Nucleated RBC 1

[Doug_2]

I just got my labs for my yearly physical back. I am 54 year old white male with no underlying health issues and just taking cholesterol meds. All my bloodwork are in normal range except for Bilirubin (it’s always high) and Nucleated RBC which was 1. I have never had that before. They corrected the WBC and that’s normal along with all the rest of my bloodwork. I am real confused and worried with all the bad outcomes associated with NRBC. I called my family Dr. and he was confused too and couldn’t explain it and said he would look into it before my physical next week. I am worried sick over it and would like to hear your opinion. Could it be a bad test? Thanks  

[Ken_PA]

I'm glad to see this end well, Doug. Thanks for the update.

[Doug_2]

Thanks Ken for taking he time to answer my questions.

[Ken_PA]

I'm glad to be of help. Let me know how things go.

[Doug_2]

My family doctor wasn’t concerned at all and said it’s because of stress and said see you next year.

[Doug_2]

I should add he said that after my full physical and he said everything else is normal. It’s just scary to see that NRBC suddenly show up out of nowhere.

[Ken_PA]

With that rodent study, no need to read it. Just take a quick look at Fig 5d, and you can see that unstressed rodents have low nRBCs from the spleen, but stressed rodents have much higher nRBCs. That little black and white graph is the only thing possibly relevant to your case. Docs rightfully won't care about rodent studies, but still it gives a glimmer of an idea about why your NRBCs are present.

[Ken_PA]

Wow, Doug, posting all the ranges made it super easy to see that you are super normal.  :)

If you are very worried nevertheless, you can push to get a smear done. Usually the error occurs when NRBCs are really present, but they are not detected because they get mistaken to be WBCs. I suppose, though, it is theoretically possible for the opposite to occur: your automated analysis *thinks* there are NRBCs, but there really aren't. Are you following me on that?

But still, if a smear test does show that NRBCs are indeed present, it's possibly more of a curiosity than something bad.

[Doug_2]

Your answer make perfect sense and thanks for taking the to answer my concerns. Thanks again

[Ken_PA]

"pantoprazole on occasion. I was taking it for a few days before the test."

The idea there is that reducing acid means iron won't get absorbed as well, and iron is needed to make proper RBCs. Maybe that's a contributing factor. Maybe not.

"My stress level has been real high for a few months"
Maybe that's a contributing factor. Stress can affect blood cell production.

Well, the following is not a very convincing cite, as it concerns only rodents. But it did demonstrate that social stress increases release of NRBCs, a lot. In figure 5D:
https://www.cell.com/cell-reports/pdf/S2211-1247(18)31724-8.pdf

Your doc might not be impressed with that rodent study. It does say that the NRBCs are produced in the speen, not as usual in the bine marrow - so that's an unusual thing and is probably not known well yet.

Your doc might decide to get a smear test done (which would be in a separate report). Your doc might decide to just wait 2-3 months and redo your automated CBC - especially as your RBC is high end of normal, so there is probably not destruction or bleeding going on.

I'm guessing your doc is not very alarmed by this. Btw, were you subjected to any toxins/poisons? Inhaled, or food/water?

[Doug_2]

I haven’t been exposed to things as far as I know.

[Ken_PA]

"Could it be a bad test?"
Usually, automated analyzers look at a sample of blood. They can make mistakes. But a followup blood smear is done by a person with a microscope. That is unlikely to produce a mistake. I'm assuming you had the blood smear done. Correct?

[Doug_2]

I am not sure if a blood smear was done the results didn’t say.

[Doug_2]

Ken here are my complete CBC:

Narrative
Fasting patient
Component Results
WBC
Your Value
6.1 10*3/uL
Standard Range
4.0 - 12.0 10*3/uL
Corrected WBC
RBC
Your Value
5.10 10*6/uL
Standard Range
3.50 - 5.55 10*6/uL
Hemoglobin
Your Value
15.8 g/dL
Standard Range
12.6 - 16.5 g/dL
Hematocrit
Your Value
44.4 %
Standard Range
42.0 - 49.5 %
MCV
Your Value
87 fL
Standard Range
80 - 100 fL
MCH
Your Value
30.9 pg
Standard Range
27.0 - 33.0 pg
MCHC
Your Value
35.5 g/dL
Standard Range
31.0 - 37.0 g/dL
Platelet Count
Your Value
242 10*3/uL
Standard Range
150 - 400 10*3/uL
RDW
Your Value
12.9 %
Standard Range
11.6 - 14.0 %
MPV
Your Value
8.5 fL
Standard Range
7.3 - 11.5 fL
Neutrophils
Your Value
67.6 %
Standard Range
49.0 - 81.0 %
Lymphocytes
Your Value
22.7 %
Standard Range
14.0 - 41.0 %
Monocytes
Your Value
6.6 %
Standard Range
0.0 - 11.0 %
Eosinophils
Your Value
2.2 %
Standard Range
0.0 - 6.0 %
Basophils
Your Value
0.9 %
Standard Range
0.0 - 3.0 %
Absolute Neutrophils
Your Value
4.10 10*3/uL
Standard Range
1.96 - 9.72 10*3/uL
Absolute Lymphocytes
Your Value
1.40 10*3/uL
Standard Range
0.56 - 4.92 10*3/uL
Absolute Monocytes
Your Value
0.40 10*3/uL
Standard Range
0.00 - 1.32 10*3/uL
Absolute Eosinophils
Your Value
0.10 10*3/uL
Standard Range
0.00 - 0.72 10*3/uL
Absolute Basophils
Your Value
0.10 10*3/uL
Standard Range
0.00 - 0.36 10*3/uL
Differential
Your Value
Automated
Nucleated RBC
Your Value
1

[Ken_PA]

Hi, Doug. What usually jumps out to anybody researching their potential health problem are the worst possible causes. That's only natural. So let's start with a possible blood cancer, which seems to be your main worry. For a leukemia, we'd expect abnormal cells counts on your WBC - which you dont have (e.g, very high lymphoctyes for a lymphocytic leukemia). If a leukemia or lymphoma were harming your normal bone arrow, we'd also expect other suspicious cells on your blood smear, which apparently you don't have. So at this point, there doesn't seem to be reason to suspect a blood cancer.

Overall, it's better to first consider what the most *likely* causes might be. Since you have no symptoms, some other causes are eliminated. But what about being low on oxygen somehow? Have you had any infections? Lead poisoning? If you press on your spleen, is it tender? Any drugs that suppress stomach acid? Intestinal bleeding? Yep, we're grasping at straws here. I'd tend to look at this as a medical mystery, rather than the onset of something disastrous. Btw, I think your doc is admirable for wanting to figure it out, rather than just pushing you off to a hematologist right away.

As for using logic? Bilirubin is a breakdown product of red blood cells; so then if RBCs go low because of destruction, your system rushes new NRBCs into circulation to compensate. That's another angle -- of seeing if anything is destroying your RBCs (hemolytic anemia, where "lytic" means destruction). Yet your RBC count is normal, so there's mystery there... unless it's very low normal.

[Doug_2]

I do have acid reflux and take pantoprazole on occasion. I was taking it for a few days before the test. My stress level has been real high for a few months for different reasons for what it’s worth.

[Doug_2]

RBC was 5.10 and the range is 3.5 to 5.55