Iron dysregulation and inflammatory stress erythropoiesis associates with long-term outcome of COVID-19, 2024, Hanson et al

Thanks for comments.

I had recently the standard stool test for blood and that was negative. (Have been getting them every couple of years for a while now as routine screening, because of age. Don't know how definitive they are. Also my stools have always been normal colour, for what that is worth.)

Started taking the iron supplement with orange juice initially, but swapped to a 500mg Vit C tablet. No sugar to deal with, a lot cheaper, and doesn't take up fridge space.

Was already thinking about alternating daily between a Maltofer tablet and eating something iron rich like liver or some beef to minimise the side effects of the Maltofer. So will try that.

One thing I am fairly sure of is that I am not lacking iron in my normal diet to start with. Whether I am able to absorb it properly, or am losing it somehow (e.g. GI bleeding), is another question.

It may be possible it is just going to take a long time to get the levels back up. OTOH, after 3 months of 2 x 100mg Maltofer daily it had barely moved from 6 to 10 (minimum is 35, IIRC).
 
Sean said:
I had recently the standard stool test for blood and that was negative.
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I don't know if this is still true - the tests may have improved in the last 10 - 15 years. But the FOBT (Faecal Occult Blood Test) from years gone by had a high risk of giving false positive and false negative results. Just taking vitamin C or eating lots of citrus fruits (which have high levels of vitamin C) or antacids could give false negatives or false positives (I can't remember which).

https://www.ncbi.nlm.nih.gov/books/NBK537138/
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2729926
https://www.mayoclinic.org/tests-procedures/fecal-occult-blood-test/about/pac-20394112
 
Sean said:
Thanks for comments.

I had recently the standard stool test for blood and that was negative. (Have been getting them every couple of years for a while now as routine screening, because of age. Don't know how definitive they are. Also my stools have always been normal colour, for what that is worth.)

Started taking the iron supplement with orange juice initially, but swapped to a 500mg Vit C tablet. No sugar to deal with, a lot cheaper, and doesn't take up fridge space.

Was already thinking about alternating daily between a Maltofer tablet and eating something iron rich like liver or some beef to minimise the side effects of the Maltofer. So will try that.

One thing I am fairly sure of is that I am not lacking iron in my normal diet to start with. Whether I am able to absorb it properly, or am losing it somehow (e.g. GI bleeding), is another question.

It may be possible it is just going to take a long time to get the levels back up. OTOH, after 3 months of 2 x 100mg Maltofer daily it had barely moved from 6 to 10 (minimum is 35, IIRC).
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Really hope you/your docs figure it out. Do keep badgering them to follow you up if they're not doing that already or if your levels aren't going up. Good luck with all the tests. Crossing fingers for you.
 
Just wondering how you're getting on now in terms of iron, @Sean ?

My ferritin, transferrin saturation and serum iron have dropped again. In a sense this is good, because I've been feeling extra-crappy and now I know why. My hair is also falling out, having never fully replenished itself after I was severely anaemic a couple of years ago. Am waiting for an iron infusion as I can't tolerate any oral iron supplements.
 
Evergreen said:
Just wondering how you're getting on now in terms of iron, @Sean ?

My ferritin, transferrin saturation and serum iron have dropped again. In a sense this is good, because I've been feeling extra-crappy and now I know why. My hair is also falling out, having never fully replenished itself after I was severely anaemic a couple of years ago. Am waiting for an iron infusion as I can't tolerate any oral iron supplements.
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Can I ask is your haemoglobin/haematocrit/rbc ‘not low’ - which is apparently polycythemia (of some type) ?

Or are they all low ?
 
bobbler said:
Can I ask is your haemoglobin/haematocrit/rbc ‘not low’ - which is apparently polycythemia (of some type) ?

Or are they all low ?
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Ferritin, transferrin saturation and serum iron are the only ones that are low for me at this point. All other measures, including haemoglobin, are in the normal ranges. What I have is iron deficiency, and if I don’t get an iron infusion, that will keep going until haemoglobin also drops below the normal range, and it’s offically iron deficiency anaemia rather than just iron deficiency.

