Megaloblastic and other

macrocytic anaemia
Dr. Nilukshi Perera
Consultant Haematologist
Requirements for Red
Blood Cell Production
Proteins, required
 Erythropoietin
 Proteins, required for globin synthesis
 Iron
 Vitamin B12 and folic acid
 Vitamin B6 , B1, B2
 Vitamin C , E
 Thyroid hormones, estrogens and androgens
 Zinc Iron
Calculation of RBC Indices
 Mean corpuscular volume (MCV)=
 Average RBC volume.
 MCV= HCT X 10/RBC
 Normal= 76-96 fl
Mean corpuscular heamoglobin
(MCH)=
 Average weight of Hb in RBC.
 MCH= Hb X 10/RBC
 Normal= 27-32 pg
Calculation of RBC indices …….
 Mean corpuscular heamoglobin
concentration (MCHC)=
 Concentration of Hb in 100ml of RBCs.
 MCHC= Hb X 100/Hct
 Normal= 32-36 g/dL
RED CELL DISTRIBUTION WIDTH
(RDW)
 Degree of Red Cell size variability in a
blood sample
 Coefficient of variation of the size of
the RBCs
 Expressed as %
 Derived from automated instruments.
 Normal: 11-15 %
MACROCYTIC ANEMIAS
 Macrocytic anemias are characterized by
large RBCs with a normal hemoglobin
content.

 Macrocytic anemias are classified as either

megaloblastic or non-megaloblastic
are associated with defective DNA synthesis and therefore,
abnormal RBC maturation in the bone marrow (a
nuclear maturation defect)the granulocytic and
megakaryocytic maturation are also affected and this
Macrocytic anaemia causes
 Excess alcohol  Reticulocytosis
 Liver disease  (Haemolytic
 B12/folate deficiency anaemia)
 Myelodysplasia  Myeloma
 Drugs  Hypothyroidism
 Cytotoxics /myxoedema
 Phenytoin, etc  Smoking
 Pregnancy
 Neonatal
Megaloblastic Anaemia
Caused by :

1. Vitamin B12 deficiency

2. Folate deficiency
 Where is the defect
in the red cell in
megaloblastic
anaemia??

In the membrane,
cytoplasm or the
haemoglobin ??
 Megaloblastic anemias are associated with
defective DNA synthesis and therefore,
abnormal RBC maturation in the bone
marrow (a nuclear maturation defect).

 In megaloblastic anemias, the granulocytic and

megakaryocytic maturation are also affected and
this leads to pancytopenia
Megaloblastic anaemia
Characteristic erythroblast abnormality.
 Delayed nuclear maturation relative to
cytoplasm.
 Open, stippled lacy nucleus.
 Normal Hb formation.
 Second most common type of anemia due to’
Vitamin B12/Folic acid deficiency
 Pernicious anaemia
 autoimmune, Gastric atrophy, VitB12 def.
Actions of Cobalamin & Folate
Vitamin B12
 Normal daily intake  7-30g
 Main foods  Animal products only
 Cooking  Little effect
 Minimal daily  1-2g
requirement & body 2-3mg (enough for 2-
stores 4yrs)
Absorption
 site  Ileum
 mechanism  Intrinsic factor
 Usual therapeutic form  Hydroxocobalamin
VITAMIN B12 ABSORPTION

Mucosal cell
B12 absorption
 Vitamin B12 and IF bind to mucosal cells
in the ileum and B12 enters.
 When B12 is released from the mucosal
cell, it binds to transport proteins in the
bloodstream (transcobalamine IIII).
Type II is the primary transport protein.
Therefore a congenital deficiency in
type II can lead to a megaloblastic
anemia.
 B12 is transported to the bone marrow
for use or to the liver for storage.
So ,
 Everything that walks, swims or flies
contains vitamin B12. Nothing that
grows out of the ground contains
vitamin B12.
 Causes of B12 Deficiency:

1. Nutritional

Especially vegans

2. Malabsorption

Gastrectomy
Ileal resection or bypass
Ileal disease (TB, lymphoma, amyloid, post-radiation, Crohn’s)
Enteropathies (protein losing, chronic diarrhea, celiac ,sprue)
Fish tapeworm (Diphyllobothrium latum) infection
Bacterial overgrowth

3. Inherited

Trans-Cbl II or IF deficiency
CAUSES OF B12 DEFICIENCY
Folic Acid
 Normal daily intake  200-250g
 Main foods  Liver, greens, yeast
 Cooking  Easily destroyed
 Minimal daily  100-150g
requirement & body 10-12mg (4mths supply)
stores
 Absorption site  Duodenum and jejunum

 mechanism
 Converted to methyl THF
 Usual therapeutic form  Folic acid
Causes of Folic Acid
Deficiency
 Nutritional -old age, poverty, diet etc
 Malabsorption- tropical sprue, coeliac
disease, Crohn’s disease
 Excess utilization
Physiological-pregnancy, lactation, prematurity
Pathological-haemolytic anaemia,
myelofibrosis, malignant disease, inflammatory
disease
 Drugs-anticonvulsants
 Mixed-liver disease, alcoholism, intensive care
Megaloblastic Anaemia:
Clinical
 Insidious onset of symptoms and signs of anaemia
 Lemon yellow jaundice
 Glossitis, angular stomatitis
 Purpura
 Neuropathy-subacute combined degeneration of the cord
(neuropathy affecting the peripheral sensory nerves and
posterior and lateral columns)
 Deficiency during pregnancy cause nural tube defect in
baby.
Glossitis

