Macrocytic Anemias

Anemias where the cells are BIG

Macrocytic anemias
 Macrocytic anemias are characterized by
large RBCs with a normal hemoglobin
content.
 Macrocytic anemias are classified as either
megaloblastic or non-megaloblastic
 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 anemias
 The biochemical basis for this is as follows:
 Megaloblastic dyspoiesis (abnormal synthesis)
occurs when the DNA synthesis in the
hematopoietic system is disrupted or slowed
down.
 Other rapidly proliferating cells in the body are
also affected.
 Administration of drugs that interfere with DNA
metabolism can be the cause of a megaloblastic
anemia.
 On rare occasions there is an inherited disorder
that affects DNA synthesis
Megaloblastic anemias
 However, the primary defect in DNA replication is
usually due to depletion of thymidine triphosphate
which leads to retarded mitosis, and therefore
retarded nuclear maturation.
 The depletion of thymidine triphosphate is usually due to
a deficiency of vitamin B12 or folic acid.
 Vitamin B12 deficiency is usually due to a deficiency of a
factor necessary for B12 absorption while a folic acid
deficiency is usually due to an inadequate dietary intake.
 Absorption and metabolism of vitamin B12 and folic acid:
 Vitamin B12 (cyanocobalamine)
 Is found in meats, eggs, dairy products, and liver.
 Is absorbed via a binding protein called intrinsic factor

(IF)
Megaloblastic anemias
 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.
Vitamin B12 absorption
How is B12 involved in DNA synthesis?
 Vitamin B12 is involved in the following reaction:
Megaloblastic anemias
 Decreased vitamin B12 therefore results in no
conversion of N5-methyl THF to THF. Thus, the
net result is that dTMP for DNA synthesis is not
made.
 Humans need 3-5 ug of vitamin B12 per day.
Since 70% of dietary B12 is absorbed, the diet
needs to contain 5-7 ug/day.
Megaloblastic anemias
 Folic acid (pteroyl glutamic acid)
 Is found in most foods, including eggs, milk,

yeast, and liver.

 Is abundant in green, leafy vegetables and is

synthesized by many microorganisms.

 Is destroyed by heat

 Absorption occurs in the small intestine

How is folic acid involved in DNA
synthesis?
 Is involved in the following reaction:
Megaloblastic anemias
 Therefore, with decreased folic acid, the net
result is the same as that for decreased vitamin
B12 – there is decreased conversion of dUMP to
dTMP, and thus, dTTP which is required for DNA
synthesis.
 Defective DNA synthesis may occur when dUTP
gets used in place of dTTP because there is a
great increase in erroneous DNA copying where
dUTP is put in place of dTTP.
 Humans need to get about 50 ug/day of folic
acid from the diet
 Causes of megaloblastic anemia
 Vitamin B12 deficiency
Megaloblastic anemias
 85% is due to lack of intrinsic factor (IF)
secondary to gastric atrophy – this is called
pernicious anemia (PA) and it occurs most often
in older adults (over 40), most commonly in
individuals of Northern European descent.
Antibodies against the parietal cells in the G.I.
tract and against IF are commonly found in
these individuals.
 After gastrectomy
 Malabsorption syndrome
 Inadequate dietary intake (rare)
 Defective or absent transport proteins
(transcobalamine)
Causes of B12 deficiency
Megaloblastic anemias
 Folic acid deficiency
 Inadequate diet is the major cause and this occurs

most often in the poor, elderly, and alcoholics.

 When there is increased requirement such as in

pregnancy, hemolytic anemia, leukemia, etc.

 Malabsorption – may be due to diseases of the upper

small intestine such as ileitis, tropical and nontropical

sprue, and overgrowth of bacteria
 When there is increased loss such as in patients

undergoing hemodialysis
 Drug inhibition – examples are oral contraceptives,

anticoagulant drugs, and phenobarbitol

Megaloblastic anemias
 Clinical manifestations occur in two categories – those
found in folic acid or vitamin B12 deficiency, and those
only found in B12 deficiency
 In both types of deficiency the symptoms include pallor,
weakness, lightheadedness, a smooth,sore tongue, and
diarrhea alternating with constipation
 In vitamin B12 deficiency only, there are neurological
disturbances including numbness and tingling of
extremities, gait abnormalities, and mental disturbances.
 This is due to a defect in the degradation of propionyl

CoA to succinyl CoA leading to an accumulation of

propionyl CoA:
Megaloblastic anemias
 When there is a build up of propionyl CoA (3
carbons), it is used in place of acetyl CoA (2
carbons) as a primer for fatty acid synthesis.
 Fatty acids with odd numbers of carbons get
incorporated into neural membranes
 This leads to disruption of membrane function
with subsequent demyelination of nerve fibers.
 Lab findings
 Macrocytic, normochromic anemia (MCV=100-140,
MCHC is normal))
 MCH is increased (due to increased cell size)
Megaloblastic anemias
 Hemoglobin and RBC counts are decreased
 WBC and platlet 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:
 Anisocytosis is usually moderate

 Poikilocytosis is striking with nucleated RBCs,

polychromatophilia, and cabot rings (spindle

remnants).
 RBC dimorphism is seen with concomitant IDA.

 The absolute reticulocyte count is decreased

because of ineffective erythropoiesis.

Peripheral smear of
megaloblastic anemia
Peripheral smear of
megaloblastic anemia
Megaloblastic anemias
 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.
 In folic acid deficiency – there will be decreased serum and
RBC folate
 In B12 deficiency – there will be decreased serum vitamin
B12
 Specific tests for PA
 Gastric analysis – if there is no free HCl after

histamine stimulation, this may indicate PA since the

same cells that secrete HCl, also secrete intrinsic
factor (IF)
Megaloblastic anemias
 Schilling test – is the definative 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 PA
Schilling test
Schilling test results
Non-megaloblastic macrocytic anemia
Non-megaloblastic macrocytic anemia

 Note that the macrocytic RBCs are not

oval, but are round.
 There are no hypersegmented
neutrophils or Howell-Jolly bodies
Differential diagnosis with
increased MCV
Differential diagnosis with a
high MCV
Lab results of megaloblastic vs non-
megaloblastic macrocytosis