with higher range ferritin levels. Labtestsonline reads "Ferritin is an acute phase reactant and thus may be increased in people with inflammation, liver disease, chronic infection, autoimmune disorders, and some types of cancer. Ferritin is not typically used to detect or monitor these conditions" http://labtestsonline.org/understanding/analytes/ferritin/tab/test

4ef079c57d2140bba4dbf4e30240a645

(4413)

on July 02, 2012
at 03:01 AM

Right! I agree and now that you mention it, my ferritin has been lowest at points when I had the most inflammation as measured by labs for Tpo Antibodies and Cardiac CRP.

6120c989fd5b69f42a0834b69b87955b

(24553)

on July 02, 2012
at 02:57 AM

I've read that really high ferritin can cause inflammation, but I hadn't heard about it being influenced the other way around, either way, I doubt it is a linear equation. In the past I've had a lot of inflammation and simultaneously had ferritin levels that were off the bottom of the reported range at 7. If one is directly tied to the other, I would have either had higher ferritin, or started with none at all.

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2 Answers

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121a16aded2bed8dca492d3c9662ef4c

on July 04, 2012
at 07:24 PM

Hi Daz -- I saw this a couple of days ago and thought, "This is right up my alley", but didn't answer because I wasn't sure I completely understood your question.

I'll give it a try now :)

The first part:

Which made me think, even if your tested ferritin level comes back as a good number, could it still be possible that it is actually at a ???good??? level due to it being raised by inflammation...and without the inflammation the real ferritin level would be below optimal (inflammation may be raising tested ferritin levels, from sub-optimal to optimal).

The answer to this question is: it absolutely can. This case report describes an 83 year-old man who had restless legs syndrome that was unresponsive to drug therapy. He had a history of heart disease, slightly elevated erythrocyte sedimentation rate, and a ferritin level of 93 ??g/L. There was no anemia:

Blood tests were essentially normal. In particular, hemoglobin was 12.7 g%, mean corpuscular volume was 89, transferrin saturation was 25% and serum ferritin was 93 ??g/L. ESR was slightly elevated at 52.

He was treated with oral iron, ferrous fumarate equivalent to 90 mg of oral iron per day. After 4 months, the ferritin level was 136 ??g/L. (By this point his RLS had almost totally resolved.)

The interesting thing about this case report is the astounding finding that a bone marrow biopsy tested negative for iron, despite a ferritin level of 93 ??g/L and a blood count which would not qualify as anemia!

Where to set the point at which an elevated ferritin level rules out an iron deficiency is an open question. I know of no published evidence that establishes a relationship between other markers of inflammation and ferritin levels, so this is one area where a great deal of care and attention is needed to avoid missing what may indeed be an iron deficiency.

The British Columbia Ministry of Health's clinical practice guidelines remind physicians that the ferritin level is a factor in determining the probability of iron deficiency:

Serum ferritin levels and iron status:

Adults (ug/L)

less than 15 ??? diagnostic of iron deficiency

15 - 50 ??? probable iron deficiency

50 - 100 ??? possible iron deficiency

more than 100 ??? iron deficiency unlikely

persistently more than 1000 ??? consider test for iron overload

Children (ug/L)

less than 12 ??? diagnostic of iron deficiency

Of note, the guidelines also say:

  • may be unreliable in patients with chronic disease or malignancy

  • non-hematologic symptoms can occur when the serum ferritin is in the low normal range (less than 50 ug/L)

  • higher levels of serum ferritin do not exclude iron deficiency

  • persistently elevated serum ferritin levels (greater than 1000 ug/L), but without chronic inflammatory disorder ??? recommend testing for iron overload (refer to Iron Overload - Investigation and Management)

The second last one is what gets people into trouble.

You asked about my labs. Here they are:

Test 1: December 14, 2010:

RBC 4.2 * 10^6 /??L [L!]

hemoglobin 129 ??g/L [L!]

haematocrit 38% [L!]

platelets 222 * 10^3 /??L [L!]

MCH 30 pg

MCHC 34 g/dL

MCV 89 fl

This is mild anemia. No intervention recommended. Gamma globulins were elevated on this test, so the doctor suspected an infection as the cause of the anemia.

