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2 | RBC and Bleeding Disorders Anemia II

PATHOLOGY
BATCH AUMONT TRANS DR. JA. TINDOC 16 NOV 2021

Outline Page

Anemias of Diminished Erythropoiesis 1

Megaloblastic Anemia 1
Pernicious Anemia 1
Vitamin B12 Deficiency 3
Folic Acid Deficiency 5
Iron Deficiency Anemia 5
Anemia of Chronic Inflammation 6
Aplastic Anemia 6
Pure Red Cell Aplasia 7
Other forms of Marrow Failure 7

(Refer to image above)

ANEMIAS OF DIMINISHED ERYTHROPOIESIS *Neutrophil with 6 segments. (Normally, it’s just 3-5 lobes)
Anemia: not a problem of increased destruction, but a problem *The background has enlarged RBCs but it is difficult to determine by looking
of decreased production. at the peripheral blood smear alone since everything is enlarged.
● Megaloblastic Anemia *But under the RBC indices, it has increased MCV, mean corpuscular volume.
There are a few target cells, which can be nonspecific.
● Iron Deficiency Anemia
Both are nutritional disorders
● Anemia of Chronic Inflammation
● Aplastic Anemia
● Pure Red Cell Aplasia
Can be congenital
● Others

MEGALOBLASTIC ANEMIA
● Macrocytosis
○ enlarged RBCs, seen in elevated levels of MCV
● Megaloblastosis
○ not only increased MCV, but also with presence of
macro ovalocytes and hypersegmented neutrophils in
the peripheral blood. It has a much more extensive
involvement than macrocytic anemia.
(Refer to image above)Bone marrow biopsy of a Px with Megaloblastic
● Impairment of DNA Synthesis leading to ineffective
Anemia.
hematopoiesis and distinctive morphology of RBCs (large) *Arrows A and C- Enlarged precursors, notice the bluish cytoplasm and
● 2 Primary Examples: enlarged nuclei.
1. Pernicious Anemia *Arrow B- Orthochromic normoblast undergoes hemoglobinization, but despite
2. Folate Deficiency Anemia its maturation, the nucleus is still enlarged
- Both disorders mediate their effect by causing a PERNICIOUS ANEMIA
problem in the formation of: ● An autoimmune disease that leads to decreased
● Thymidine - due to decreased dTMP, deoxythymidine amounts of serum Vitamin B12
monophosphate
Vitamin B 12 Reactions:
1. Essential cofactor for the conversion of Homocysteine
to Methionine

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● Homocyteine acted upon by Methionine Synthase,
converts Methionine
● Methionine Synthase needs Vitamin B12/Cobalamin to
function properly.
○ Decreased amounts of Vitamin B12 - limited
conversion of Homocysteine to Methionine
○ Decrease amount of Folic Acid w/c translate
into decrease amount of thymidine
● Mediated by thymidylate synthase and DTMP leading
to the formation of DNA
● Both B12 and folic acid have the same end-point effect
in this megaloblastic anemia
● Then, it is endocytosed and released up into the
luminal surface into the portal veins and is transported
○ The intrinsic factor is destroyed
○ The B12 will be attached to Transcobalamin
II(w/c is the transporter)
DAILY REQUIREMENTS
● 2-3 microgram
● meat, fish, milks, eggs
● Very little in plants and vegetables
● Hepatic stores enough to last for years
PA AUTOANTIBODIES
● Type I- blocks binding of b12 to IF
● Type II-blocks binding of the B12-IF complex to the
cubilin in the ileal cells
● Type III-recognize subunits of gastric proton pump; it
will reduce the acidity of the stomach
○ Both Type I and II are found in gastric juice and
sometimes in the serum as well. Both also specific
for pernicious anemia
○ Type III- less specific form of antibody

2. Isomerization of Methylmalonyl coenzyme A to

Succinyl coenzyme A
● Associated with neural presentation/neuropathies a
opposed to folic acid deficiency w/c is plainly
anemia

