MACROCYTIC ANAEMIA

WHAT IS ANAEMIA?
Anaemia is defined as insufficient RBC
mass to adequately deliver oxygen to
peripheral tissue

Any of these three concentration

measurement is used for detection of
anaemia,1.Hb, 2.Hct, 3.RBC count
ANAEMIA CLASSIFICATION:
It is classified according to
• Morphology
• Haemoglobinisation
• Etiology
According to morphology (size of RBC) ,it is
classified into 3 types:
• Normocytic
• Microcytic
• Macrocytic
 MACROCYTIC ANAEMIA
It is defined as anaemia in which MCV is
greater than 96 fl
Practically on p/s size of RBC is compared
with the nucleus of small lymphocyte. If it
is more then size of nucleus it is defined as
macrocytic anaemia.
 CLASSIFICATION
Morphological and biochemical criteria
allowed it to be divided into 2 types
• MEGALOBLASTIC MACROCYTIC
ANAEMIA
• NONMEGALOBLASTIC MACROCYTIC
ANAEMIA
 AETIOLOGY OF
MEGALOBLASTIC ANAEMIA
Vit B12 Deficiency
Folate Deficiency
Other causes
 VIT B12 Deficiency
1. Dietary deficiency
2. Malabsorption:
 Pernicious anemia
 Gastric surgery
 Functionaly abnormal intrinsic factor
 Biological competition for vit B12
 Small bowel bacterial overgrowth
 Fish tapeworm disease
 Familial selective VitB12 malabsorption syndrome
 Chronic pancreatic disease
 Zollinger ellision syndrome
 Ileum resection , Regional eneritis,ileal disease
3. Transport and uptake defects:
1. Transcobalmin 2 deficiency
2. Nitrous oxide toxicity
4. Increased requirment:
 Rarely in hypermetabolic states
FOLATE DEFICIENCY
1. Dietary deficiency
2. Increased requirements
 Pregnancy
 Infancy
 Chronic hemolytic anemia
3. Malabsorption:
 Tropical sprue
 Coeliac diseaese
 Jejunal resection
 Congenital folate malabsorption
4. Alchoholism and Drug induced
5. Inborn errors of tranport and metabolism
 OTHER CAUSES
Inherited disorders of DNA synthesis
• Orotic aciduria
• Lesch-Nyhan syndrome
• Thiamine responsive megaloblastic anemia
• Homocystinuria and methyl malonic aciduria
Drugs and toxins induced disorders of DNA synthesis
• Folate antagonist
• Pyrimidine antagonist
• Purine antagonist
• Zidovudine
• Oral contraceptives
CAUSES OF NON MEGALOBLASTIC
MACROCYTIC ANEMIA
• Associated with accelerated erythropoesis
• Hemolytic Anemia
• Post haemorrhagic anemia
• Alchoholism
• Liver disease
• Myelodysplastic syndrome
• Aplastic anemia
• Acquired sideroblastic anemia
• Congenital dyserythropoetic anemias
• Diamond Blackfan syndrome
• Hypothyroidism
 PATHOPHYSIOLOGY OF
NONMEGALOBLASTIC
MACROCYTIC ANAEMIA
In Hemolytic Anaemias ,MCV is increased due to
1.reticulocytosis
2.premature release of reticulocytes
3.high cell turnover

In liver disease, increased surface area to volume

ratio results in target cells & thin macrocytes
In bone marrow disease abnormality of marrow
function results in macrocytes.
 PATHOPHYSIOLOGY OF
MEGALOBLASTIC ANAEIMIA
It is a panmyelosis,
Biochemical abnormality which leads to
hematological features is
It leads to defective DNA synthesis
That leads to lack of nuclear maturation
relative to cytoplasm
Nucleus maturation lags behind the
cytoplasmic growth,resulting in larger size
of cell.
Megaloblastic cells are arrested in S phase
of cell cyle and in subsequent phases.
 APPROACH TO PATIENT WITH
MACROCYTIC ANAEMIA
• AGE :Megaloblastic anaemia is rare in infancy and
childhood
Seen only in following conditions:
-Nutritional anaemia due to folate deficiency
-Juvenile pernicious anaemia
-Congenital disorders of Vit B12 and
folate deficiency
-Orotic aciduria,
-Thiamine responsive megaloblastic anaemia.

