Hematology

511
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432 Hematology Team

Done By: Ammar Al-Yamani
Reviewed By: Rihaf Al-Gain

Color Index:Female notes are in Green. Male notes are in Blue. Red is important. Orange is explanation.
432HematologyTeam Megaloblastic Anemia

Megaloblastic Anemia

Mind Map:

Classificaton
of Anemia

Microcytic Normocytic Macrocytic

Non-
Megaloblastic
megaloblastic

Vitamin B12 Folate

deficiency deficiency

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432HematologyTeam Megaloblastic Anemia
Introduction
Normal RBCs values;

Adults Children

Indices Male Female Hemoglobin (g/dL)

Hemoglobin (g/dL) 13.5-17.5 11.5-15.5
Newborn 15.0 –21.0g/dL
Hematocrit (PCV) (%) 40-52 36-48
3 months 9.5 – 12.5g/dL
Red Cell Count (×10¹²) 4.5-6.5 3.9-5.6
Mean Cell Volume (MCV) 1 year to
80-95 puberty
11.0 – 13.5g/dL
(FL)size of the cell
Mean Cell Hemoglobin (MCH)
27-34
(pg)
Mean cell haemoglobin
30 – 35
concentration g/dL)

Reticulocyte count (x109/L) 25 – 125

Anemia:

Microcytic, Hypochromic Normocytic, Normochromic

Anemia Due to hemoglobin Anemia Due to a problem in RBC
Anemia
disorder (e.g. thalassemia and count (e.g. sickle cell anemia and
iron def. anemia) aplastic anemia)
1- Iron deficiency. 1- Many hemolytic anemias.
Causes 2- Thalassemia. 2- Anemia of chronic disease
3- Lead poisoning. (some cases).
4- Sideroblastic anemia (some 3- After acute blood loss.
cases). 4- Renal disease.
5- Anemia of chronic disease 5- Mixed deficiencies.
(some cases). 6- Bone marrow failure, e.g. post-
chemotherapy, infiltration by
carcinoma, etc.

1- MCV < 80 fL (Low) 1- MCV 80 – 95 fL (normal)

RBCs values
2- MCH <27pg (Low) 2- MCH>26pg (high) not important

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Megaloblastic Anemia

Macrocytic anemia:
Characterized by large size erythrocyte (MCV >95) Due to DNA disorder (e.g.
Megaloblastic anemia).

Divided into:
- Non-Megaloblastic (non-megaloid, Macrocytosis).
- Megaloblastic anemia (megaloid) enlarged erythroid precursor.

Non-Megaloblastic (Non-megaloid, Macrocytosis)

Enlarged RBCs in the peripheral blood with normal erythrocyte production from the
bone marrow.

Causes:
Macrocytosis with Normoblasts
Macrocytic anemia (Macrocytosis)
(erythroid precursure is normal)

1- Alcohol (most common) 1- Normal neonates (Physiological)

2- Liver disease (especially alcoholic) 2- Chronic alcoholism*
Most important

3- Reticulocytosis (increase in 3- Myelodysplastic syndromes*

haemolysis or haemorrhage) RBCs 4- Chronic liver disease*
in the stage before maturation, 5- Hypothyroidism
gives wrong reading.
6- Normal pregnancy
4- Hypothyroidism.
7- Therapy with anticonvulsant
5- Myelodysplasia MDS including
acquired Sideroblasticanaemia. drugs* Dr. FATMA said
6- Pregnancy. that these are the
only causes she wants
7- Newborn. us to know

1. Haemolyticanaemia.
1. Myeloma and 2. Chronic lung disease (with
Less important

macroglobulinaemia. hypoxia).
2. Leucoerythroblastic anaemia. 3. Hypoplastic and aplastic
3. Myeloproliferative disease. anaemia.
4. Aplastic anaemia or red cell 4. Myeloma.
aplasia.
*Some patients show B12- and folate-
5. Chronic respiratory failure.
independent megaloblastic erythropoiesis.

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432HematologyTeam Megaloblastic Anemia

REMEMBER:
1. Non-megaloblastic anemia (Macrocytosis): abnormality is in the
peripheral blood, not in the bone marrow.
2. Macrocytosis with Normoblasts can be normal in neonates.