Test 2: January 4, 2011

RBC 4.7 * 10^6 /??L

hemoglobin 14.2 ??g/L

haematocrit 42%

platelets 214 * 10^3 /??L

MCH 30 pg

MCHC 34 g/dL

MCV 89 fl

ferritin 95,7 ??g/L

Suddenly, the anemia is gone. The ferritin has been tested and is normal. Note that at this point, all I have done since the last appointment is take some B-vitamins. I was not eating a paleo diet yet. By now, the doc has ruled out an iron deficiency as the cause of my troubles.

Test 3: June 3, 2011

This was done by the endocrinologist. By this point I have seen not one but four specialists. I am getting sick of doctors.

RBC 4.6 * 10^6 /??L

hemoglobin 139 ??g/L

haematocrit 39%

platelets 199 * 10^3

MCH 31 pg

MCHC 36 g/dL

MCV 86 fl

ferritin 99.3 ??g/L

Test 4: June 6, 2011

Three days later, I am back at my primary physician. For some reason, he orders a serum iron alone, and thinks to check CRP:

RBC 4.6 * 10^6 /??L

hemoglobin 139 g/L

haematocrit 40%

platelets 240 * 10^3

MCH 31 pg

MCHC 35 g/dL

MCV 87 fl

serum iron 188 g/L [H!]

CRP (standard) <0.8 mg/L

The MCV on the last two tests has been lower. The serum iron is high; it has a circadian rhythm and can vary enormously, but as this is a single measurement and not alarmingly high, and since everything else looks okay, the doc doesn't think it is of interest.

Test 5: August 2011

I saw a second endocrinologist in August. (Unfortunately, I do not have a copy of the labs. I am due for a follow up this coming September, and I'll ask for one.)

On reviewing the labs with me, he said I appeared mildly anemic, asked about my dietary habits and recommended I make an effort to get more iron in my diet (I presume he measured ferritin and did a blood count; he wrote me a letter that covered only the endocrinological aspects of the test results).

Test 6: December 12, 2011

RBC 4.5 * 10^6 /??L

hemoglobin 136 g/L [L!]

haematocrit 41%

platelets 206 * 10^3 /??L

MCH 30 pg

MCHC 33 g/dL

MCV 91 fl

Vitamin D is checked at this visit because I was complaining of joint pain and had been deficient in the past. It is 21 ng/mL (52 nmol/L), so I go back on supplementation.

Test 7: February 19, 2012

I am back in my old hometown and go to see my previous doctor. He has seen me every year or so the past few years. Some things have gotten better over the last 18 months, other things worse. To rule out inflammatory disease he orders a range of tests.

I have been paleo for about two months at this point, but I still don't feel right. My sleep -- never good to begin with -- is getting worse, and I'm depressed. All my muscles are sore and tense. I can't concentrate, which makes work difficult.

lipid panel

total cholesterol 5.52 mmol/L [H!]

triglycerides 0.49 mmol/L [L!]

HDL cholesterol 2.26 mmol/L

total:hdl ratio 2.4

LDL, calculated 3.04 mmol/L

His words: "This looks fine. You have lots of the good stuff, so I see no reason to be concerned about your cholesterol."

Inflammatory markers:

erythrocyte sedimentation rate 7 mm/h

CRP (sensitive) 0.1 mg/L

The blood count:

RBC 4.3 * 10^6 /??L [L!]

hemoglobin 132 g/L [L!]

haematocrit 39% [L!]

platelets 208 * 10^3 /??L

MCH 30.6 pg

MCHC 33.8 g/dL

MCV 92 fl

The "anemia light" is back, and...

ferritin 11 ??g/L [L!]

to which I can only say, what the hell happened here?

The doctor prescribes iron replacement. Minimum duration 3 months, with a follow-up recommended at 4 weeks. I started taking 70 mg of elemental iron per day, in the form of ferrous gluconate.

Test 8: April 13, 2012

After five weeks of iron replacement, now back with the doctor who ordered the first three tests:

RBC 4.8 * 10^6 /??L (Never in all my years has the RBC been this high.)

hemoglobin 142 g/L

haematocrit 45% (Ditto for hematocrit.)

platelets 253 * 10^3 /??L (Ditto.)