• SEX: - Pernicious anaemia and hypothyroidism-

more common in females.
- Alcohol important cause in males.
History:
• In non megaloblastic anaemia – According to aetiology.
• In Megaloblastic anaemia –
Folate Deficiency: Rapid evolution,associated with other
nutritional deficiencies.
Vit. B12 Deficiency: Slower onset,specific deficiency of
Vit. B12.
Clinical features and Physical examination: Apart from
features of anaemia,
 G.I.T.: Diarrhoea, Wt.loss, Sore tongue, Glossitis
Spleenomegaly if present is mild
 Skin: Lemon yellow tinge, premature graying, patchy skin
Hyperpigmentation
 Neurological features: Peripheral neuropathy, Post. Lat.
Spinal cord degeneration, Cerebral involvement.
 CVS: due to homocystinuria- increased risk of
atherosclerosis.
LABORATORY APPROACH
Routine investigation
Specific test for confirmation of
diagnosis
Test for causes of macrocytic
anaemia
ROUTINE INVESTIGATION:
 Haemoglobin
 Blood indices
1. MCV:
 average volume of RBCs
 Usually in non megaloblastic anaemia 100-110fl and
in megaloblastic anaemia >100fl
 Measured by : manual methods or counters
 Falsely high MCV may occur in cold
agglutinins,spherocytosis,if plasma osmolarity is
increased
 Previous levels of MCV is important
2. MCH: decreased
3. MCHC: normal
4. RDW:
 measurement of anisocytosis
 Upper limit is 14.6%
 Increased in megaloblastic anaemia
 P/S examination:
• RBC series:
 in megaloblastic anaemia characteristic finding is
macroovalocyte.
 Other features: Anisocytocis, nucleated RBC, howell-jolly bodies,
Basophillic stippling, Cabot’s ring.
 In hemolytic anaemias:macrocytes,spherocytes,nucleated
RBCs ,polychromasia.
 In liver disease: target cells, thin macrocytes seen.
• WBC SERIES::
 in megaloblastic anaemia, hypersegmented neutrophils are seen.
 One or more neutrophils with six or more lobes
 At least 4-5% neutrophils have 5 lobes
 First abnormality to appear
 Also found in CML, Myelofibrosis, Hereditary condition
 Total count:
 decreased in megaloblastic and aplastic anaaemia.
 increased or normal in hemolytic anaemia
 Platelets series:
 count decreased in megaloblastic anaemia
 Reticulocyte count:
 Normal or decreased in megaloblastic anaemia

 Serum LDH:
 Increased in megaloblastic anaemia and haemolytic anaemia

 Serum Indirect Billirubin:

 Increased in megaloblastic anaemia
 BONE MARROW:
• Cellularity :
 hypercellular in most causes

• Myeloid erythroid ratio:

 Decreased (Due to erythroid hyperplasia)

• In megaloblastic anaemia following changes are

seen
Erythroid series:
• Cell size: increased
• Nucleus: chromatin more open, fine reticular pattern
– “Sieve like”
- Identification of orthochromatic
megaloblast helpful in recognition of megaloblastic
anaemia
• Dissociation of cytoplasmic and nuclear maturation
• Mitosis: More common sometimes abnormal
• Maturation: Increase in proportion of more
primitive cells
• Iron storage: Increase in no. and size of Iron
granules
- Ring sideroblast not seen
Myeloid series:
• large atypical granulocytes seen.
• Special evident at metamyelocyte stage
• Die within the bone marrow.