Megaloblastic anemia
It’s a group of anemias that results from the abnormal synthesis of DNA during
erythropoiesis in the bone marrow. (Asynchronous DNA synthesis: maturation of the
RBCs nucleus being delayed relatively to that of the cytoplasm).

Most important features of megaloblastic anemia are:

- Macrocytes (large cells).
- Hypersegmented neutrophils.

Hypersegmented neutrophils (classical in vitamin B12 deficiency): mainly

found in megaloblastic anemia but could appear in non-megaloblastic in cases of:

1- Renal failure
2- Congenital (familial) abnormality
3- Iron deficiency

NOTE:
- Abnormal DNA synthesis will inhibit the division of the cells, which will
make the cell bigger.
- Pernicious anemia is associated with deficiency of vit B12 or folic acid.

Causes of megaloblastic anemia:

1- Cobalamin (vitamin B12) deficiency or abnormalities of cobalamin
metabolism most common.
2- Folate deficiency or abnormalities of folate metabolism 2nd most common.
3- Therapy with antifolate drugs (e.g. methotrexate)
4- Independent of either cobalamin or folate deficiency and refractory to:
a) Some cases of acute myeloid leukemia, myelodysplasia. (Poor absorption
of folate and cobalamin).
b) Oroticaciduria (responds to uridine)
c) Therapy with drugs interfering with synthesis of DNA (e.g. cytosine
arabinoside, hydroxyurea, 6-mercaptopurine, azidothymidine (AZT)
d) Thiamine responsived.

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432HematologyTeam Megaloblastic Anemia
Other causes : (Not Important)
5- Suggested but poorly documented causes of megaloblastic anaemia not due
to cobalamin or folate deficiency or metabolic abnormality:
a) Vitamin E deficiency.
b) Lesch-Nyhan syndrome (responds to adenine).
6- Abnormalities of nucleic acid synthesis
a- Drug therapy:
 Antipurines (mercaptopurine, azathioprine)
 Antipyrimidines (fluorouracil, zydovudine (AZT))
 Others (hydrozyurea)
b- Oroticaciduria (abnormality in DNA synthesis).
7- Uncertain aetiology.
8- Myelodysplastic syndromes, * erythroleukaemia.
9- Some congenital dyserythropoietic anaemias.
* Some patients show normoblastic erythropoiesis (these causes are not characteristic).

REMEMBER:
1. Megaloblastic anemia due to inhibition of DNA synthesis and affect RBCs
in the bone marrow.
2. Most common causes of megaloblastic anemia B12 deficiency then
folic acid deficiency.

Vit B12 & folate nutrition and absorption:

Vitamin B12 Folate
Only food of animal Most foods, especially liver, green
Dietary source origin, red meat, vegetable and yeast; destroyed by
especially liver cooking.

Average daily intake 7 - 30 µg 200-250 µg

Minimum daily requirement 1-3 µg 100-200 µg

Body stores* 3-5 mg, mainly in the liver 8-20 mg, mainly in the liver

Time to develop deficiency

in the absence of intake or Anemia in 2-10 years Macrocytosis in 5 months.
absorption*

Conversion of polyglutamates to
Requirements for Intrinsic factor secreted
monoglutamates by intestinal folate
absorption by gastric parietal cells
conjugase

Site of absorption Terminal ileum Duodenum and jejunum

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 432HematologyTeam Megaloblastic Anemia
VitaminB12:

Causes of vitamin B12 deficiency:

1- Inadequate intake. 9- Diversion of dietary B12.
2- Veganism, lactovegetarianism (some cases). 10- Abnormal intestinal bacterial flora
3- Inadequate secretion of intrinsic factor. multiplejejunal diverticula, small intestinal
4- Pernicious anemia. strictures, stagnant intestinal loops.
5- Total or partial gastrectomy. 11- Diphyllobothrium latum (fish tapeworm).
6- Congenital intrinsic factor deficiency (rare). 12- Malabsorption (one of the main causes).
7- Inadequate release of B12 from food. 13- Crohn’s disease, ileal resection, chronic
8- Partial gastrectomy (common, bypass tropical sprue, congenital selective
surgery), vagotomy, gastritis, acid-suppressing B12malabsorption with proteinuria
drugs, alcohol abuse. (Imerslund-Grasbeck syndrome).