MCH 29 pg (My poor bone marrow has never been so happy in its entire existence. Finally getting enough iron, it's churning out red blood cells so fast the MCH is actually dropping.)

MCHC 33.8 g/dL

MCV 93 fl

iron panel:

serum iron 124 ??g/L

ferritin 35.9 ??g/L [L!]

transferrin 296 ??g/L [H!]

transferrin saturation 29.7% (I had taken an iron tablet about 90 minutes before testing.)

The total iron binding capacity is high. Even though ferritin has gone up 25 ??g/L, it's clear that the system is still iron-hungry. (This throws a new light on Test 4 from the previous June, after I had started running regularly; without a TIBC result, I can only speculate, but my hunch is that the serum iron was elevated because my TIBC was going up. More transferrin means increased absorption from diet.)

Upon seeing this result, the doc says he wants me on iron for at least three more months, with follow-up testing at that time. That's scheduled for the end of July.

The hematological response to the iron replacement is apparent and this response is considered (quite apart from the low ferritin on the previous test) diagnostic of iron deficiency.

This is despite the fact that I had anemia sometimes, and sometimes not, and always very mild. The hemoglobin was nearly always normal. Ferritin was normal as late as June 2011, and all the while -- already in 2010 -- I had the same symptoms which are now going away on iron replacement.

So: In a person with symptoms, these tests are simply inadequate.

I honestly can't say whether the ferritin at 95 ??g/L was an accurate reflection of my iron stores. The other inflammatory markers were unremarkable, but I suspect that something was going on. It may have been as simple as light inflammation caused by lots of physical activity. I am very physically active. I'm convinced that an active person "consumes" iron in ways a sedentary person does not (one does refer to "runners anemia" in the medical literature.)

But apart from all the labs, which are really just tools, I feel the best I have in years. All the things I mentioned in this answer still hold true, only even more so a month later.

And that's what counts.

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 05, 2012
at 06:56 AM

epic, thanks for taking the time to post. With regards to serum Ferritin and iron, it seems you could say that if ferritin is low, then you may (likely?) have an iron deficiency. But if it is normal or high....it is still possible that that you may have an iron deficiency. Normal ferritin by itself cannot rule out iron deficiency. Which kinda answers my question, inflammation &/or infection can raise ferritin so it 'looks' normal. & it may be hard to tell if/when you have inflammation &/or infection

2
4ef079c57d2140bba4dbf4e30240a645

on July 02, 2012
at 02:44 AM

Dang Daz this is a REALLY good question.

How high is your ferritin? I mean unless its really really high... that's not a worry.

I think its easy to ignore inflammation as something else, or rather to attribute some symptoms that may be inflammation to other things. Especially if you are young.

I get my Cardiac CRP (or high sensitivity CRP) level checked 3 x year as Ive had inflammatory issues and I am working to lower it through diet and supplements and in fact have lowered it significantly I want mine no higher than 1.00 and it is now 1.20 so Im getting close!!

Most every disease or illness has inflammation and oxidative stress at its root.
An unhealthy gut or dysbiosis and or leaky gut for instance all have inflammation as one of the underlying problems.

I guess I wonder why you are so concerned about Ferritin?

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 02, 2012
at 04:27 AM

thx Crowlover. actually i am not at all concerned with my ferritin level. its been right where i like it over my last three tests (between 40 & 75). But after reading that inflammation/infection could raise ferritin, i was wondering if even low levels of ferritin could be misleading with regards to iron stores, & better to get a full iron panel done. eg. inflammation/infection has raised ferritn level to say 35 ng/ml, when without the inflammation/infection it may be too low. But may be none of this applies to low level ferritin (eg sub 200 ng/ml).

4ef079c57d2140bba4dbf4e30240a645

(4413)

on July 02, 2012
at 04:35 AM

Yes. Get a full iron study and also ask for the high sensitivity CPR or Cardiac CRP. 1.00 or below is Ideal/Optimal but you definitely want it no higher than 1.5. Best of luck.

543a65b3004bf5a51974fbdd60d666bb

(4493)

on July 02, 2012
at 04:29 AM

so, as i say, it may be better to get a full iron panel done, rather than rely soley of ferritin as a marker for iron. Where i live doctors generally just do a ferritin test (for iron). getting a full iron panel can cost or take some persuasion.

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