Megaloblastic
Anemias
DEPT OF MEDICINE
ACMS
Anemia
MCV
<80 fL 80-100 fL >100 fL
Microcytic Normocytic Macrocytic
Defective hemoglobin Decreased Defective DNA
synthesis production synthesis
Megaloblastic
anemia
Chronic infections • B12 deficiency
Aplastic anemia • Folate def
Iron deficiency (Fe2+)
Anemia
MCV
<80 fL 80-100 fL >100 fL
Microcytic Normocytic Macrocytic
•Iron •Chronic infections • Megaloblastic
•Aplastic anemia anemia
deficiency
Megaloblastic Anemia - Introduction
• What is a Megaloblast ?
• Megaloblasts are large cells with an increased
nuclear/cytoplasmic ratio in which nuclear
maturation is delayed, while cytoplasmic
maturation is more advanced.
Megaloblastic Anemia - Introduction
• What is a Megaloblast ?
• Megaloblasts are
– Large cells with
– Increased nuclear/cytoplasmic ratio
Megaloblastic Anemia - Introduction
• Increased nuclear/cytoplasmic ratio :
a. Nuclear maturation is delayed, while
cytoplasmic maturation is more advanced.
b. The cytoplasm starts acquiring
hemoglobin where as the nucleus is still
immature-looking : Nuclear-cytoplasmic
Asynchrony.
Megaloblastic Anemia - Introduction
• Increased nuclear/cytoplasmic ratio :
a. Nuclear maturation is delayed, while
cytoplasmic maturation is more advanced.
b. The cytoplasm starts acquiring
hemoglobin where as the nucleus is still
immature-looking : Nuclear-cytoplasmic
Asynchrony.
Megaloblastic Anemia - Introduction
Two imp features:
• Megaloblastic changes are not limited to RBCs
even neutrophils are involved –
(hypersegmented neutrophils can be seen).
Megaloblastic Anemia - Introduction
Two imp features:
• Megaloblastic changes are not limited to RBCs
Even neutrophils are involved –
(hypersegmented neutrophils can be seen).
Megaloblastic Anemias:
Definition
• Megaloblastic anemias are disorders caused by
impaired DNA synthesis.
• The presence of megaloblastic cells is the
morphologic hallmark.
(Megaloblasts are usually abundant in bone marrow).
The peripheral blood in severe megaloblastic
anemia
The bone marrow in severe megaloblastic
anemia
Pathophysiology
1. A defect in DNA synthesis in rapidly dividing
cells.
2. To a lesser extent, RNA and protein synthesis are
impaired.
3. Unbalanced cell growth and impaired cell
division occur since nuclear maturation is
arrested.
4. More mature RBC precursors are destroyed in the
bone marrow prior to entering the blood stream
(intramedullary hemolysis).
Pathophysiology
1. A defect in DNA synthesis in rapidly dividing
cells.
2. To a lesser extent, RNA and protein synthesis are
impaired.
3. Unbalanced cell growth and impaired cell
division occur since nuclear maturation is
arrested.
4. More mature RBC precursors are destroyed in the
bone marrow prior to entering the blood stream
(intramedullary hemolysis).
Megaloblastic Anemia : Causes
• The most common causes are –
1. Cobalamin (vitamin B-12)
deficiency.
2. Folate deficiency.
Cobalamin deficiency
(Vitamin B12 deficiency)
Major causes :
[Link] deficiency :
Esp. in strict vegetarians who avoid meat, eggs,
and dairy products. (otherwise it rarely causes
megaloblastic anemia,)
[Link] gastritis and achlorhydria
( commonly in elderly persons.)
Cobalamin deficiency
Other Causes
3. Impaired/Mal - absorption
a) Gastric causes
• Poor stomach acidity
• Gastrectomy
• Pernicious anemia - Decreased secretion
of intrinsic factor due to gastric atrophy
b) Pancreatic cause
• Chronic pancreatitis - Decreased
digestive enzyme secretion
Cobalamin deficiency
(Vitamin B12 deficiency)
other causes
c) Intestinal disease
• Ileal resection
• Ileal disease
–Chron’s disease
–Celiac sprue
–Fish tapeworm ( Diphyllobothrium latum)
• Blind loop
–Intestinal bacterial overgrowth
Folate Deficiency
Causes
1. Dietary
Particularly in: old age, infancy, poverty,
alcoholism, chronic invalids.
