Dramatically Elevated Folate Level

[aim-agm]

For a theoretical patient, what would you make of a folate level >44?

---

Members don't see this ad.

 

[gutonc]

In what theoretical context?

 

[aim-agm]

In what theoretical context?

One of anemia and general not doing well workup. In that workup Iron and B12 resulted as low, and there is an unexplained mild but chronic eosinophilia; already be on folic acid 1 mg daily, but that I wouldn't think that is enough to explain a result greater than the upper limit of detection in this theoretical context.

I honestly don't even begin to have a differential or understanding the clinical significance (if any) of a theoretical result like that.

 

[iniquus]

Easy, stop checking it.

 

[Crayola227]

Easy, stop checking it.

Normally I might agree, if we were talking an asymptomatic patient or one whose symptoms were easily explained by known diagnoses. This feels like we need more info.

 

[aim-agm]

Normally I might agree, if we were talking an asymptomatic patient or one whose symptoms were easily explained by known diagnoses. This feels like we need more info.

It's a pretty complex (theoretical) patient with a whole bunch of symptoms, and figuring out the cause each of the symptoms is difficult but progressing. I was surprised by the folate level, but more so have no idea what to do with it, if it matters, or why it might be so high. Hence this thread.

 

[mszzeta]

It's a pretty complex (theoretical) patient with a whole bunch of symptoms, and figuring out the cause each of the symptoms is difficult but progressing. I was surprised by the folate level, but more so have no idea what to do with it, if it matters, or why it might be so high. Hence this thread.

An elevated folate level is probably useless for the diagnostic purpose in the majority of clinical setting, no matter how "interesting" the patient is.

If you know experts who know genetical disorders involving the folate pathway, you may send them a email, or maybe talking to a Medical Geneticist (not sure if you have access to this speciality in your area). I have completely no knowledge about this. And these are really long shots.

 

[johnwalldance]

Agree with stop checking folate as folate deficiency seems to be exceptionally rare based on this article

Also they note - Intake of folate through a meal or ingestion of an oral supplement directly preceding evaluation of serum folate can lead to falsely elevated levels (false negatives).

Error - Cookies Turned Off

www.journalofhospitalmedicine.com

 

[Crayola227]

High Folate Levels: What Do They Mean? | Ro

Folate, also known as vitamin B9, is a water-soluble nutrient essential for creating healthy red blood cells and repairing DNA. Learn more.

ro.co

A search for "elevated folate levels" on Google was interesting.

I would first be concerned that the patient is taking too many multivitamins. While taking more folate than you need is generally not considered very dangerous, if this is a clue they are taking too much of some kind of pill/supplement or eating too much of certain foods, that might be good to know, and it might lead you to catch they are overdoing something genuinely dangerous.

Interesting patients with interesting things going on, are sometimes doing interesting things to themselves.

If I get a puzzingly high level of a vitamin in someone that otherwise it isn't obvious what it means, I probably want to explore whatever they're ingesting in greater detail.

Interestingly there is some association with cancer or dementia. So even when it seems like people are supposed to excrete something they are getting a lot of, I still would want to find out if there's a habit generating the issue and emphasize that it's possible to overdo just about anything. More is not always better.

 

[Crayola227]

What Causes High Folate Serum Levels? | Livestrong.com

The terms folate and folic acid are sometimes used interchangeably. Folate is a water-soluble B-complex vitamin. Common dietary sources of folate include cereals, leafy green vegetables, asparagus, legumes and organ meat.

www.livestrong.com

Obvs I don't think livestrong is a great source, but I'm googling at home for fun.

A lot of people here are admitting that we're not exactly experts on the weirder aspects of folate metabolism.

I think it might be worth considering in greater depth.

 

[HemeOncHopeful19]

Did they recently eat a sandwich or a bowl of cheerios?

Just don’t do like the midlevels in our system and click “stat refer to heme”

 

[sloh]

Diagnostic cascades. Don’t overtest, especially for vague subjective symptoms.

 

[aim-agm]

Did they recently eat a sandwich or a bowl of cheerios?

Just don’t do like the midlevels in our system and click “stat refer to heme”

I'll inquire with the (theoretical) patient

I wouldn't want to refer to heme for this, ya.

Thanks everybody for your input; sounds like nothing urgent. I guess my plan would be (in this theoretical case) to treat his B12 and iron deficiencies, chalk the high folate up to lab error/false increase/maybe increased absorption in response to other nutrition deficiencies.

 

[aafisahar]

it's basically impossible to be folate deficit in the modern world; like 1 slice of bread is enough folate for a month.

 

[Crayola227]

I'll inquire with the (theoretical) patient

I wouldn't want to refer to heme for this, ya.

Thanks everybody for your input; sounds like nothing urgent. I guess my plan would be (in this theoretical case) to treat his B12 and iron deficiencies, chalk the high folate up to lab error/false increase/maybe increased absorption in response to other nutrition deficiencies.

One thing I read said pernicious anemia could do as you've described.

 

[BorntobeDO?]

One of anemia and general not doing well workup. In that workup Iron and B12 resulted as low, and there is an unexplained mild but chronic eosinophilia; already be on folic acid 1 mg daily, but that I wouldn't think that is enough to explain a result greater than the upper limit of detection in this theoretical context.

I honestly don't even begin to have a differential or understanding the clinical significance (if any) of a theoretical result like that.

They are eating more folate gummies than you prescribed

 

[QuizzicalApe]

it's basically impossible to be folate deficit in the modern world; like 1 slice of bread is enough folate for a month.

The people with significant folate deficiencies I diagnose will be pleasantly surprised to hear this.

That aside, folate is reasonable to check in a patient with anemia (especially macrocytic), but if it is high just... stop checking it. My center stops counting after 14 ng/mL

 

[vc7777]

What an interesting hypothetical thought experiment!

What is your imaginary reference laboratory range for serum folate (since it will vary slightly from one pretend region or make-believe population to another). What's their theoretical age/gender? I'm assuming this is in a fake outpatient clinical setting?

I would first recheck under carefully controlled conditions. That is, I would agree with others and first assume it's either a sample handling, lab error, or spurious result. Folate assays are affected by biotin supplementation, or very low serum levels of biotin, too. So in addition to making sure they are not on some crazy diet like "raw eggs", make sure they stop any supplements/vitamins for at least 3 days before the repeat lab.

If you do find that it remains elevated, then recall that "a good internist always blames the medications." So consider all the 'usual suspects' like antiepileptic medications and things of that sort.

If it still remains elevated, I would entertain the idea that their constellation of complaints may represent a genetic disorder of folate metabolism. I would therefore make a quick phone call to your local geneticist with biochemical metabolism subspecialty training. Don't be discouraged because they are employed by Pediatrics because they treat adults, too. Besides, they're probably lonely. They will appreciate talking about biochem pathways most medical students think are irrelevant.

 

[Redpancreas]

For a theoretical patient, what would you make of a folate level >44?

I wouldn't worry about it. Maybe they recently came off folate supplementation. Either way it's more than likely clinically irrelevant unless you want to know if they were previously folate deficient and placed on a supplement in which case you'd just ask. Always draw labs before replacing when you're doing replacements for Iron, Folate, B12, etc. Unless you have to give blood urgently, there's no reason to give any of these urgently and if you check it after, you run into a diagnostic dilemma of whether they are deficient or not.

 

[Elixir6]

Probably means nothing, but and I wouldn't redraw, but if trying to get accurate level agree that you could make sure they didn't just take a folate supplement.

If they are having bloating or diarrhea, and/or have risk factors for SIBO can treat that (probably wouldn't treat, just treat). SIBO can cause high folate and low B12.