NOTE: Ingestion of food containing vitamin B12Parietal cell in stomach

secrete intrinsic factor  bend to B12 in terminal ileum get absorbed by
TC2(transcobalamin 2) in the terminal ileum. Anything will interfere with this
process will cause vitamin B12 deficiency.

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432HematologyTeam Megaloblastic Anemia
Folate:
Dietary Folate must be converted to mythel THF (tetrahydrofolate) to get absorbed
in the small intestine. Then with the help of B12 and homocysteine, mythel THF will
be converted to THF. If any one of the three: mythel THF, homocysteine or vit B12 is
absent the reaction won’t happen.

NOTE: 1- Homocysteine level will be high in case of vitamin B12 deficiency.

2- Vitamin B12 deficiency will also cause indirect folic acid deficiency.

Causes of folate deficiency:

1. Inadequate dietary intake.
2. Malabsorption: (Coeliac disease, jejunal resection, tropical sprue)
3. Increased requirement: (Pregnancy, premature infants, chronic haemolytic
anemia, myelofibrosis, various malignant diseases)
4. Increased loss: (Long-term dialysis, congestive heart failure, acute liver
disease)
5. Complex mechanism: (Anticonvulsant therapy, * ethanol abuse*)
* Only some cases with macrocytosis are folate deficient.

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432HematologyTeam Megaloblastic Anemia

Clinical Features of Megaloblastic anemia

1. Weakness, anorexia, weight loss, diarrhea or constipation, tiredness,
shortness of breath, angina of effort, heart failure. (due to low Hemoglobin).
2. Mild jaundice (hemolytic anemia), glossitis (with enlargement and redness of
the tong) (beefy tongue), stomatitis, angular cheilosis. (Fissures around the
lips).
3. Purpura, melanin pigmentations.
4. Infections.
5. Neuropathy due to vit B12 and folate deficiency:
It’s mostly due to vitamin B12 deficiency.
Progressive neuropathy affecting:
• The peripheral sensory nerves.
• Posterior and lateral columns of the spinal cord (subacute combined
degeneration of the cord).
• Optic atrophy.
• Psychiatric symptoms. (e.g hallucination).
• The neuropathy is likely due to accumulation of S-adenosyl
homocysteine and reduced level of S-adenosyl methionine in nervous
tissue resulting in defective methylation of myelin and other
substrates.

6. Neural tube defect (NTD):

- (Anencephaly, spina bifida or encephalocoele) in the fetus due to folate
or Vitamin B12 deficiency in the mother. This result in build-up of
homocysteine and S-adenosylhomocysteine in the fetus, which impair
methylation of various proteins and lipids.
- Genetic a mutation in the parents in 5,10 methylene
tetrahydrofolatereductase (absence of this enzyme)low serum red cell
and folate and high serum homocysteine and fetus with NTD.
- Cleft palate and hair lip.
*NTD happens due to deficiency more than Genetic

REMEMBER: Neuropathy and hypersegmented neutrophils are classical to

Vitamin B12 deficiency.

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432HematologyTeam Megaloblastic Anemia

Hematological findings in Megaloblastic Anemia:

Peripheral Blood:
- Macrocytic anaemia, oval macrocytes, anisocytosis, poikilocytosis high MCV.
- Dimorphic anemia when it is associated with iron deficiency or with thalassaemia
trait.
- Hypersegmented neutrophils.
- Leucopenia and thrombocytopenia

Bone Marrow:
- Hypercellular marrow with M:E ratio in normal or reduced.
- Accumulation of primitive cells due to selective death of more mature cells.
- Megaloblast (large erythroblast which has a nucleus of open, fine, lacy
chromatin).
- Dissociation between the nuclear and cytoplasmic development in the
erythroblasts.
- Mitosis and dying cells are more frequent than normal.
- Giant and abnormally shaped, metamyelocytes, polypoid megakaryocytes.
(most important finding).
- Increased stainable iron in the macrophage and in the erythroblasts.