2. Malabsorption
Major causes of deficiency
• Tropical sprue,
• Gluten-induced enteropathy
(in children and adults, )
Minor causes of deficiency
Extensive jejunal resection, Crohn's disease, partial gastrectomy,
congestive heart failure,
Causes of Folate Deficiency
3. Excess utilization or loss
• Physiologic
Pregnancy and lactation, prematurity
• Pathologic
a)Hematologic diseases: chronic
hemolytic anemias, sickle cell anemia,
thalassemia major,
b)Malignant diseases: carcinoma,
lymphoma, leukemia, myeloma
Causes of Folate Deficiency
[Link] utilization or loss
Pathologic
c) Inflammatory diseases: Crohn's disease
psoriasis, tuberculosis,
d) Excess urinary loss: congestive heart
failure, active liver disease
e) Hemodialysis, peritoneal dialysis
Causes of Folate Deficiency
4. Antifolate drugs
– Anticonvulsant drugs (phenytoin,)
– Antibiotics: Nitrofurantoin, tetracycline,
sulphasalazine
– Dmards : Methotrexate
– Drugs interfering with synthesis of DNA [cytosine
arabinoside, hydroxyurea, 6-mercaptopurine,]
5. Mixed causes
Liver diseases, alcoholism, intensive care units
Megaloblastic Anemia : Causes
Independent mech of megaloblastic anemia-
(refractory to cobalamin and folate therapy):
– HIV infections: Direct interference of DNA
synthesis
– Myelodysplastic disorders.
– Thiamine-responsive
SOURCES of VITAMIN B12
• The primary sources of vitamin B-12 (a cobalt-
containing vitamin) are
– Meat, fish, and dairy products.
• Large amounts are stored in liver.
• Body stores : 2–3 mg,
( sufficient for 3–4 years if supplies are completely
cut off.)
Dietary Requirements - Cobalamin
• A normal Western diet contains :
5–30 µg of cobalamin daily.
• Adult daily losses :
1–3 µg
(mainly in the urine and feces)
• Daily requirements are about : 1–3 µg.
(The body does not have the ability to
degrade cobalamin)
VITAMIN B12– Available Forms:
• Natural forms: methyl-Clb and hydroxo-Clb
• Synthetic form: Cyano - Clb
2. FOLIC ACID : Sources and forms
• Exists in nature as two forms –
Monoglutamate and
Polyglutamate forms
Available in
• Vegetables, fruits and
• Animal protein.
Dietary Requirements of folate
• The folate content of an average Western diet :
250 µg daily
• Most foods contain some folate.
• The highest concentrations are found in
liver, yeast, spinach, other greens, and nuts
(liver contains the largest store >100 µg/100 g).
• Daily adult requirements : 100 µg,
Dietary Folate
• Total-body folate in the adult is 10 mg,
• Stores are sufficient for only 3–4 months in
normal adults.
• The amount varies widely according to
– the type of food eaten and
– the method of cooking.
– Folate is easily destroyed by heating,
particularly in large volumes of water.
Dietary Folate
• Total-body folate in the adult is 10 mg,
• Stores are sufficient for only 3–4 months in
normal adults.
• The amount in food varies widely according to
– the type of food eaten and
– the method of cooking.
– Folate is easily destroyed by heating,
particularly in large volumes of water.
Absorption of FOLATE
• From the upper small intestine (jejunum)
• On average, 50% of food folate is absorbed.
• Monoglutamates are more efficiently
absorbed than polys.
• Polyglutamate forms are hydrolyzed to the
monoglutamate derivatives.
• All dietary folates are converted to 5-
methylTHF (5-MTHF) within the small-
intestinal mucosa before entering portal
plasma
B12 deficiency
• MECHANISM
– Ingested B12 is protein bound
– Trypsin and acid in stomach
release B12
– B12 binds R-binding protein
which carries it to the jejunum
– Also in the stomach (fundus
and body) intrinsic factor is
secreted.
– In the jejunum, pepsin releases
B12 from R-binding protein
– B12 binds intrinsic factor and is
carried to the ileum
– B12 is absorbed in the ileum
Absorption and
transport of vitamin B12
Clinical Features of megaloblastic anemia
1. Many symptomless .
2. The main clinical features in more severe
cases are those of anemia.
– Anorexia is usually marked,
– Weight loss, diarrhea, or constipation.
– Glossitis,
– Angular cheilosis,
Glositis and angular cheliosis
Clinical Features
– Mild fever in more severely anemic
patients,
– Jaundice (unconjugated),
– Reversible melanin skin hyperpigmentation
also may occur with a deficiency of either
folate or cobalamin.
Clinical Features
3. Thrombocytopenia sometimes - bruising,
( and this may be aggravated by vitamin C
deficiency or alcohol in malnourished patients.)
4. The anemia and low leukocyte count may
predispose to infections, particularly of the
respiratory and urinary tracts.
5. Cobalamin deficiency has also been associated
with impaired bactericidal function of
phagocytes.
