MACROCYTIC ANEMIAS

Dr RAMASWAMY A S ASSISTANT PROFESSOR DEPARTMENT OF PATHOLOGY PESIMSR KUPPAM

MACROCYTIC ANEMIAS
 These are the anemias in which the RBC

have an MCV of greater than 100fl  There are 2 groups of macrocytic anemias 3. Megaloblastic anemia 4. Non megaloblastic macrocytic anemia

MEGALOBLASTIC ANEMIA
 These are a group of disorders in which the

cause the anemia is due to deficiency of vitamin B12 and folic acid
 The macrocytes in this condition is usually

“oval” - hence they are also called as MACRO OVALOCYTES

NON MEGALOBLASTIC MACROCYTIC ANEMIAS
   4. 5. 6. 7. 8. 9.

These are disorders in which the macrocytosis is not due to vitamin B12 or folic acid deficiency Here the macrocytes are “ROUND” The conditions in which such round macrocytes are seen are Reticulocytosis Hypothyroidism / myxedema Myelodysplastic syndrome Scurvy Sideroblastic anemia Liver disorders

MEGALOBLASTIC ANEMIA
 Vitamin B12 and folic acid are important

nutrients required in the process of nuclear maturation  They are required during erythropoiesis during DNA synthesis  These anemias may be caused because of a nutritional deficiency or impaired absorption mainly.

MEGALOBLASTIC ANEMIA
 Impaired DNA synthesis  Defective cell maturation and cell division  Nuclear maturation lags the cytoplasmic

maturation – NUCLEAR CYTOPLASMIC ASYNCHRONY  Abnormally large erythroid precursors and red cells

FOLIC ACID
 Widely prevalent in all foods  Best sources are in fresh vegetables, fruits  It is absorbed in the upper third of the small

intestine  Tetrahydrofolate is the metabolically most important form

METABOLIC FUNCTION
 Purine synthesis  Conversion of homocysteine to

methionine ( which also requires B12 )  Deoxythymidilate synthesis.

FOLIC ACID DEFICIENCY
1. INCREASED DEMAND 2. DECREASED INTAKE 3. DECREASED ABSORPTION 4. METABOLIC INHIBITION

INCREASED DEMAND
 Pregnancy  Lactation  Infancy  Puberty and growth period  Patients with chronic hemolytic anemias  Disseminated cancer

DECREASED INTAKE
 Elderly  Lower socio economic status  Chronic alcoholics

DECREASED ABSORPTION
 Acidic food substances in foods like

legumes, beans  Drugs like phenytoin, oral contraceptives  Celiac disease and tropical sprue which affect the gut absorption  Heat sensitive – more loss during cooking

METABOLIC INHIBITION
 Drugs like methotrexate inhibit the

dihydrofolate reductase enzyme which is required in formation of tetrahydrofolate

VITAMIN B12
 Abundant in animal foods  Microorganisms are the ultimate origin of

cobalamin  Strict vegetarians have a deficiency  It is stored in liver for many years  It is efficiently reabsorbed from bile  It is resistant to cooking and boiling

VITAMIN B12

+ COBALOPHILINS/ R- BINDERS

R-B12 COMPLEXES
PANCREATIC PROTEASES

FREE B12 + INTRINSIC FACTOR-IF
DISTAL ILEUM

IF RECEPTORS

ABSORPTION

CIRCULATION WITH TRANSCOBALAMIN II

VITAMIN B12 DEFICIENCY
 INCREASED REQUIREMENT  DECREASED INTAKE  IMPAIRED ABSORPTION

INCREASED DEMAND
 Pregnancy  Lactation  Puberty  Growth period  Hyperthyroidism  Disseminated cancer

DECREASED INTAKE
 Inadequate intake  Vegetarian diet

IMPAIRED ABSORPTION
 INTRINSIC FACTOR DEFICIENCY

- PERNICIOUS ANEMIA - GASTRECTOMY  Malabsorption states  Diffuse intestinal diseases. Eg., lymphoma, systemic sclerosis  Ileal resection, ileitis  Competitive parasitic uptake – fish tapeworm  Bacterial overgrowth in blind loops and diverticula

METABOLIC REQUIREMENT
HOMOCYSTEINE B12 METHIONINE

PROPIONYL CoA

B12

METHYL MALONYL CoA

SUCCINYL CoA

dUMP DNA N5,10 Methylene FH4 dTMP

FH4

Methyl-Cbl

Homocysteine

N5 Methyl FH4

Cbl

Methionine

CLINICAL FEATURES
Weakness and lassitude Pallor Knuckle pigmentation Atrophic glossitis- “beefy” tongue Cheilosis, dermatitis Neurological manifestations – severe paresthesias in lower limbs, spastic paraparesis, sensory ataxia  Degenerative changes in ganglia of posterior roots and in peripheral nerves  Both sensory and motor pathways involved – “subacute combined degeneration” / “combined system disease”
     

PERIPHERAL BLOOD FINDINGS
1. 2. 3. 4. 5. 6. 7. 8. 9.