I found this which lays out how iron deficiency anaemia develops – I’m probably somewhere between stage 2 and stage 3:
https://www.msdmanuals.com/professi...esis/iron-deficiency-anemia#Diagnosis_v969037

Stages of iron deficiency

Laboratory test results help stage iron deficiency anemia.

Stage 1 is characterized by decreased bone marrow iron stores; hemoglobin (Hb) and serum iron remain normal, but the serum ferritin level falls to < 30 ng/mL (< 67.4 pmol/L). The compensatory increase in iron absorption causes an increase in iron-binding capacity (transferrin level).

During stage 2, erythropoiesis is impaired. Although the transferrin level is increased, the serum iron level decreases; transferrin saturation decreases. Erythropoiesis is impaired when serum iron falls to < 50 mcg/dL (< 9 micromol/L) and transferrin saturation to < 16%. The serum transferrin receptor level rises (> 8.5 mg/L).

During stage 3, anemia with normal-appearing RBCs and indices develops.

During stage 4, microcytosis and then hypochromia develop.

During stage 5, iron deficiency affects tissues, resulting in symptoms and signs.
[bolding added]
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I am not a doctor, but from what I can see, polycythaemia is a different scenario altogether, where haemoglobin can be high, and treatment can include phlebotomy. I’m in the opposite camp.
 
Evergreen said:
Ferritin, transferrin saturation and serum iron are the only ones that are low for me at this point. All other measures, including haemoglobin, are in the normal ranges. What I have is iron deficiency, and if I don’t get an iron infusion, that will keep going until haemoglobin also drops below the normal range, and it’s offically iron deficiency anaemia rather than just iron deficiency.

I found this which lays out how iron deficiency anaemia develops – I’m probably somewhere between stage 2 and stage 3:


I am not a doctor, but from what I can see, polycythaemia is a different scenario altogether, where haemoglobin can be high, and treatment can include phlebotomy. I’m in the opposite camp.
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Me too, but it is termed as some form of polycythemia even where ferritin is very low and the rest in normal range (but probably high end)

if the iron is high end or keeps increasing your haematocrit / rbc etc but not ferritin (stored) ie like the proportion (from ‘intake’) going to each is ‘off’ vs normal, rather than absorption if neither are sufficient and the haemoglobin drops next. I don’t know where the line is because you get different causes and there is relative polycythemia etc too (and which of these is that really?)

I mention it because quite a few pwme seem to have this type of thing or polycythemia and because this paper talks of erythropoiesis.
 
Evergreen said:
Just wondering how you're getting on now in terms of iron, @Sean ?

My ferritin, transferrin saturation and serum iron have dropped again. In a sense this is good, because I've been feeling extra-crappy and now I know why. My hair is also falling out, having never fully replenished itself after I was severely anaemic a couple of years ago. Am waiting for an iron infusion as I can't tolerate any oral iron supplements.
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Thanks for asking.

The only low reading I am getting is ferritin, but very low. The other iron measures seem more-or-less okay, including no anaemia.

Had real trouble getting the ferritin level to even start coming up, took a year of daily iron to move it from 12 to just 46, which is barely into the minimum 'healthy' level (30-250, IIRC). Soon as I stopped taking it started falling quickly again. Went from 46 to 20 in two months, despite a diet that should have enough iron in it.

Standard oral iron supplements (ferrous sulphate, and Maltofer), in pill form, were very unpleasant to deal with. Lot of gut pain and bowel disruption. Switching to the liquid form of Maltofer solved the pain, but not the bowel trouble.

Gastroenterologist said the gut tends to settle down in most patients once it gets used to the iron supplements, but didn't for me. Was talking about starting me on direct infusions of iron.

But some good news: I have recently discovered a fairly new product developed in Italy that uses a completely different method of iron delivery (SiderAL Forte, in capsule form). It somehow hides the iron from the gut's natural defence mechanism against being exposed to excessive iron. Only started it recently so don't know how effective it is yet at raising levels. But no pain so far, and bowel seems to be finally settling down.

Looks like I have some kind of problem absorbing iron in the gut, at least from food and standard supplements.

