Megaloblastic Anaemia

Mulyadi
Soewandhie’s Hospital
Definition
• A type of anaemia due to deficiency of
– vitamin B12
– folic acid
• It is characterised by
– macrocyte in peripheral blood
– megaloblast in bone marrow
Megaloblastic Anaemia due to
Vitamin B12 Defciency
Causes of Vitamin B12 Deficiency
Diet • Strict vegetarians
Stomach pathology • Hypochlorhydria
• Total or partial gastrectomy
• Carcinoma of stomach
Pernicious anaemia • There is gastric mucosal atrophy causing intrinsic factor
deficiency
Small bowel pathology • Ileal disease : Crohn’s disease, ileal resection
• Pancreatic exocrine insufficiency : Vitamin B12 deficiency
occurs in 30% patients
• Motility disorders : Can cause bacterial overgrowth and
vitamin B12 deficiency
• Fish tapeworm (Diphyllobothrium latum)
Symptoms
• Weakness, malaise, weight loss
• Breathlessness, sore mouth
• Paraesthesiae, poor memory, depression,
hallucinations
• Visual disturbance
Signs
Tongue • Smooth, shiny with atrophy of papilla
Lips • Angular cheilosis
Skin • Skin pigmentation, lemon yellow tint, vitiligo
Neuropathy • Peripheral nerves : neuropathy (gloves and stocking pattern)
• Spinal cord (causing subacute combined degeneration) :
- there is loss of vibration and position sense (posterior column
lesion)
- upper motor neuron sings (due to corticospinal tract lesion)
• Cerebral : dementia
• Optic atropy
Investigations
• CBC : low Hb%, may be pancytopenia
• PBF : shows macrocytes, hypersegmented
neutrophils
• Serum vitamin B12 (low)
• Parietal cell and intrinsic factor antibodies for
pernicious anaemia
• Bone marrow aspiration : shows increase
cellularity, megaloblasts
• Others : low reticulocyte count and high LDH
Treatment
• Blood transfusion : in severe anaemia
• Injection Hydroxycobalamine
– 1000 µg IM daily 6 dose, for 2 or 3 days apart
– Then 1000 µg every 3 months (life-long therapy
should be given for pernicious anaemia)
Megaloblastic Anaemia due to
Vitamin B12 Deficiency
• Pernicious Anaemia
• It is an autoimmune disease
• There is atrophy of gastric mucosa
– with loss of parietal cells
– causing intrinsic factor deficiency
• Vitamin B12
– is not absorbed due to the deficiency of intrinsic
factor
– there is anti-intrinsic factor antibodies and
antiparietal cell antibodies
Megaloblastic Anaemia due to Folic
Acid Deficiency
Causes of folate deficiency are as follows :
• Less intake of vegetables
• Malabsorption :
– due to any cause (e.g. coeliac disease, tropical
sprue)
• Increased demand :
– pregnancy, haemolysis
• Drugs :
– methotrexate, phenytoin
Megaloblastic Anaemia due to Folic
Acid Deficiency
Investigation of Folic Acid Deficiency :
• Serum folate levels  low
• Red cell folate level  low
Megaloblastic Anaemia due to Folic
Acid Deficiency
Treatment
• Tablet folic acid 5 mg daily for 3 weeks
– then 5 mg weekly
• Prophylactic folic acid in pregnancy
– should be given
– also in haemolytic anaemia
Megaloblastic Anaemia due to Folic
Acid Deficiency
• Folic acid alone should not be given, if there is
Vitamin B12 deficiency, otherwise
– may aggravate neurological lesion