*Gastric corpus / gastric body

● B12 is found in protein diet

● In the food, it bind with a binding protein
● Salivary gland will release haptocorrin
● The B12 will be released in the binding proteins by the
actions of pepsin in stomach
● It is attached to haptocorrin from the salivary gland
forming a haptocorrin-B12 complex
● It proceed into the duodenum and eventually enter
further deeper to these smaller intestines where it is
act upon by the proteases produced by the pancreas
● The proteases will break down the association of
haptocorrin and vitamin B12 complex allowing it to Pernicious anemia
bind to the intrinsic factor(from the stomach) *There is an inflammation that is deep seated and the inflammation tends to
○ intrinsic factor comes from the stomach destroy your fundic epithelium leaving only the superficial foveolar epithelium
○ It only binds with B12 *The absence of the more pink eosinophilic glands in the deeper parts of
mucosa is seen in a progressing pernicious anemia.
● Vitamin B12 together with intrinsic factor finds its way
to ileum attaches to ileal cell through the
cubilin(intrinsic factor receptor)
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In severe circumstances, there is an intestinalization of the gastric mucosa
such that you find the presence of goblet cells in the mucosal layer where
goblet cells remind us of the small intestinal epithelium, sometimes the large
intestinal epithelium.
VITAMIN B12 DEFICIENCY
● Because of the effects of deficiency, you will have a
shiny, beefy red tongue of Vitamin B12 deficiency
● Sometimes you can have angular cheilitis (right
picture)
● Other effects of Vitamin B12 Deficiency
○ The absence of vit b12 causes a form of
degeneration of the dorsal and lateral
columns of the spinal tracts.
*Spinal cord with the Wale stain (left) and Luxol fast blue stain (right). Notice
that there is decolorization in the areas of the spinal cord that is seen typically
in Vitamin B12 Neuropathies.
DIAGNOSIS OF VIT B12 DEFICIENCY
● Moderate to severe megaloblastic anemia
● Leukopenia with hypersegmented granulocytes (more than
5 segments seen)
● Low serum vitamin B12 (microbiological assays are the
gold standard for Vit B12 levels)
● Elevated serum levels of homocysteine and methylmalonic
acid
○ In Vit b12 deficiency, there is a problem in conversion
of the homocysteine to methionine, hence you will
have elevated amounts of homocysteine.
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○ B12 is also needed for the isomerization of methyl
malonic acid to succinyl-CoA, hence you will have
elevated amounts of methylmalonic acid
● Serum autoantibodies to intrinsic factor
FOLIC ACID DEFICIENCY
● Outcome is you have megaloblastic anemia
● Pteroylmonoglutamic acid (FH4 derivatives).
1. Purine synthesis
2. Conversion of homocysteine to methionine
3. dTMP synthesis
*In these reactions, the folic acid serves as a one-carbon
acceptor that carries it to the molecule for the formation of your
purine and your dTMP
*For the formation of methionine and purines, the FH4
derivatives are actually regenerated
*In the formation in the synthesis of dTMP however, the FH4 is
not regenerated and it ends up being the FH2. For FH2 to be
regenerated in FH4 in this particular branch of the reaction, you
would need dihydrofolate reductase.
*Dihydrofolate reductase - one of the targets for our drugs like
methotrexate, or some drugs for fungal infections.
MAJOR CAUSES OF FOLIC ACID DEFICIENCY
1. Decreased intake
2. Increased requirements
3. Impaired utilization
➔ Folic acid in comparison to B12 are more abundant in
green vegetables; Heat sensitive (5-10 mins boiling →
95% loss)
➔ Absorption: 5-methyltetrahydrofolate (transport form)
➔ Storage: weeks to months
If you notice Folic acid is not just for Megaloblastic anemia, it's
also associated with neural tube defects in the newborn. That is
one of the reasons why we have gardenia enriched with folic
acid because you would need folic acid for pregnant women.
Gardenia is one way of reducing the risk of neural tube defects
due to folic acid deficiency
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 IRON METABOLISM
VITAMIN B12 DEFICIENCY
● Normal Diet: 10-20mg iron (mostly heme iron from the
Decreased Intake muscles or from the meats)
● 20% of heme iron is absorbable (1-2% of nonheme
Inadequate diet; vegetarianism iron)
● 2.5 grams in women; 6 grams in men
Impaired Absorption ● Storage pool (if not needed)→ transferrin →
Intrinsic factor deficiency functional pool (if needed)
Pernicious anemia ○ transition from one to the other is mediated by
Gastrectomy
transferrin
Malabsorption states
Diffuse intestinal disease (e.g. lymphoma, systemic sclerosis) ● Serum: 120 ug/dL (men) and 100 ug/dL (women)
Ileal resection, ileitis ● Ferritin (cytosol and lysosomes) → hemosiderin
Competitive parasitic uptake ○ storage form of iron is in ferritin which is seen
Fish tapeworm infestation - Diphyllobothrium latum in the cytosol of cells and sometimes in
bacterial overgrowth in blind loops and diverticula of bowel lysosomes
○ partially degraded shells of ferritin can come
FOLIC ACID DEFICIENCY together to form hemosiderin
○ This iron is in its free form (toxic) and has to
Decreased Intake
be stored in a more stable form
Inadequate diet, alcoholism, infancy