Due for another iron test soon. So we shall see.
 
bobbler said:
Me too, but it is termed as some form of polycythemia even where ferritin is very low and the rest in normal range (but probably high end)

if the iron is high end or keeps increasing your haematocrit / rbc etc but not ferritin (stored) ie like the proportion (from ‘intake’) going to each is ‘off’ vs normal, rather than absorption if neither are sufficient and the haemoglobin drops next. I don’t know where the line is because you get different causes and there is relative polycythemia etc too (and which of these is that really?)

I mention it because quite a few pwme seem to have this type of thing or polycythemia and because this paper talks of erythropoiesis.
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All I know is mine is not a form of polycythemia! I don't have high or nearly high red cell count, haematocrit or haemoglobin.

I can't parse the second sentence so can't comment on that.

Yeah, I dunno, I don't think there's any good evidence of a link between ME/CFS and iron issues, but it would be interesting if there were one. Iron deficiency anaemia is common, and iron deficiency without anaemia even more so, particularly among menstruating females, so there's bound to be plenty of it in the population of people with ME/CFS. We're also probably more likely than the average person to be getting blood tests done so things that might go unnoticed in a healthy person might get documented for us.
 
Have you had your ceruloplasmin levels tested? Mine was below ref range when my ferritin kept dropping for 25 years.
  • Role in Iron Metabolism:
    Ceruloplasmin plays a role in iron metabolism, specifically in the release of iron from cells and its transport in the blood.
  • Iron Transfer: Ceruloplasmin and ferritin are involved in the transfer of iron in and out of cells.
 
Sean said:
Looks like I have some kind of problem absorbing iron in the gut, at least from food and standard supplements.
Due for another iron test soon. So we shall see.
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Good to hear how you’re doing.

That’s a long time with unpleasant side effects. Great that you’ve found a supplement you might be able to tolerate better. But it sounds like you’ve definitely earned the right to regular iron infusions!

My ferritin was 2 a couple of years ago when I had severe iron-deficiency anaemia, rose to 154 after an iron infusion, dropped to 23 nine months later, and is now at 9. In females it drops during menstruation so my mean ferritin for the month is likely lower than 9.

I looked back in old tests and ferritin was measured 6 times since 2010 as I worked my way down from mild to severe. It was below the range you quoted 3 times and within it 3 times (but only 30-40). I've no idea if I ever had nice middle-of-the-range levels of ferritin.

I know we’re not in the same position because I’m female and you’re male, but clearly neither of us can hang onto iron for long!

Hope your next test goes well.:thumbup:

Edited to change "nice high levels of ferritin" to "nice middle-of-the-range levels of ferritin" since that's what I meant.
 
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Mij said:
Have you had your ceruloplasmin levels tested? Mine was below ref range when my ferritin kept dropping for 25 years.
  • Role in Iron Metabolism:
    Ceruloplasmin plays a role in iron metabolism, specifically in the release of iron from cells and its transport in the blood.
  • Iron Transfer: Ceruloplasmin and ferritin are involved in the transfer of iron in and out of cells.
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I've never heard of it but it sounds blue!
 
Getting back to the Hanson article, this is interesting:
Speculatively, the generally increased prevalence of iron deficiency in pre-menopausal women may contribute to the higher risk of PASC amongst this demographic7,9,10 by enhancing the relative magnitude of infection-related iron redistribution against a baseline of lower iron stores.
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It is unlikely that these observations are SARS-CoV-2 specific. Disruption of host iron homeostasis is a consequence of many viral infections, both through direct viral mechanisms of interference and as a consequence of the evoked inflammatory response50,84. Many infectious diseases—including Ebola85,86, influenza87 and SARS88—elicit broadly similar post-acute sequelae, suggesting similar iron-redistribution strategies may be considered. This study has implicated disrupted iron homeostasis and iron-deprived stress erythropoiesis that persisted for more than 2 weeks from symptom onset as potential drivers of PASC.
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I would like to go back in time, please. With an iron infusion.
 
Mij said:
@Sean am I reading this correctly that SiderAL Forte has 30,000mg of iron (214%) per capsule??
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Evergreen said:
In Italy, France etc the comma is used where other countries would have a period so I think it's 30.00mg i.e. 30mg of iron.
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30mg is correct.

IIRC, in Europe they use the comma instead of the period for the decimal point, to avoid confusion because the period can also represent multiplication.
 
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