MACROCYTIC AND

MEGALOBLASTIC ANEMIA
Renny A. Rena
Hematology Medical Oncology Division
Internal Medicine Dept – Sanglah General Hospital
Udayana Medical Faculty - 2017
MACROCYTOSIS

is a descriptive term for red blood cell (RBC) size

larger than the normal range.

It is strictly a morphologic term and does not imply

a specific pathophysiology.

can be documented using the mean corpuscular

volume (MCV in femtoliters) or by observing larger-
than-normal RBCs on the peripheral blood smear.
MEGALOBLASTIC
In conditions in which cell division is impaired such
as lack of a nutrient required for DNA synthesis, the
synchrony between nuclear and cytoplasmic
maturation may be lost, resulting in large, immature
nuclei relative to the cytoplasm, along with other
megaloblastic changes (eg, binucleate cells).

The ultimate basis for production of the

megaloblast is inadequate conversion of
deoxyuridine to thymidylate (thymidine), which
leads to slowing of DNA synthesis and delayed
nuclear maturation.
 Megaloblastic anemia is a form of
Macrocytic anemia in which nucleic
acid metabolism is impaired, leading to
reduced efficiency of cell division and
nuclear-cytoplasmic dyssynchrony.
CAUSES OF
MACROCYTOSIS/MACROCYTIC
ANEMIA
 Alcohol
Liver disease
(Human immunodeficiency virus infection (and therapy)
Myelodysplastic syndrome
Hereditary stomatocytosis
 Hypothyroidism
Pregnancy
Aplastic anemia
Multiple myeloma
Bariatric surgery (or, less commonly, other gastrointestinal surgery)
Down syndrome
Copper deficiency
CAUSES OF
MACROCYTOSIS/MACROCYTIC
ANEMIA
 B12 deficiency

 Folate deficiency

 Medications that interfere with DNA synthesis

Cobalamin deficiency
Key Concepts

Folate and Cobalamin (vitamin B12) play key

roles in the metabolism of all cells, particularly
proliferating cells.

􏰀 Folate in its tetrahydro form is a transporter

of one-carbon fragments which is an
important step in biosynthesis of purines,
thymidine, and methionine.

􏰀 Cobalamin is required for 2 reactions:

intramitochondrial conversion of methylmalonyl
coenzyme A to succinyl CoA and cytosolic
conversion of homocysteine to methionine.
Role of Vitamin B12 and
Folate in DNA synthesis
 Vitamin B12: Cobalamin

 SOURCE:Meat and dairy products only

 Minimum daily requirement 6-9 mcg/d

 Total body store 2-5 mg.

 Helps to synthesize thiamine, thus deficiency

leads to problems with DNA replication.
release
B12: Cobalamin absorption
 Initially bound to protein in diet, liberated by acid
and pepsin, then binds to R factors in saliva and
gastric acids
 Freed from R factors by pancreatic proteases then
binds to Intrinsic Factor secreted by gastric parietal
cells
 Absorbed together (Cbl + IF) in ileum
 Released from IF in ileal cell then exocytosed bound
to trans-Cbl II
 Cbl bound to transcobalamin II binds to cell surface
receptors and is endocytosed
COMPONENTS AND MECHANISM FOR COBALAMIN
ABSORPTION
Transport of Cobalamin
 Following absorption by the ileal mucosal
cells, vitamin B12 is carried in the plasma
by various transporting proteins:
Transcobalamin I
Transcobalamin II
Transcobalamin III
TRANSCOBALAMIN

 Transcobalamin I (TC I) is an alpha-globulin produced by

granulocytes. It functions as a circulating reserve store of
B12. TC I carries mostly methylcobalamin.

 Transcobalamin II (TC II) is a beta-globulin formed in the

liver and is the dominant carrier of B12 immediately after
absorption. It is the main agent for rapid transport of B12
to the body cells.

