FREQUENCY OF PANCYTOPENIA AMONG PATIENTS WITH VITAMIN

B12 DEFICIENCY
INTRODUCTION:
` Pancytopenia refers to a reduction below normal values of all 3 peripheral blood lineages
i.e. leukocytes, platelets and erythrocytes1. It is not a disease but a triad of findings that may
result from a number of disease processes. These disorders may affect bone marrow either
primarily or secondarily resulting in manifestations of pancytopenia. 2 Pancytopenia may be
acquired inherited (genetic but not necessarily present at birth) 3 The pathogenesis of
pancytopenia is either a failure of production of hematopoietic progenitors or peripheral
destruction of cellular element due to infection, immune mediated damage or hypersplenism.4
Pancytopenia requires microscopic examination of a bone marrow biopsy specimen and a
marrow aspirate to assess overall cellularity and morphology.1 Bone Marrow Examination is one
of the important diagnostic procedures for many hematological disorders. In most cases it gives
the specific diagnosis however in few cases additional tests are required. The presenting
symptoms are often attributable to the anemia or thrombocytopenia or leucopenia5
The etiological spectrum of pancytopenia varies according to geographical distribution
and genetic disturbances. Aplastic anemia was found more common hematological disorder
(20.2%) than Megaloblastic anemia (14.6%) in a study conducted in Pakistan whereas iron
deficiency anemia and idiopathic thrombocytopenic purpura were the other common causes with
frequency of 7.6% and 15.7% respectively.6
The recognition and treatment of vitamin B12 deficiency is critical since it is a reversible
cause of bone marrow failure and demyelinating nervous system disease. Vitamin B12
(cobalamin) is synthesized by microorganisms and detected in trace amounts mostly in foods of
animal origin7. The interaction between folate and B12 is responsible for the megaloblastic
anemia seen in both vitamin deficiencies. Dyssynchrony between the maturation of cytoplasm
and that of nuclei leads to macrocytosis, immature nuclei, and hypersegmentation in
granulocytes6 in the peripheral blood8.
Humans cannot synthesise vitamin B12. Early detection and prompt treatment of vitamin
B12 deficiency is essential, since it is a reversible cause of bone marrow failure. After
diagnosing vitamin B12 deficiency, tracking down the root cause of the deficiency is important
in individualising the treatment approach9. In one study, out of 94 patients presenting with low
vitamin B12 levels, macrocytosis was seen in 29.8%, dimorphic blood picture of microcytic
hypochromic cells and macrocytes was seen in 17%. 27.7% patients had a microcytic and
hypochromic picture while 25.5% had a normochromic, normocytic picture. 5.4% had
pancytopenia10.
The present study is designed to determine the frequency of pancytopenia among patients
with vitamin B12 deficiency. Vitamin B12 deficiency is not uncommon in our population and
duet to its critical role in bone marrow cell lines and nervous system, it critical to evaluate the
complications associated with it. Reduction is cell lines due to bone marrow failure secondary to
vitamin B12 deficiency is critical and therefore, we designed this study to determine the burden
of pancytopenia among local population with vitamin B12 deficiency. The results of this study
will be shared with local health professionals to make them aware of the gravity of the problem
and design future research and treatment recommendations.
OBJECTIVE:
To determine the frequency pancytopenia among patients with vitamin B12 deficiency.
OPERATIONAL DEFINITIONS:
Pancytopenia: Patients with all the following condition will said to have Pancytopenia, when
peripheral smear of blood shows.
 Hemoglobin< 10g/dl
 Total leucocyte count < 4,000
 Platelets < 150,000
 Reticulocyte count <2%
Vitamin B12 Deficiency: Serum vitamin B12 levels less than 150 pmol/L measured in hospital
laboratory will be considered vitamin B12 deficiency.
MATERIAL AND METHODS:
Study Design: Descriptive cross sectional study
Setting: Department of Hematology, Hayatabad Medical Complex, Peshawar
Duration: Minimum six months after approval of synopsis
Sample size: Using WHO sample size calculator for sample size calculation, a sample size will
be 252 using 4.27% proportion of pancytopenia among patients with vitamin B12 deficiency10,
95% confidence level and 2.5% margin of error, under WHO software for sample size
determination.
Sampling techniques: Non probability consecutive sampling.
SAMPLE SELECTION
Inclusion Criteria:
a. All patients with severe vitamin B12 deficiency with duration > 2 years.
b. Patients in age range 18-60 years
c. Either gender
Exclusion Criteria:
a. Patient already on treatment for diseases like cancer chemotherapy, Aplastic
anemia and leukemias as detected by history and medical record.
b. Already diagnosed cases of iron deficiency anemia, aplastic anemia,
Megaloblastic anemia, leukemias and infectious diseases.
DATA COLLECTION PROCEDURE:
Permission will be taken from ethical board before starting study. A written informed
consent will be taken from all patients. Objectives of study and risks involved in bone marrow
aspiration will be informed and explained to patients. The privacy implications of the collected
information will be clearly explained to the patients at the time of taking written consent.
All those patients who fulfill inclusion criteria will be included in our study. From all
patients, a sample of venous blood will be obtained and sent to hospital laboratory for the
peripheral smear examination. Pancytopenia will be diagnosed on the basis of Peripheral smear
showing Hemoglobin< 10g/dl, Total leukocyte count < 4,000, Platelets < 150,000, Reticulocyte
count <2%. All the peripheral smears will be done by an expert hematologist who will be a
fellow of CPSP and having a minimum of five years of experience. Strictly exclusion criteria
will be followed so that to avoid cofounders and make the study results clear of any bias. All
investigations will be done free of cost in our hospital
All the above mentioned information including name, age, sex, duration of vitamin B12
deficiency, mal absorption, nutritional deficiency, serum B12 Levels will be recorded on pre-
designed Performa.
DATA ANALYSIS:
All the collected information on proforma will be entered and analyzed through SPSS
22. Mean and Standard Deviation will be calculated for numerical variable i.e. age, duration of
vitamin B12 deficiency, serum B12 Levels. Frequency and percentages will be calculated for
gender, mal absorption, nutritional deficiency and pancytopenia. Pancytopenia will be stratified
among the age, gender, duration of vitamin B12 deficiency, mal absorption, nutritional
deficiency to see the effect modification using chi square test with p value of < 0.05 as
significant. All the results will be presented in tables and graphs.
REFERENCES:
1. Gupta N, Khajuria A. Pancytopenia: A clinico-haematological evaluation and correlation
with bone marrow examination. leukemia. 20151;3:6.
2. Desalphine M, Bagga PK, Gupta PK, Kataria AS. To evaluate the role of bone marrow
aspiration and bone marrow biopsy in pancytopenia. J Clin Diagn Res. 2014;8(11):FC11.
3. Young NS, Dumitriu B, Ogawa S. Acquired Aplastic Anemia: New Genetics, New
Genomics. Blood. 2014;124(21):SCI-21.
4. Wang YH, Fu R, Dong SW, Liu H, Shao ZH. Erythroblastic islands in the bone marrow
of patients with immune-related pancytopenia. PloS one. 2014;9(4):e95143.
5. Ojha S, Haritwal A, Meenai FJ, Gupta S. Bone marrow examination findings in cases of
pancytopenia-a study from central India. Ind J Path Oncol 2016;3(3):479-84.
6. Ahmad A, Idrees M, Afridi IG, Rehman G. To determine the etiology and frequency of
pancytopenia in pediatric population and compare it with other studies. KJMS.
2016;9(2):186.
7. Nielsen MJ, Rasmussen MR, Andersen CB, Nexø E, Moestrup SK. Vitamin B(12)
transport from food to the body’s cells-a sophisticated, multistep pathway. Nat Rev
Gastroenterol Hepatol 2012;9:345-54.
8. Heil SG, de Jonge R, de Rotte MC. Screening for metabolic vitamin B12 deficiency by
holotranscobalamin in patients suspected of vitamin B12 deficiency: a multicentre study.
Ann Clin Biochem 2012;49:184-9.
9. Anitha P, Sasitharan R, Thambarasi T, Krithika P, Mohan M, Venkataraman P, et al.
Vitamin B12 deficiency presenting as pancytopenia and retinopathy in a young boy--
Helicobacter pylori, a novel causative agent. Aust Med J. 2014;7(3):143-48.
10. Bhatia P, Kulkarni JD, PAI SA. Vitamin B12 deficiency in India: mean corpuscular
volume is an unreliable screening parameter. National Med J Ind 2012;25(6):336-38.
FREQUENCY OF PANCYTOPENIA AMONG PATIENTS WITH VITAMIN
B12 DEFICIENCY
PROFORMA