Other sequelae of B12 deficiency
6. Neurologic defects seen with B12
deficiency
• Peripheral neuropathy
–Disturbances of vibratory sense
and proprioception
• Dorsal and lateral column
demyelination
–Spastic ataxia
• Brain
–Dementia, psychosis, somnolence
Folic acid deficiency in pregnancy
Investigations
Normal blood smear
They have a zone of central pallor about 1/3 the size of the
RBC
Megaloblastic anemia
The size of the RBC's is also increased (macrocytosis, which is
hard to appreciate in a blood smear).
Pernicious Anemia
Microcytic Anemia (peripheral smear)
Diagnosis
1. Clinical findings
2. Morphology –
•Peripheral blood
•Marrow
Megaloblastoid morphologic
changes
Diagnosis
• Folate deficiency
– Serum Folate level:
• Reflects recent levels of ingestion
– RBC Folate:
• Reflects stores (2-3 months)
• Will be decreased in B12 deficiency
• Folate levels are decreased in B12 deficiency
also, should always be checked.
Diagnosis
• B12 deficiency
– Serum level of B12, We check -
• Methylmalonic acid and homocystine levels
–Both are elevated: B12 deficiency,
–Only homocystine elevated : Folate
deficiency.
– Schillings test
• Helps to identify the source of B12
deficiency
Screening hematology laboratory
tests for megaloblastic anemia
• In all cases:
• Blood Count
• Serum B12
• RBC Folate
• In selected cases:
• Bone Marrow
• Homocystine and MMA
• Serum Folate
• Bilirubin
• LDH
Screening hematology laboratory tests for
megaloblastic anemia
1. CBC
– Macrocytic anemia
• MCV is usually >110 fL and often >120 fL
• Pancytopenia is seen in some cases
Screening hematology laboratory tests for
megaloblastic anemia
2. Peripheral blood morphology
– RBC:
• Oval macrocytes
• Nucleated RBCs, Howell Jolly bodies,
basophilic stippling
– Neutrophil
• nuclear hypersegmentation
– 4 - 5 lobed neutrophils per 100 WBC
PBS
PBS
Megaloblastic anemias
Morphology--Marrow
Normal
marrow
Megaloblastic anemias
Morphology
• Bone marrow
– Nuclear cytoplasmic
asynchrony in both
erythroid and myeloid
lineages
Megaloblastic
Normal Megaloblastic
Megaloblastic
Diagnosis
The Folate Trap
Pernicious Anemia
• Decreased secretion of intrinsic factor due to
gastric atrophy and loss of parietal cells
• More common in individuals greater than age 50
• Diagnosis
– Intrinsic factor antibodies (commonly blocks
B12 binding site)
– Specificity ~100%
– Parietal cell antibodies
– Less specific
– ~50% sensitive
Therapy
• Vitamin B12 Supplementation:
– Oral or intramuscular therapy
– Both work well but IM is preferred for patients
with an absorption problem
– Replenishment of body stores with:
Six 1000- µg IM injections of hydroxocobalamin
given at 3- to 7-day intervals.
Therapy
B12
• Because of the poorer retention of cyanocobalamin,
e.g., 1000 µg IM, monthly, for maintenance
treatment may be given.
• Subsequently, For maintenance therapy:
1000 µg hydroxocobalamin IM once every 3
months is satisfactory.
Therapy
• Large daily oral doses (1000–2000µg) of
cyanocobalamin have been used in PA for
replacement and maintenance of normal
cobalamin status .
Therapy
Folate Deficiency :
• Oral doses of 5–15 mg folic acid daily
• Continue therapy for about 4 months,
(all folate-deficient red cells will have been
eliminated and replaced by new folate-replete
populations.)
• Before large doses of folic acid are given,
cobalamin deficiency must be excluded and, if
present, corrected;
Therapy
• Response
– Reticulocytes rise after Day 4 and peak on day
5-8
– Hemoglobin rises 2-3g/dL every 2 weeks
– Marrow begins to respond within few days
– Hypersegmented neutrophils may persist for
up to 2 weeks
Mrs. M is a 46-year-old female who was referred to the clinic for evaluation
and treatment of anemia. Her past medical history is notable for ulcerative
colitis. She is status post colectomy 3 years ago followed by resection of the
ileum due to small bowel obstruction. She notes history of paresthesias at her
toes and fingers which predated the ileum resection.
10.1
5.7 322
29.7
• MCV = 101.2 fl
• RDW = 12.3
• Reticulocyte Count = 1.8%
Mrs. M is a 46-year-old female who was referred to the clinic for evaluation and
treatment of anemia. Her past medical history is notable for ulcerative colitis. She is
status post colectomy 3 years ago followed by resection of the ileum due to small
bowel obstruction. She notes history of paresthesias at her toes and fingers which
predated the ileum resection.
• MCV = 101.2 fl
10.1
• RDW = 12.3
5.7 322 • Reticulocyte Count = 1.8%
29.7 • Peripheral Blood Smear:
Thank you
