Anemia Caused by

Defects of DNA
metabolism
KLIENSTAR CIARA MAGBOO, RMT MLS(ASCPI)
Introduction
•Impaired DNA metabolism: causes systemic effects by
impairing production of all rapidly dividing cells of the body.
Skin
Epithelium of GIT
Hematopoietic stem cell
•The hematologic effects, especially megloblastic anemia,
have come to be recognized as the hallmark of the diseases
affecting DNA metabolism.
Megaloblastic anemia
•Impaired DNA synthesis
•Has a very large cells of the bone marrow that develops a
distinctive morphology due to the reduction in the number
of cell division
•Macrocytic anemia
•Rare cases: Mutations in (SCL19A2) gene encoding a
thiamine transporter.
•Deficiency of Vitamin 12 and Folic acid (Leading cause)
Physiologic roles of Vitamin B12 and
folate
•Vitamin B12 (cobalamin) is an essential nutrient consisting of a
tetrapyrrole (corrin) ring containing cobalt that is attached to 5,6-
dimethylbenzimidazolyl ribonucleotide.
•It has various analogs, including hydroxycobalamin and
cyanocobalamin and coenzyme forms, methylcobalamin and 5,9-
deoxyadenosylcobalamin
Two biochemical reaction in human:
isomerization of methylmalonyl coenzyme A to succinyl CoA
Transfer of a methyl group from 5-methyltetrahydrofolate to homoxysteine
Nutritional requirements and absorption
Vitamin B12
◦ Produced by microorganisms and molds
◦ Dietary sources: animal protein (meat, fish, eggs, milk)
◦ RDA: 3ug; Pregnancy RDA: 4 ug
◦ 3- 5 ug absorbed daily
◦ Liver storage: approx. 1- 10 mg
Physiologic roles of Vitamin B12 and folate
Vitamin B12
•Adenosylcobalamin: produced by covalent linkage of 5'-
deoxyadenosine to the cobalt atom (75% of B12 in the liver
and most in RBCs and in kidneys)
•Methylcobalamin: produced by the linkage of a methyl
group to the cobalt
•Cyanocoalamin: cyanide atom covalently linked to cobalt;
treatment fro B12 defficiency
Physiologic roles of Vitamin B12 and folate
•Folate is the general term used for any form of the vitamin folic acid.
•Folic acid is the synthetic form in supplements and fortified food.
•Folates consist of a pteridine ring attached to para-aminobenzoate with one or
more glutamate residues
•The function of folate is to transfer carbon units in the form of methyl groups
from donors to receptors.
•Deficiency of the vitamin leads to impaired cell replication and other metabolic
alterations
Nutritional requirements and absorption
Folate
•Dietary sources: green leafy vegetablesliver, kidney, whole grain
cereals, yeast, and fruit
•RDA: 50 ug folic acid; 400 ug food folate (in polyglutamate form)
•Pregnant RDA: doubled
•Storage: approx.. 5 mg (consumed quickly by the body)
Megaloblastic anemia
•Vitamin B12 deficiency causes defective
•DNA synthesis that results in megaloblastic anemia.
•First proposed in the early 1960s as the“methylfolate trap”
hypothesis.
•MCV-Increased
•MCHC-Normal
 Peripheral Blood Megaloblastic Changes
• Hgb values: 7 or 8 g/dL
• Hct: <20%
• Erythroblasts with megalobastic nuclei with occasional promegaloblast
• MCV is usually 100 to 150 fl, commonly >120 fL
• MCH increased
• MCHC within reference range
• RDW elevated
• Oval macrocytes and hypersegmented neutrophils
• Low absolute reticulocyte count specially in severe anemia
• Dacryocyte, RBC fragments aand microspherocytes
• Howell-Jolly bodies and basophilic stipplings
Leukocyte and Platelet Counts
Normal range: Erythrocyte Morphology
Platelet: 140 to 400 K/uL -Macroovalocytes with little or no central
pallor
Leukocyte:4.5 to 11.0 x 109/L
-Anisocytosis -common
Leukocyte count
-Increase RDW (Red Cell Distribution width)
Early stage-normal
-Macroovalocytes-most prominent
Severe anemia-1.0-3.0x10 /L 9
poikilocytes
Platelet count -Teardrops and Fragments
Fall below 100x109/L
Peripheral Blood Megaloblastic Changes
Severe Anemia Megaloblasts
-Extremely Bizarre poikilocytes -Large, abnormal, nucleated red cells