Impaired Absorption
Malabsorption states
Intrinsic intestinal disease
Anticonvulsants, oral contraceptives

Increased Loss
Hemodialysis

Increased Requirement
Pregnancy, infancy, disseminated cancer, markedly increased
hematopoiesis

Impaired Utilization
Folic acid antagonists

Unresponsive to Vitamin B12 or Folic Acid Therapy

Metabolic inhibitor of DNA synthesis and/or folate metabolism
(e.g. methotrexate)

IRON DEFICIENCY ANEMIA

● In contrast to megaloblastic anemia, this is now a
microcytic hypochromic anemia
● Most common nutritional disorder

Pool Men Women ● Iron is absorbed in the proximal duodenum, some in

the book would say in the duodenum and upper
Total (milligrams) 3450 mg 2450 mg jejunum but this would be in comparison to B12 which
3-6 g is absorbed to the ileum.
● Then, this is brought into the plasma through the
Functional transferrin and transported into the liver for storage.
Hemoglobin 2100 1750 And sometimes, it is transported to the marrow by
Myoglobin 300 250 transferrin to provide iron for the erythroid precursors.
Enzymes 50 50 ● At times, it reaches the skin, gut and endometrium
Storage
which are stored in the epithelial cells.
Ferritin, hemosiderin 1000 400 ● These epithelial cells are shed daily, leading to a loss
of 1-2 mg/day of iron
● There is no easy way of getting rid of iron in the body
except by shedding of epithelial cells or blood loss