 Transcobalamin III (TC III) is an alpha-globulin. TC III may

act as a defence mechanism by depriving pathogens of
B12 at sites of infection
Functions of Cobalamin
 B12 deficiency
 Dietary sources
 Animal products (meat and dairy)

 Metabolism
 Ingested B12 is protein bound
 Trypsin and acid in stomach release B12
 B12 binds R-binding protein which carries it to the jejunum
 Also in the stomach (fundus and body) intrinsic factor is
secreted.
 In the jejunum, pepsin releases B12 from R-binding protein
 B12 binds intrinsic factor and is carried to the ileum
 B12 is absorbed in the ileum

 Body stores 2-5mg (mostly in the liver)

 Need 3-5 micrograms per day for maintenance of stores
 Increased need in pregnancy, lactation, growth
 Depletion takes longer that folate
 It takes years to develop megaloblastic anemia due to B12
deficiency
Clinical presentation

A number of non hematologic manifestations of vitamin B12 and folic

acid deficiency may appear clinically. These include effects on epithelial
tissues, such as the characteristic beefy, red, smooth tongue (vitamin B,
and folic acid deficiency), and neuropsychiatric manifestations (vitamin
B12 deficiency only).

a.The neuropsychiatric manifestations of vitamin B12 deficiency are

thought
to be due to the requirement for vitamin Bl2 in myelin synthesis and may
include the clinical signs and symptoms associated with the following:
 Peripheral neuropathies (e.g., paresthesia, numbness, hyporeflexia)
 Dorsal column involvement (e.g., loss of position and vibratory sense,
ataxia)
 Subacute combined degeneration of the spinal cord
 Optic atrophy
 Psychiatric symptoms (e.g., dementia, psychosis, personality change)
Clinical presentation
b.The neuropsychiatric manifestations induced by vitamin B12
deficiencymay be present in the absence of anemia and other
hematologic abnormalities.
These clinical manifestations are reversible if the vitamin B12 de-
ficiency is treated early.
Hematologic manifestations of
megaloblastic anemia

1.CBC and peripheral blood smear examination

a. The morphologic appearance of the peripheral blood is the
same whether the deficiency causing megaloblastic anemia is
of vitamin B12 or folic acid.
In both cases, the erythrocytes demonstrate an increased MCV
with anisocytosis (elevated RDW) and poikilocytosis.
b. Polymorphonuclear neutrophils (PMNs) may demonstrate
nuclear hypersegmentation, defined as 5% of PMNs with five
lobes or one PMN with six lobes.
c. Mild to moderate leukopenia and thrombocytopenia may be
present
2.Bone marrow aspiration
a. Bone marrow aspirate typically reveals
hypercellularity with hyperplasia of all three
major hematopoietic cell lines and abnormal
appearance of the hematopoietic cells.
b. The hematopoietic cell abnormalities in the bone
marrow are often confused with those of acute
erythroblastic leukemia.
 Megaloblastic anemias:
Morphology
 Bone marrow
 Nuclear cytoplasmic
asynchrony in both erythroid
and myeloid lineages

Megaloblasti
c
Normal Megaloblastic

Megaloblastic
Laboratory evaluation of
cobalamin deficiency
1.Serum cobalamin (vitamin B12) level
a. This assay is a fairly reliable measure of total body cobalamin status.
b. Some situations may lead to levels that are falsely low (e.g., folate defi-
ciency, pregnancy, oral contraceptives), elevated (e.g., liver disease,
chronic myelogenous leukemia), or normal (e.g., nonspecific
interactions with some assay kit components).
2.Serum homocysteine and methylmalonic acid levels
a. The total serum homocysteine level is elevated in patients with either
cobalamin or folic acid deficiency.
b. Methylmalonic acid (a measurable precursor of L-methylmalonyl-CoA)
is elevated only in patients with cobalamin deficiency.
c. These levels will increase before serum cobalamin levels decrease.
FOLIC ACID
DEFICIENCY
FOLIC ACID DEFICIENCY

a.Folic acid deficiency occurs most often in malnourished

individuals.
b.Total body folic acid stores are estimated to be 5-10 mg, with
the liver containing most of the body's folic acid. Normal
body folic acid stores are adequate for only 2-4 months.
c. Rich sources of dietary folic acid include fresh green leafy
vegetables, yeast,legumes, fruits, and animal proteins and
parenchymal organs. Folic acid is thermolabile, so cooking
decreases the amount of usable folic acid in a given food.
d.Daily folic acid requirements are as follows:
Adult: 100 ug
Child: 50 ug (5-10 times that of an adult on a weight-for-
weight basis)
Pregnant or lactating woman: 300-400 ug
e.The active coenzyme forms of folic acid are derivatives of
tetrahydrofolate, which acts as a methyl donor for purine
and pyrimidine synthesis and for the conversion of
deoxyuridine monophosphate to deoxythymidine
monophosphate for DNA synthesis.
 Etiology of folic acid deficiency

