Basics in

Deficiency
Anaemias

Hiroshani Kulatunga
 Basic Nutrients needed for
haemopoiesis
Iron
Folate
Cobalt
Vitamin B12
Vitamin B6

Also androgens, thyroxine

 Iron
• Iron deficiency - most common cause of deficiency
anaemias.
Why??
• body’s iron absorption ability is
limited
• excess loss of iron via hemorrhage
• dietary intake is inadequate from
childhood

-causes microcytic hypochromic anemia

Body Iron Distribution and
Transportation
Body Iron distribution,
• Haemoglobin iron (70%)

• Tissue Iron (25%) – Myoglobin and

respiratory enzymes

• Storage iron (3%) – Ferritin , haemosiderin

• Transport iron (2%) – Transferrin

Dietary sources

• Organ meat – best (liver, heart, kidney, spleen)

• Egg yolk – poorly utilized

• Dark green leafy vegetables

 Absorption of Iron
Maximal absorption takes place in duodenum by
mucosal epithelial cells

• Amount of iron in the body is regulated by

changes in absorption

• Absorptive process can be considered in three

phases
• Absorptive process can be considered in three
phases,

1. The intra luminal phase – food is digested and iron

is made available in soluble form

2. The mucosal phase – Fe is taken up by absorptive

cells and transported across to the serosal side or
retained in the cell

3. The transport phase– absorptive cell passes Fe to

plasma transferrin, to be carried to the liver and
erythropoietic tissue
1. The luminal phase

• Iron in the diet,

Haem iron
Non-haem iron
Haem iron

• Absorption is very high and minimally affected by

other elements in the diet

• Binds to an apical transport protein in enterocytes

• Carried into the cytoplasm

• Remove Fe from porphyrin by haem oxygenase

and add to intracellular Fe+2 pool
Non haem iron
• Vegetable food
• Meat iron not in the form of heam
• Inorganic fortifications in the diet

• Only a soluble form of iron is available for

absorption

• Ascorbic acid act as a reductant to form Fe 2+

Fe 3+ Fe 2+

• Help in the absorption of soluble complex of Fe2+

 Ferric ions combine with gastroferrin, a mucin
containing carbohydrate or

Chelate with amino acids (cys), fructose etc

Prevent precipitation at alkaline pH of duodenum

• State of iron stores in the body affect iron
absorption
• Rate of erythropoiesis

• Iron deficiency  increased rate of absorption

• Erythropoiesis  increased rate of absorption

Anoxia, haemolytic anaemia, growth, pregnancy

2.The mucosal phase

• Fe 2+  bind to a carrier protein (transporter

ferroportin)  transport directly in to plasma

• The balance, Fe 2+ Fe 3+

binds to apoferritin

Ferritin

• Ferritin bound iron is lost from the body when intestinal

cells slough
3.The Transport Phase

Fe2+ entering blood is oxidized to Fe 3+

This oxidation is catalyzed by enzyme Ceruloplasmin

Normal Fe conc in serum 13-32 µmol/l

Couple with transferrin, the transport protein.

Transferrin has 2 binding sites for iron
It deliver iron to tissues that have transferrin
receptors. Especially in erythroblasts of bone marrow.
The transferrin is reutilized.

Transferrin is the form that iron is transported

between intestinal mucosa – red cell precursors in
bone marrow and liver
Iron absorption,

• Increased by - Fe2+
reducing substances

• Reduced by - Phytates
Oxalates
Fe3+
tea
 Stored Iron
• Iron is stored in macrophages in reticuloendothelial
system (liver, spleen, bone marrow)

• Hepatocytes also store iron

Iron is in Fe3+

Ferritin- Water soluble protein- iron complex

Present in cytosol

Haemosiderin - Water insoluble protein-iron complex seen as

golden yellow intra-cytoplasmic granules)

Derived from partial lysosomal digestion

of aggregates of ferritin molecules
 Causes of Iron Deficiency
1. Inadequate supply of iron due to a dietary deficiency or poor
absorption

e.g. Coeliac disease, gastrectomy patients due to decreased gastric

acid secretion

2. Excessive loss of iron

From uterine or from gastrointestinal tract

Hook worm infestation ,Bleeding chronic peptic ulcers

• (Hook worm infestation - the most common cause of Fe deficiency

anaemia world wide)
3. Increased requirement in growth & pregnancy
Eg : Infancy, adolescence, pregnancy, lactation,
menstruating women
 Clinical Features in Iron Deficiency

When iron deficiency developes,

Iron stores in reticuloendothelial system

Deplete completely before anemia occurs

General signs and symptoms of anemia
Other than general signs and symptoms,

Brittle, ridged or koilonychia

Painless glossitis
 Angular stomatitis

In children,
Irritability
Poor cognitive function
Decline psychomotor actions
Iron deficiency cont…

Laboratory Findings
1. FBC and red cell indices
RBC count - decrease
Hb concentration - decrease
MCV/ MCH - decrease relative to
severity of anaemia.

2. Reticulocyte count - decrease relation to the

severity of anaemia
3. Blood picture
hypochromic, microcytic red cells
occasional pencil cells and target cells.
(Poikilocytosis)
4. Bone marrow iron

Not essential except in complicated cases.