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● After the erythroid precursors make use of the iron, it
is incorporated in the hemoglobin and becomes part of
the circulating erythrocytes, which when destroyed
either in intravascular or extravascular forms of
hemolysis or in the usual physiologic destruction of
RBCs, it is stored in the mononuclear phagocytes.
● Normally, in the body you have the heme iron and the
non-heme iron
● It was mentioned that around 20% of heme iron is
easily transported and mediated by a form of heme
transporter and once it is in the enterocyte or in the
duodenal cell, it is released as a form of ferrous iron
● The non-heme iron, which is usually in the ferric state,
cannot be easily absorbed in that state, but must be
acted upon duodenal cytochrome b enzymes, and is
converted to its ferrous state, and makes use and is
transported through the divalent metal transporter 1
and allows entry into the duodenal cell cytoplasm
● Once in the cytoplasm, it will exit into the abluminal part
leading to the circulation. It will exit through ferroportin
● But as a ferrous state, it cannot bind to plasma
transferrin, hence it must be converted back to ferric
state by hephaestin and as a ferric state, it can now be
attached to plasma transferrin where it is brought to the
erythroid precursors into the marrow or into the liver for
storage
● As the iron levels increase in the liver, the liver secretes
plasma hepcidin which provides negative feedback to
ferroportin
● In the cases of high plasma iron or in cases of systemic
inflammation, there is a lot of iron in the body so that
the liver now produces a lot of plasma hepcidin
● This plasma hepcidin will trigger the endocytosis and
destruction of ferroportin
● The ferrous iron will stay in the duodenal cell for the
rest of the duodenal cell’s life, and it is shed. So, you
will not absorb the iron and you will lose the iron
through mucosal shedding.
● In some cases where there is low plasma iron,
ineffective erythropoiesis, or in cases of
hemochromatosis, the liver does not produce enough
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plasma hepcidin so there is no feedback into the
duodenal cells
● Because of the low levels of iron in the plasma, there
is decreased production of hepcidin, leading to
reduced degradation of ferroportin transporters
allowing more flux of iron into the transferrin in the
plasma
ETIOLOGY OF IRON DEFICIENCY ANEMIA
1. Dietary Lack
● lack of dietary iron; mother’s milk has around 0.3
mg/L of iron and cow’s milk has more of it, but not
easily absorbed.
2. Impaired Absorption
● seen in increased intake in some inhibitors of
absorption including tannates (found in tea),
carbonates, oxalates, and phosphates. There is
increased absorption of iron when taken together
with ascorbic acid, citric acid, amino acids, and
sugars in the diet
3. Increased requirements
● States of increased requirement of iron can occur
in times of increased erythropoiesis and pregnancy.
In those situations, iron deficiency anemia (IDA)
can ensue because of inappropriate supply in the
face of increasing demand
4. Chronic Blood loss
● Is one of the most common causes of IDA in adults
in high-income countries. If we have adult males
who have IDA, we would be considering the
possibility of chronic blood loss as the cause of
that anemia. The most common cause of an occult
chronic blood loss in an adult male would fall
under the gastrointestinal
malignancies/colorectal carcinomas; a
colonoscopy might be needed in those situations
DAILY IRON REQUIREMENT:
● 7-10mg for males
● 7-20mg for females
● In reality, 1 mg of iron is needed per day to compensate
for the loss of 1mg of iron per day as well
● Only 10-15% of ingested iron is absorbed.
PBS of px with IDA: Microcytic, hypochromatic cell (pointed)
*central pallor should only consume about 1/3 of a normal RBC
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*Some pencil cells (pointed) would also be seen. As the body tries to produce
more RBCs in the face of reduced hemoglobin, there would be increased RDW
○ Antimetabolites ● Viral infections
(red cell distribution width) ○ Benzene ● Hepatitis (unknown
○ Chloramphenicol virus)
○ Inorganic arsenical *5% of the cases wil progress
● Idiosyncratic in persistent marrow aplasia
○ Chloramphenicol ● Cytomegalovirus
○ Phenylbutazone infections
○ Organic arsenicals ● Epstein-Barr Virus
○ Methylphenyl Ethyl infections
Hydantoin ● Herpes zoster
○ Carbamazepine (varicella zoster)
○ Penicillamine
○ Gold Salts