Megakaryocytic series :
• normal or decreased
• Sometimes with atypical nuclear chromatin
TEST MEGALOBLASTIC APLASTIC HEMOLYTIC
ANAEMIA ANAEMIA ANAEMIA

P/S •MACROOVALOCYTES •MACROCYTES •MACROCYTES

•HYPERSEGMENTED •PANCYTOPENIA •POLYCHROMASIA
NEUTROPHILLS •NUCLEATED RBCS
•PANCYTOPENIA •NEUTROPHILLIA

B/M •HYPERCELLULAR HYPOCELLULAR •HYPERCELLULAR

•M:ERATIO:↑ •M:E RATIO;N •M:ERATIO; ↑
•MEGALBLASTIC •NORMOBLASTIC •NORMOBLASTIC

RETIC •DECREASED •DECREASED •INCREASED

COUNT
SERUM •N OR INCREASED •N •INCREASED
BILLIRUB
IN
 SPECIFIC TEST FOR
CONFIRMATION OF
DIAGNOSIS
In Non-megaloblastic anaemia, routine
investigations are sufficient for
confirmation of diagnosis.
In megaloblastic anaemia,following tests
should be done;
• Serum level lf VIT B12,Folate and RBC level of Folate
• Metabolic tests like plasma homocystine and methyl
malonic acid level, dU suppression test.
SERUM AND RBC LEVEL OF VIT
B12 AND FOLATE
Serum B12 level:
 Normal- 200-550ng/ L
 Measured by microbiological or radioisotope method
 Falsely low in
 Pregnancy
 Folte defi.
 Transcobalamin 1 defi
 Aplastic anaemia
 HIV infection
 Falsely high in
 CML
 Acute promyelocytic leukemia
Serum folate:
• <2.5 microgm/L indicates folate deficiency
RBC folate:
• Better indicator because serum level fluctuates
with intake
• <160microgm/L indicates folate deficiency
• Decreased also in B12 deficiency
• Falsely high in reticulocytosis
 METABOLIC TESTS
Plasma homocystine:
• Measured by HPCL
• 12-14 mmol/L in females and 14-15 mmol/L in male
• Increased in both B12 and folate deficiency
• Other conditions in which it is increased
• VIT B6 deficiency
• Renal failure
• Acute lymphocytic leukemia

Methyl malonic acid:

• Increased in B12 defi. Only
• >280 mmol/l considered as increased
 TESTS FOR CAUSES OF
MACROCYTIC ANAEMIA
FOR COBALAMIN DEFICIENCY
FOR FOLATE DIFICIENCY
FOR NONMEGALOBLASTIC ANAEMIA
 TESTS FOR CAUSES OF
COBALMIN DEFICIENCY
Tests for free cobalamin absorption:
• Classical test is “Schilling test”
• Measures urinary excretion of oral dose of radio labeled
cyanocobalamin
• Patient is tested in fasted state and given
cyanocobalamin im 2 hrs after oral dose to minimize
diversion of cobalamin to TC2 and tissues
• If radioactivity is <8% it is considered subnormal
• If it improves with oral IF or antibiotics it is diagnostic
of pernicious anaemia or bacterial overgrowth
respectively.
• Disadvantage is that patient must be free from renal
disease
 Yes No

Serum Vit.B12 & Folate

measurement Reticulocytosis

Vit.B12 Folate
Def. Def.
Others Yes No
Schilling Consider Alcohol/
Haemolytic or
test with Liver
Post Haemorrhagic
Intrinsic Disease / Bone
anaemia Marrow Dysfunction
factor

Co Not
rre cor
cte rec
d ted

Pe Ileal
rni Dis
eas
cio e or
us Bac
an teri
al
ae Ove
mi rloa
a d
 TREATMENT
In VIT B12 deficiency, hydroxycobalamin
is given in dose of 1000microgm daily for
one week then once every 3 months orally
or by im route.
In folate deficiency, folic acid is given in
dose of 5 mg daily orally.
RESPONSE TO TREATMENT
P/S examination:
Increase in retic. count(2nd or 3rd day)
Increase in Hb(5-6 weeks)
MCV falls(10 weeks)
Hypersegmented neutrophills disappear(2 weeks)
Serum bilirubin and LDH returns to normal
B/M examination:
• Changes start after 6 hrs and within 3-4 days B/M is
normoblastic.
 FAILURE OF RESPONSE TO
TREATMENT
CAUSES ARE:
1. incorrect diagnosis,
2. incorrect route,
3. imparied bone marrow response due to
chronic infection, chronic renal failure,
occult malignancy,drugs,
4. occult GI bleeding.
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