MEGALOBLASTIC
ANEMIA
Dr. Ram Thapa
MCOMS
Introduction
• Impairment of DNA synthesis that
leads to ineffective hematopoiesis and
distinctive morphologic changes,
including abnormally large erythroid
precursors and red cells
Cause
• Vitamin B12 deficiency
• Folic acid deficiency
Causes of vitamin B12 deficiency
Caues of Vitamin B12 deficiency
Decreased Intake
• Inadequate diet
• Vegetarianism
Impaired Absorption
• Intrinsic factor deficiency
• Pernicious anemia
• Gastrectomy
• Malabsorption states
• Diffuse intestinal disease (eg. Lymphoma, systemic sclerosis)
• Ileal resection/ Ileitis :Competitive parasitic uptake, Fish tapeworm
• Bacterial overgrowth in blind loops and diverticula of bowel
Causes of Folic Acid Deficiency
Causes of Folic acid deficiency
Decrease Intake:
• Inadequate diet, alcoholism, infancy
Impaired Absorption:
• Malabsorption states
• Intrinsic intestinal disease
• Anticonvulsants, oral contraceptives
Increased Loss:
• Hemodialysis
Increased Requirement
• Pregnancy, infancy, disseminated cancer, markedly increased hematopoiesis
Impaired Utilization:
• Folic acid antagonists
• Unresponsive to Vitamin B12 or Folic Acid
therapy:
• Metabolic inhibitors of DNA synthesis and/or
folate metabolism (e.g., methotrexate)
Normal Vitamin B12 Metabolism
• “Cobalamin” - present in animal products such as
meat, fish, milk, and eggs
• Daily requirement – 2-3µg
• Diet from animal products – more than adequate
daily requirement --- intrahepatic stores ---- sufficient
to last for several years
• Vitamin B12 --- freed from binding proteins in food
through the action of pepsin in the stomach ---
binds to a salivary protein called haptocorrin
• In the duodenum -- B12 is released from
haptocorrin by the action of pancreatic proteases ---
associates with intrinsic factor.
• The complex is transported to the ileum
• Ileum – endocytosed by ileal enterocytes that express a
receptor for intrinsic factor called cubilin on their surfaces
• Within ileal cells ---vitamin B12 associates with a major
carrier protein transcobalamin II and is secreted into the
plasma
• Transcobalamin II -- delivers vitamin B12 to the liver and
other cells of the body (rapidly proliferating cells in the bone
marrow and the GI tract)
Biochemical functions of vitamin B12
1. Essential cofactor in
conversion of
homocystein to
methionine by methionine
synthase
2. Isomerization of
methylmalonyl coenzyme
A to succinyl coenzyme A
by the enzyme
methylmalonylcoenzyme A
mutase, which requires
adenosylcobalamin
• Impaired DNA synthesis in vitamin B12
deficiency ------- reduced availability of FH4,
most of which is “trapped” as N5-methyl
FH4
• A deficiency of vitamin B12 thus leads to increased
plasma and urine levels of methylmalonic acid(MMA)
• Consequent buildup of methylmalonate and
priopionate (a precursor) ---- formation and
incorporation of abnormal fatty acids into neuronal
lipids
• Myelin breakdown, producing subacute combined
degeneration of the spinal cord
Normal Folate Metabolism
• Member of water soluble B complex vitamins
pteroyl glutamic acid (PGA)
• RDA: 100-200 μg.