*Because of the absence of iron in the body, pallor would be the most general Inherited
manifestation of that anemia ● Fanconi anemia
*Aside from that, person would have koilonychia, a problem of the nails
○ Which shows defects in some kind of protein in DNA
*A form of glossitis which could involve the angular creases of the mouth
repair
*Alopecia in men because of IDA and this is brought about by the fact that
iron is also needed for some of the enzymes in the body ● Telomerase defects
○ Early apoptosis in your stem cells
ANEMIA OF CHRONIC INFLAMMATION
● Systemic inflammation as a common cause of anemia in
hospitalized patients
○ Chronic microbial infections
○ Chronic immune disorders
○ Neoplasms
● IL-6→ increased hepcidin
○ The increased levels of hepcidin will result in
destruction of ferroportin not just in the duodenal cells
but would also sometimes involve the macrophage
ferroportin as well.
● There is a limitation of the release of iron into the serum and
this will show a low serum iron and will also show a
microcytic anemia, hypochromic anemia which is very
much similar to your iron deficiency anemia
● But the difference would lie in the increased levels of ferritin *The stems cells because of environmental insults like: Viruses, Drugs etc.
and in the reduced TIBC because a lot of your iron is *It can alter those stem cells and express new antigens and because it
already stored in the body. expresses new antigens it is possible for your immune system to be sensitized
against it.
● Anemia of Chronic Inflammation are seen with people with * Aside from that it can have defects that reduce proliferative and differentiative
cancers, TB and sometimes with patient with a possibility capacity and because of this, there will be marrow aplasia, the reduced
of HIV proliferation, you have the T cell response targeted against the new antigens
so you have an immune response and an intrinsic defect in the stem cells that
APLASTIC ANEMIA converge to form a marrow aplasia.
● Chronic primary hematopoietic failure
● Autoimmune
○ Aplastic Anemia tends to be autoimmune, and it is
associated paroxysmal nocturnal hemoglobinuria
Acquired
● Idiopathic
● Acquired stem cell def

Chemical Agents Physical Agents

● Dose Related ● Whole-body
○ Alkylating agents irradiation

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*Under the microscope this is a normal bone marrow and we have a certain
formula for the computation of the marrow cellularity such that I can guess at
the age of this person is around 20 to 30 years old with these cellularity
*We have this trabeculae of bone in the bone marrow, fat in the bone marrow
and have a lot of proliferating stem cells either adjacent to the bony trabeculae
or even within the center of the marrow spaces with the fat.
*In a patient with aplastic anemia there are no more to very little aggregates
of the precursor cells. In fact, what is here are actually lymphocytes infiltrating
the bone marrow.
*So this is an example of aplastic anemia in high-power modification of the fat
that is present in the marrow with aplastic anemia.
PURE RED CELL APLASIA
● Only erythroid precursors are suppressed.
● Diamond Blackfan Anemia
● Thymoma and Large Granular Lymphocytic Leukemia
● Parvovirus B19
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Aplastic anemia- the entire gamut of bone marrow
hematopoietic cells are affected.
● No wbc
● No platelets or the megakaryocytes
● No rbcs
*The pancytopenia is also seen in megaloblastic anemia
*Pure red cell aplasia only affects erythroid precursors in
contrast to aplastic anemia which is pancytopenic *Diamond-
blackfan anemia (congenital) and this suppression in some
more adult patients, this can be seen secondary to thymoma
and a leukemia called large granular lymphocytic leukemia
*Transient marrow aplasia can be seen in parvovirus b19.
parvovirus b19 targets erythroid precursors which can lead to
dangerous aplastic crisis in some patients with hereditary
spherocytosis for example
*In patients without hereditary spherocytosis however, the
Parvovirus B19 can have prolonged or sustained infection.
*This can occur in patients with HIV in such that they can
develop a chronic pure red cell aplasia in those cases.
OTHER FORMS OF MARROW FAILURE
● Myelophthisic anemia
● Chronic Renal Failure
● Hepatocellular disease
● Endocrine disorders
*Other forms of marrow failure include Myelophthisic anemia,
this can be considered as part of the spent face of some of our
polycythemia vera and some of the marrow fibrosis and
sometimes even in CML and this can be seen in those diseases
*So the marrow becomes fibrotic sometimes with fat and there
is no longer any remnant of the hematopoietic precursors
*This can also be seen in the involvement of marrow by
neoplasms
*Chronic renal failure can also contribute to marrow failure over
time. for one thing the decreased amounts of erythropoietin can
lead to the reduced erythropoiesis. *Hepatocellular diseases
and endocrine disorders can also contribute to marrow failure.
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