Serial No_____________ Date:___________________

Name_________________________________________________________________________
Age_______________________ Gender_________________
Address:______________________________________________________________________
Hospital No___________________________________________________________________

Duration of vitamin B12 deficiency:__________________________

Mal absorption: Positive Negative
Nutritional Deficiency: Yes No

Serum B12 Levels: _____________________________

PANCYTOPENIA: Yes No
 ETHICAL COMMITTEE APPROVAL

I, Associate Prof. Dr. Shah Taj, as a FCPS supervisor confirm that the synopsis titled

FREQUENCY OF PANCYTOPENIA AMONG PATIENTS WITH VITAMIN B12

DEFICIENCY, Prepared by my FCPS trainee Dr. Humaira Taj Niazi, is according to the

medical ethics followed by our department and the hospital, and has been approved from the

hospital ethical committee.

SUPERVISOR:

ASSOCIATE PROF. DR. SHAH TAJ

PROFESSOR OF HEMATOLOGY
HAYATABAD MEDICAL COMPLEX, PESHAWAR
 CONSENT FORM

Date: ___________________________

S/No: ____________ Admission No: ____________________

Name of the Patients: _________________________________________________

Age: _______________________________________________________________

Gender: ____________________________________________________________

Address: ____________________________________________________________

INFORMATION PROVIDES:

1. Procedure of bone marrow aspiration.

2. Risks involved in bone marrow aspiration.
3. Using of data for research studies.

CONSENT OF THE PATIENT:

I am willing/unwilling to undergo the treatment as explained by treating doctor.

________________________

(signature of the patient)