• Sources: fresh green leafy vegetables, fruits,
liver, kidney, and to a lesser extent, muscle
meats, cereals and milk
• Normally absorbed from the duodenum and upper
jejunum
• Polyglutamate form - cleaved by the enzyme, folate
conjugase, in the mucosal cells to mono- and
diglutamates
• Further reduction in the mucosal cells to THF
• Circulates in plasma as methyl THF bound to protein
Pathogenesis of Anemia
• Deficient Vitamin B12
• B12 and Folate – coenzymes for synthesis of
thymidine (one of the four bases of DNA)
• Defective nuclear maturation due to deranged
or inadequate DNA synthesis, with an
attendant delay or block in cell division
Vit B12 and /or Folate deficiency
Defective DNA synthesis
( But RNA and protein synthesis are normal)
Nucleus maturation absent
Cytoplasmic maturation present
“dissociation between cytoplasmic and nuclear maturation”
“Nuclear –cytoplasmic maturation asynchrony”
“Nuclear maturation lagging behind cytoplasm”
All cell lines are affected
Myelopoiesis Megakaryoblasts
Erythroblast
Abnormal Abnormal
Abnormal
Abnormal myeloid Abnormal plt
Megaloblast series cells
Inadequate maturation
Ineffective erythropoiesis
( apoptosis/ get destroyed by ANEMIA
Macrophages in marrow)
RBCs in the circulation get lysed early
(increased hemolysis)
Peripheral Blood Smear Findings
• Peripheral Blood Smear:
• Macrocytes with macro-ovalocytes
• Anisocytosis and poikilocytosis
• Nucleated red cell progenitors
• Howell-Jolly bodies – DNA remnants
• Neutrophils – larger and hypersegmented (Five
or more segments)
• Giant platelets
Macrocytes with macro-ovalocytes and a hypersegmented neutrophil
Howell Jolly Bodies
• Cabot Ring – microtubule remnant from mitotic spindles
Bone Marrow Findings
• Hypercellular – Erythroid hyperplasia
• Megaloblastic changes – all stages of erythroid
development
• Megaloblasts – abnormal, large, nucleated erythroid
precursors having nuclear-cytoplasmic asynchrony i.e.
the nuclei are less mature than the development of
cytoplasm
Bone Marrow Findings..
• The nuclei are large, having fine, sieve-like and open
chromatin that stains lightly, while the
hemoglobinization of the cytoplasm proceeds
normally or at a faster rate i.e. nuclear maturation
lags behind that of cytoplasm
Bone Marrow Findings..
• Giant metamyelocytes and band forms
• Megakaryocytes – normal or decreased, abnormally
large size with bizzarre, multilobated nuclei
• Ineffective erythropoiesis – precursors undergo
apoptosis and leads to pancytopenia
serum vitamin b12 assay
serum and red cell folate assay
• The normal range of serum folate is 6-18 ng/ml.
Values of 4 ng/ml or less are generally considered to
be diagnostic of folate deficiency
Pernicious Anemia
• Autoimmune attack on the gastric mucosa
• Chronic atrophic gastritis with loss of parietal cells
• It is a disease of older adults; the median age at
diagnosis is 60 years, and it is rare in people younger
than 30 years of age
• chronic atrophic gastritis marked by a loss of parietal
cells, a prominent infiltrate of lymphocytes and
plasma cells
Pernicious Anemia
Three type of autoantibodies in many patients:
• Type I (75%) - blocks the binding of vitamin B12 to
intrinsic factor
• Type II - prevent binding of the intrinsic factor–vitamin
B12 complex
• Type III – nonspecific(antibodies are present in α and β
subunits of the gastric proton pump)
Morphology
• Megaloblastic anemia (PBS and bone marrow)
• Fundic gland atrophy
• Intestinal metaplasia
• Atrophic glossitis - tongue may take on a shiny, glazed,
“beefy” appearance
• CNS lesions – demyelination of dorsal and lateral spinal tracts
• spastic paraparesis, sensory ataxia, and severe paresthesias
in the lower limbs
Laboratory Diagnosis
• Hb ↓↓ and RBC count ↓↓
• MCV ↑↑ > 100 fL
• MCH normal or ↑ (bcoz’ large cell volume) and MCHC is
usually normal
• WBC – Normal or TLC ↓↓ Neutrophil ↓↓
• Platelet – Normal or ↓↓
• Peripheral smear
• Bone Marrow Examination
Thank You!