Beefy red painful tongue

The patient was a 45 year old woman. She had a swollen tender to
The patient was a 45 year old woman. She had a swollen tender
tongue, parasthesias of both feet and hands, decreased
proprioception and vibratory sensation, ataxia and leg weakness .
Subacute
Combined
Degeneration

Degeneration and demyelination of the

dorsal (posterior) and lateral spinal
columns
Neural tube defects
.
 Lab findings
 Macrocytic, normochromic anemia (MCV>96)
 Hemoglobin and RBC counts are decreased
 WBC and platelet counts are decreased
 On a peripheral smear, a triad of things is commonly
seen: oval macrocytes, Howell Jolly bodies (nuclear
DNA fragments), and hypersegmented neutrophils (5
or more lobes).

 In addition:
 Tear drop poikilocytosis
 The absolute reticulocyte count is decreased because of
ineffective erythropoiesis.
 Pancytopenia is common.
 Some NRBC when anaemia is severe.
Lab findings...............
 Reticulocytopenia
 Increased LDH
 Mild increase of unconjugated bilirubin
 Low serum B12 , serum & red cell folate levels.
PERIPHERAL SMEAR OF MEGALOBLASTIC
ANEMIA

Oval Macrocytes

Howell Jolly Body

PERIPHERAL SMEAR OF
MEGALOBLASTIC ANEMIA

Hypersegmented neutrophil
 Oval macrocytes

Hypersegmented
neutrophil
Bone marrow

 Hypercellular
 Dyserythropoiesis
 Giant metamyelocytes
Normal Megaloblastic
erythropoiesis erythropoiesis
 Megaloblastic marrow Megaloblastic
erythroblast

Giant
metamyelocyte
Megaloblastic Anemia – Bone
Marrow
Megaloblastic anaemia
The bone marrow will show
hypercellularity, yet there are decreased
numbers of all cell types in the
peripheral blood because ineffective
hematopoiesis is occurring and many
cells are dying prematurely in the bone
marrow.
Pernicious anaemia
 B12 deficiency due to autoimmune gastric atrophy.
 Result in loss of intrinsic factor production.
 Incidence increase after 40yrs
 Associated with other autoimmune problems
(vitiligo, myxoedema, Hashimoto’s disease, thyrotoxicosis,
Addison’s disease etc)
 Associated with blue eyes, early greying and blood group A.
 Female>Male
 Increased risk of gastric cancer
 Diagnose with Schilling Test by using radioactive Vit B12 & IF
antibody levels
 Manage with life long parenteral Vit B12 therapy
Pernicious Anemia
(PA)

 Early graying
of hair
 Blue eyes
Pernicious Anemia

 Vitiligo
 PA

Normal Gastric atrophy

Treatment for PA

 Administration of Vitamin B12

 Symptomatic and supportive therapy
 Follow up and early detection of
carcinoma of stomach
Investigating a patient
with megaloblastic anaemia
 In folic acid deficiency – there will be decreased
serum and RBC folate
 In B12 deficiency – there will be decreased
serum vitamin B12
 Schilling test – is the definitive test for the
diagnosis of PA.
 The test measures the amount of an oral dose of radioactively
labeled B12 that is absorbed in the gut and excreted in the urine.
 This is followed by an injection of unlabeled vitamin B12 to saturate
all vitamin B12 receptors in the tissue and plasma. Thus any
amount absorbed in the gut will be in excess, and will be filtered in
the kidneys to appear in the urine.
 If there is no radioactivity in the urine, this means that there is
either malabsorption or PA.
 The test is repeated, but this time the radioactively labeled B12 is
accompanied by a dose of IF.
If absorption is now normal,
this means that the patient has PAethylmalonacid – Bhas12 def.
Schilling
Test
Investigating a patient with
megaloblastic anaemia...

 Intrinsic Factor Ab test – very specific for

pernicious anemia but only 50% sensitive
 Parietal cell Ab test – quite sensitive (90%) but
not specific
Megaloblastic Anaemia:
Treatment
 Vitamin B12 (IM)1000g/day x 6,
intramuscular
 Folic acid 1-5mg per day, oral for at
least 4/12
 Continue B12 1000g once every 3
months for life / 2years depending on
the cause.
Response to treatment

 Sense of well being in 2-3 days time

 Return of appetite
 Glossitis rapidly relieved
 Blood: Retic count starts to increase on the 2-
3rd day, maximum on 6-8th day. MCV gradually
falls, HSN disappear in 2 weeks
 If diagnosis of Vit B12 or Folate deficiency is
doubtful always start treatment with Vit B12
and folate simultaneously. Never treat with
folate alone as neurological symptoms of Vit
B12 deficiency will worsen if treated with folate
alone.