Hemoglobin – decreased Hematocrit – decreased RBC count – decreased/normal MCV - >100fl ( normal 82-98fl) MCH –increased MCHC – NORMAL Reticulocyte count – low Total WBC count – normal / low Platelet count – normal/ low

PERIPHERAL SMEAR
 RBC:

-macro ovalocytes -well hemogloibised, thicker than normal -inclusions like HOWELL JOLLY BODIES, basophilic stippling, Cabot rings

PERIPHERAL SMEAR
 WBC:

Normal count or reduced count Hypersegmented neutrophils (>5 lobes) MACRO POLYMORPHO NUCLEAR CELLS (Macropolys)  PLATELETS: Normal or decreased

BONE MARROW
 Markedly hypercellular  Myeloid : erythroid ratio decreased or

reversed  Erythropoiesis : MEGALOBLASTIC

MEGALOBLAST
1. Abnormally large precursor 2. Deeply basophilic royal blue cytoplasm 3. Fine “seive like” chromatin with

prominent nucleoli 4. Nuclear cytoplasmic asynchrony 5. Abnormal mitoses 6. Maturation arrest

BONE MARROW
 LEUKOPOIESIS:

GIANT METAMYELOCTES AND STAB FORMS  MEGAKARYOPOIESIS: Abnormally large and bizarre mulilobate nuclei  Normal marrow iron stores

BIOCHEMICAL FINDINGS
 Increase in serum unconjugated bilirubin-

because of ineffective erythropoiesis  Increase is LDH  Normal serum iron and ferritin

TESTS FOR FOLATE DEFICIENCY
 Urinary excretion of FIGLU  Serum folate assay – microbiological /

radioassay  Red cell folate assay

FIGLU TEST
 Folic acid is required for the conversion of

forimimino glutamic acid (FIGLU) to glutamic acid in the catabolism of histidine  Deficiency of folate leads to an increased levels of FIGLU  Thus , on oral administration of histidine, in folate deficiency there is increased urinary excretion of FIGLU

MICROBIOLOGICAL ASSAY
 This is based on the principle that

LACTOBACILLUS CASEI requires for its growth 5 methyl THF  So growth of the micro organism is proportionate to the levels of folate in the serum

RADIO ASSAY
 Radio isotope dilution test  Measures the levels of folate through radio

active methods

RED CELL FOLATE ASSAY
 Red cells contain 20-50 times more folate

than serum  Therefore a more reliable indicator of folate stores  NORMAL SERUM FOLATE LEVELS : 612ng/ml

TESTS FOR B12 DEFICIENCY
 Serum B12 assay – microbiological /

radioassay  Schilling test / radioactive absorption test  Serum levels of methyl malonic acid and homocysteine  Normal serum B12 levels : 200-900pg/ml

MICROBIOLOGICAL ASSAY
 EUGLENA GRACILIS

RADIOLOGICAL ASSAY
 RADIO ISOTOPE DILUTION  RADIO IMMUNO ASSAY

SCHILLING TEST (radio isotope absorption test)
 GOOD RENAL FUNCTION AND PROPER

URINE COLLECTION A MUST  STAGE I : oral “hot”B12 + parenteral “cold” B12  STAGE II: same as above with oral IF  STAGE III: after treatment with antibiotics then repeating the test  Normal urinary excretion of “hot”B12 is >7% of oral 1microgram administered

PERNICIOUS ANEMIA
 Scandinavian countries more prevalent  Disease of elderly – 5th to 8th decades  Genetic predisposition  Tendency to form antibodies against

multiple self antigens

PATHOGENESIS
      

Immunologically mediated, autoimmune destruction of gastric mucosa CHRONIC ATROPHIC GASTRITIS – marked loss of parietal cells Three types of antibodies Type I antibody- 75% - blocks vitamin B12 and IF binding Type II antibody – prevents binding of IF-B12 complex with ileal receptors Type III antibody – 85-90% patients – against gastric proton pump units in the parietal cell Associated with other autoimmune diseases like autoimmune thyroiditis

DIAGNOSTIC FEATURES
          

Moderate to severe megaloblastic anemia Leucopenia with hypersegmented neutrophils Mild to moderate thrombocytopenia Mild jaundice due to ineffective erythropoiesis and peripheral hemolysis Neurologic changes related to involvement of posterolateral spinal tracts Schilling test positive Achlorhydria even with histamine stimulation Low levels of serum B12 Elevated levels of homocysteine and methyl malonic acid Striking reticulocytosis after parenteral administration of vitamin B12 Serum antibodies to intrinsic factor