-dumbbell, anvil, cocked hat, hand mirror -Pink Cytoplasm

forms Reticulocytes
-cells smaller than normal erythrocytes - Reference Range: 0.5 — 1.5 % of red blood cells
(up to 2.6% according to some laboratories
Advanced Anemia
Infants:2-6%
Red cell inclusions:
-Larger than normal
-Howell-Jolly bodies, Cabot rings(rare), and
basophilic stippling. -Reticulocyte Production Index (RPI) often is less
than 2,indicating inadequate marrow response to
anemia.
Sequence of Development of
Megaloblastic anemia
1. Decrease in vitamin levels
2. Hypersegmentation of neutrophils in peripheral blood
3. Oval macrocytes in the peripheral blood
4. Megaloblastosis in bone marrow
5. Anemia
Other causes of Megaloblastosis
•Dysplastic erythroid precursors in MDS
Macrocytic RBCs and their precursors shows delayed cytoplasmic and nuclear maturation, including
cytoplasmic vacuole formation, nuclear budding, multinucleation and nuclear fragmentation.

•Congenital dyserythropoietic anemia

Rare condition that manifests during childhood
CDA type 1: internuclear chromatin bridging of erythroid precursor or binucleated forms are observed
CDA type 3: giant multinucleated erythroblasts are seen

•Acute erythroid leukemia classified as FAB M6

Erythroblasts are macrocytic, and the immature appearance of the nuclear chromatin is similar to the
more open appearance of chromatin in megaloblasts

•HIV
Causes of vitamin deficiency
•This may arise due to the vitamin is in relatively
short supply, because use of vitamin is impaired
or because of excessive loss.
1. Folate Deficiency
Inadequate intake
Poor diet can result in deficiency
Good source:
1. Leafy green vegetables
2. Dried beans
3. Liver
4. Beef
5. Fortified breakfast cereals
6. Fruits especially orange

 Are heat labile therefore overcooking of foods can diminish their nutrient value
1. Folate Deficiency
Increased need
During pregnancy and lactation
Infants and children as they have increased need for folate during growth
Impaired absorption
Must be hydrolysed in the gut however only 50% of what iss ingested is available for
absorption
Folate transporter protein deficiency: severely decreases intestinal absorption of folate.
Sprue
Weakness, weight loss and steatorrhea
Tropical sprue: seen in the tropics where its caused by the overgrowth of enteric pathogens

Celiac disease
1. Folate Deficiency
Impaired used of Folate
Drugs
Antineoplastic
Antibacterial
Antiseizure
Macrocytosis with frank megaloblastic anemia
Excessive loss of folate
Physiologic loss occurs in kidneys
Renal dialysis
2. Vitamin B12 deficiency
Inadequate intake
Rare but possible due to strict vegetarians who do not eat meat,
eggs or dairy products
Best dietary sources:
Liver
Dairy products
Fish
Shellfish
Eggs

Not destroyed by cooking

2. Vitamin B12 deficiency
Increased need
During pregnancy, lactation and growth
Impaired absorption
Vitamin B12 is released from the food protein by acid
environment of the stomach, aided by pepsin, ad is
subsequently bound by a specific salivary protein,
haptocorrin also known as R protein or transcobalamin I.
2. Vitamin B12 deficiency
Impaired absorption
Failure o separate vit B12 from food proteins
Food cobalamin malabsorption: hypochlorhydria and the inability of the body to release vit. B12 from
food or intestinal transport proteins for subsequent binding to intrinsic factor
Gastric bypass surgery

Failure to separate vit B12 from haptocorrin

Lack of gastric acidity or lack of trypsin due to chronic pancreatic disease thus vit B12 remains bound to
haptoccorrin

Lack of intrinsic factor

Due to autoimmune disease: Pernicious anemia
Hereditary intrinsic facto deficiency or loss of parietal cells: Helicobacter pylori
Pernicious anemia
•An autoimmune disorder with impaired absorption of Vitamin B12 because of an intrinsic factor
deficiency
•Called “pernicious” due to its fatality before it was discovered
•Have an increased risk of developing gastric tumors
•Autoimmune-mediated destruction of gastric parietal cells severely reduces the amount of
intrinsic factor secreted in the stomach
•It has production of autoimmune response by producing antibodies to intrinsic factor and gastric
parietal cells that are detectable in serum
Stool Analysis for Parasites
•Vitamin B12 is found deficient in D. latum (fish tapeworm)