Possible causes:
a.Nutritional factors (e.g., inadequate intake; increased
requirements as in infancy, pregnancy, and lactation;
hemolysis; psoriasis)
b.Intestinal malabsorption (e.g., sprue, drugs, Crohn disease,
HIV-related enteropathy)
c.Drugs (e.g., ethanol, sulfa drugs, barbiturates)
d.Defective cellular uptake of folic acid (rare)
Laboratory evaluation of
folic acid deficiency
1. Folic acid level
a. A low serum folic acid level is diagnostic of folic acid
deficiency. However, because the serum folic acid level
is highly sensitive to intake (i.e., a single meal), a normal
level may be reported even in the presence of total body
deficiency.
b. Measurement of RBC folic acid is a more reliable
indicator of deficiency than measurement of free serum
levels because it is not as readily influenced by oral
intake. However, because the RBC folic acid level is 30
times that of serum folic acid, mild hemolysis can
increase the serum folic acid level and may mask a folic
acid deficiency state.
2. Serum homocysteine and methylmalonic acid levels
a.The total serum homocysteine level is elevated in
patients with folic acid deficiency.
b.Methylmalonic acid levels are normal in patients
with folic acid deficiency.
Schillings test

Allows one to determine

the level at which B12
deficiency is occurring
Dietary deficiency
Malabsorption
Absence of intrinsic factor
TREATMENT
Treatment of B12 deficiency

When possible, the underlying cause of the B]2 deficiency should be

treated.
The goal of therapy is to replenish the patient's total body stores of B12 by
administering B12 via an effective route.
a. B-12 is typically given parenterally in the form of cyanocobalamin. Various
dosing schedules are used, such as 1 mg intramuscularly (IM) daily for 3-
7 days, then 1 mg IM weekly for 4-8 weeks, then 1 mg IM monthly for life.
b. Oral replacement of B12 can be used for some conditions, such as when
the B12 deficiency is due to pancreatic insufficiency, in which case oral
administration of pancreatic extract may be sufficient.
The results of treatment can be monitored over time.
a. Reversion of megaloblastic hematopoiesis to normal hematopoiesis is
evident in the bone marrow within 12-48 hours after initiation of
therapy.
b. Reticulocyte counts increase by 2-3 days and peak by 5-8 days after
theinitiation of therapy.
c. Methylmalonic acid and homocysteine levels return to normal by the
end of the first week of therapy.
d. The RBC count, hemoglobin, and hematocrit normalize by 2 months.
e. Hypersegmented PMNs remain in the blood for 10-14 days.
f. It may take 6 months to see the maximal degree of improvement in the
neurologic manifestations, and some may be irreversible.
 Treatment of folic acid deficiency

When possible, the underlying cause of the folic acid deficiency should be
Treated.
Oral folic acid at 1-5 mg daily is usually adequate to treat deficiency, even
when intestinal malabsorption of food folate is present. Therapy should be
continued until complete hematologic recovery is documented.
Prophylactic folic acid should be given to:
a. All women contemplating pregnancy to prevent neural tube defects
b. Pregnant or lactating women, who have increased daily requirements
c. Patients with chronic hemolysis and increased erythropoiesis .
Folic acid supplementation decreases homocysteine levels. Therefore,
elevated homocysteine levels, which have been associated with an
increased risk of cardiovascular disease, should be treated with folic acid.
Pernicious Anemia
 Decreased secretion of intrinsic factor due to gastric atrophy
and loss of parietal cells
 More common in individuals of Northern European descent
greater than age 50
 Most common cause of vitamin B12 deficiency
 Diagnosis
 Intrinsic factor antibodies (commonly blocks B12 binding site)
 Sensitivity 50-84%
 Specificity ~100%
 Parietal cell antibodies
 Less specific
 ~50% sensitive
Summary
Macrocytic anemias can be megaloblastic or non
megaloblastic
Megaloblastic anemia has characteristic
morphologic features
 Nuclear cytoplasmic asynchrony
B12 and folate deficiency are 2 reversible causes
of megaloblastic anemia