Other laboratory abnormalities (Not Important)

- Chromosomal abnormalities
- Ineffective haemopoiesis. (Intramedullary cell death by apoptosis) associated
with increased serum indirect bilirubin.
- ↑ urobillinogen and faecalstercobillinogen.
- ↑ LDH ↑ serum iron ↑ blood carbon monoxide.
- ↑ Serum lysozyme.
- ↓ Reduced haptoglobins.

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432HematologyTeam Megaloblastic Anemia
Treatment:
Even if the diagnosis is confirmed we must test for vit B12 and folic acid levels.
Large amount of hydroxocabalamin  neural defect in pregnant ladies.

Important Treatment of Megaloblastic anemia

Vitamin B12 deficiency Folate deficiency
Compound Hydroxocobalamin Folic acid
Route Intramuscular Oral
Dose 1000 µg 5 mg
6x1000 µg over 2-3
Initial dose Daily for 4 months
weeks
Depends on underlying disease; life-long
1000 µg every 3 therapy may be needed in (1)chronic
Maintenance
months inherited haemolytic anaemia,
(2)yelofibrosis, (3) renal dialysis

(1)Total gastrectomy (1)Pregnancy, (2)severe haemolytic

Prophylactic
(2)Ileal resection anaemias, (3)dialysis, (4)prematurity

Summary (from Essential Hematology)

1. Macrocytic anemia show an increased size of circulating red cells (MCV>98fl).

2. Causes include vitamin B12 (B12, Cobalamin) or folate deficiency, alcohol,
liver diseases, hypothyroidism, myelodysplasia, paraprotenemia, cytotoxic
drugs, aplastic anemia, pregnancy and the neonatal period.
3. B12 or folate deficiency cause megaloblastic anemia, in which the bone
marrow erythroblasts have a typical abnormal appearance.
4. B12 deficiency is usually caused by B12 malabsorption brought about
pernicious anemia in which there is autoimmune gastritis, resulting in sever
deficiency of intrinsic factor, a glycoprotein made in the stomach which
facilitate B12 absorption by the ilium.
5. Other gastrointestinal diseases as well as vegan diet may cause B12
deficiency.
6. Folate deficiency may be caused by a poor diet, malabsorption (e.g. glutin-
induced enteropathy) or excess cell turnover (e.g. pregnancy, heamolytic
anemias, malignancy).
7. Treatment of B12 deficiency is usually with injections with hydroxycobalamin
and of folate deficiency with oral folic (pteroyglutamic) acid.

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 432HematologyTeam Megaloblastic Anemia

Questions
1/ A 43-year-old woman complains of constant tiredness, light-headedness, and
occasional palpitations and shortness of breath while ascending the stairs.
Physical examination shows pallor of the oral mucosa and glossitis. Neurologic
examina tion reveals paresthesias, numbness, decreased vibration sensation,
and loss of deep tendon reflexes. The results of laboratory studies include
hemoglobin of 7.2 g/dL, WBC of 4,500/mL, platelets of 140,000/mL, serum
vitamin B12 of 40 pg/mL (normal >200 pg/mL),. Examination of peripheral
blood shows macrocytic anemia, with poikilocytosis of RBCs and
hypersegmented neutrophils. Bone marrow examination in this patient will
reveal which of the following pathologic findings?
(A) Absent stainable bone marrow iron
(B) Atypical megakaryocytes with fibrosis
(C) Hypercellularity with megaloblastic erythroid maturation
(D) Hypocellularity with absence of erythroid precursors

2/ which of the following mechanisms of disease best describes the

pathogenesis of anemia in the patient described in Question 1?
(A) Bone marrow fibrosis
(B) Defective heme synthesis
(C) Immune destruction of circulating erythrocytes
(D) Impaired DNA synthesis

3/ A patient with a history of chronic alcoholism presents with a macrocytic

anemia and thrombocytopenia. Blood smear examination demonstrates
numerous oval macrocytes and hypersegmented neutrophils. Which of the
following is the most likely diagnosis?
(A) Anemia of chronic disease
(B) Folic acid deficiency
(C) G6PDdeficiency
(D) Iron deficiency anemia
Answers:

- 1- C
- 2- D
- 3- B

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432 Haematology Team Leaders: Good Luck ^_^

P a g e | 11 Roqaih Al-Dueb & Ibrahim Abunohaiah