Complete absence of iron from stores (macrophages)
and from developing erythroblasts.

The erythroblasts are small and have a ragged

cytoplasm.
What is the stain used to stain iron stores?

Perl’s stain
5. Serum Iron Studies

Serum iron -
(Transferrin bound iron)
TIBC -
UIBC -
Percentage saturation -
Serum ferritin -
Total Iron Binding Capacity
(TIBC)
Investigation for the cause of
Iron deficiency
 Macrocytic Anaemias
Abnormally large RBC
(MCV ˃98fL)

Macrocytic
anaemia

Megaloblastic Non
anaemia megaloblastic
anaemia
 Megaloblastic anaemias
Bone marrow erythroblasts shows a characteristic
abnormality.

Nuclear maturation is delayed relative to that of

cytoplasm

Underline defect for asynchronous maturation of

nucleus – defective DNA synthesis due to Vitamin
B12 or Folate deficiency
Causes of Megaloblastic anemia
• Vitamin B12 deficiency

• Folate deficiency

• Abnormalities of vitamin B12 or folate metabolism

(e.g.transcobalamin deficiency, nitrous oxide, antifolate
drugs)

• Other defects of DNA synthesis

Congenital enzyme deficiencies (e.g. orotic aciduria)
Acquired enzyme deficiencies (e.g. alcohol, therapy with
hydroxyurea, cytosine arabinoside)
 Vitamin B12
• Synthesized by micro-organisms.
• Found in foods of animal origin.
Eg: liver, meat, fish dairy products
 Absorption and Transportation
of Vitamin B12/ Cobalamin
B12 is released from food and combine
with Intrinsic factor

B12-IF complex bind to specific surface

receptor for IF (Cubulin)

Cubulin-B12-IF complex bind with

amnionless, a protein which directs for
endocytosis of cubulin IF-B12 complex in
the distal Ileum

B12 is absorbed in the distal Ileum and IF

is destroyed
B12 absorbed into portal blood and bind
with Transcobalamin

Transcobalamin deliver B12 to Bone

marrow, liver and other tissues
 Folate
Humans can’t synthesize folate structure. Therefore
should take preformed folate as a vitamin.

Dietary folates are converted to methyl THF during

absorption through the upper small intestine.

Inside the cell, they are converted into folate

polyglutamate.

Folate binding proteins are present on cell surfaces

including the enterocytes and facilitate the entry of
reduced folates into cells
 Causes of Vitamin B12
Deficiency
1. Nutritional - Vegetarians
2. Malabsorption -
Pernicious anaemia
3. Gastric causes -
Congenital Intrinsic factor deficiency or
functional abnormality
Total or partial gastrectomy
4. Intestinal causes -
Crohn’s disease
ileal resection

5. Transcobalamin deficiency
 Causes for Folate deficiency
1. Dietary

2. Malabsorption
gastrectomy
extensive jejunal resection
Crohn’s disease
3. Excess utilization -
Physiological - pregnancy and lactation
prematurity

Pathological - Haematological diseases

Malignant diseases
Inflammatory diseases
4. Excessive urinary folate loss
Acute liver disease
congestive heart failure

5. Drugs - Anticonvulsants
sulfasalazine

6. Mixed - Liver disease

alcoholism
intensive care
 Clinical Features of
Megaloblastic Anaemia
Onset is insidious with gradual
progressive signs and symptoms
of anaemia.

Mildly jaundice
Angular stomatitis
Glossitis
Symptoms of malabsorption
purpura
 Diagnosis of B12/ Folate
Deficiency

History Examination Investigations

• Dietary condition • Pallor

• Autoimmune
condition • Yellow
• Surgery history complexion
• Long term drugs
like anti folates • Painful glossitis
 Investigations
1. FBC -
RBC count - low
Hb concentration - low
WBC count - low
platelet count - low
MCV - ˃98fL (Often as high as 120-
140fL)
MCH -high
MCHC -normal
RDW - high
2. Blood Picture
Oval macrocytes
NRBCs
Circulating megaloblasts
Marked anisopoikilocytosis
Hypersegmented neutrophils
Howell Jolly bodies (nuclear
DNA fragments),
RBC fragments
3. Reticulocyre count - low
4. Bone marrow smear -
Hypercellular marrow
large erythroblasts with failure of
nuclear maturation
Giant and abnormal metamyelocytes
5. Serum unconjugated bilirubin – high
Due to marrow cell
breakdown
6. Lactate dehydrogenase - high

Tests for B12 or Folate Deficiency

7. Serum B12/Cobalamine -low
8. Serum folate level -
low in folate deficiency
high in B12 deficiency
9. Red cell folate
low in folate deificiency
low in B12 deficiency
10. Serum methyl malonic acid - for B12 deficiency
11. Serum homocysteine level - for folate or B12
deficiency

To find the cause of deficiency,

12. Schilling test
13. Intrinsic factor antibody test
Non Megaloblastic anaemia
Alcohol
Liver disease
Myxoedema
Cytotoxic drugs
Aplastic anaemia
Pregnancy
Smoking
Reticulocytosis
Myeloma and paraproteinaemia
Neonatal