1. Authors: Preetam Nath Prof Madhukar Rai Serum Lactate Dehydrgenase as a differentiating tool between Megaloblastic & Non-Megaloblastic Macrocytic anemia

2. Introduction: Macrocytic Anemia 1  Macrocytic anemia accounts for 2.6 – 3.6% patients of Anemia 1 2  Most common cause is Megaloblastic Anemia followed by Myelodysplastic Syndrome 2  High MCV, Macroovalocytes & Hypersegmented Neutrophils are indicators of Megaloblastic Anemia. 3  Megaloblastic anemia and Myelodyplastic syndrome are mutually exclusive and at times difficult to diagnose even after performing bone marrow examination 3 4 but has not been studied systematically.  High LDH favors the diagnosis of Megaloblastic Anemia 4 but has not been studied systematically. Ref: 1 -Indian J Haematol and Blood Transfus:24; 155-2008, National Med J of India : 2007;20;172 Ref: 2 - Unnikrishnan et al;Clinico-etiologic profile of macrocytic anemias :. Indian J. Hematol. Blood Transfus.2008; 24(4): 155 – 165. - McPhedran et al;Interpretation of electronically determined macrocytosis. Annals of Int Med. 1973; 78:677-683 Ref: 3- Aitelli C, Wasson L, Page R. Pernicious anemia: presentations mimicking acute leukemia. South Med J. 2004 Mar;97(3):295-7 Ref: 4- Jaswal et al; Serum LDH in diagnosis of megaloblastic anemia. Indian J. Pathol. Microbiol. 2000. 43(3): 325 – 329

3. Aims & Objectives: To study the etiological spectrum of various diseases presenting with Macrocytic Anemia in the adult population serum LDH To evaluate the role of serum LDH in diagnosis of Megaloblastic anemia & differentiate it from other non- megaloblastic anemia

4. Material & Methods: 141 consecutive adult patients with Hemoglobin <10 gm/dl & MCV ≥ 100 fl were included Evaluated with CBC (by Coulter Counter), GBP,RC LFT, LDH, Iron studies, BMA whenever necessary. 2 ml of serum was preserved for assay of B12 and folic acid and stored at – 80 0 C & Estimation was done at the end of study Patient were treated with injectable Vit B12 and folic acid & reevaluated at 7, 14, 28 and 56 days Patient responding completely were labeled as Megaloblastic Anemia Those didn’t respond were evaluated for other causes

5. Results (Total patients=141) *Patients responding to B12 & Folate Therapy

6. Results (Total patients=141) ParametersMegaloblastic anemia (mean ± SD) n=78 Non-megaloblastic anemia (mean ± SD) n=63 P value Hb6.4 ± 1.47.2 ± 1.50.002 MCV114.4 ± 11.5110.5 ± 9.10.030 LDH3716.1 ± 3117.1513.4 ± 373.2<0.001 Patients with LDH < 1400 Percentage  Bone Marrow: Type of Erythroid Series

7. Results (Continued…) Box Plot MCV & LDH

8. ROC Curve LDH Reference Line MCV

9. Results (Continued…)

10. Conclusions: All patients should be evaluated through a proper history thorough examination, CBC (by Coulter Counter) GBP, RC LFT, LDH & Thyroid Function Test in necessary cases. High LDH (>1190.6 U/L) conclusively rules out Myelodysplastic Syndrome & highly predictive of Megaloblastic Anemia. In a resource limited setup, where facilities to measure vitamin B 12 and Folate are unavailable, a trial of haematinic therapy can be given to patients with markedly elevated serum LDH (>1190.6 U/L) & low RC. Those not responding to treatment can be re-evaluated for causes of Refractory Anemia CBC: Complete Blood Count, GBP: General Blood Picture, RC: Reticulocyte Count, LFT: Liver Function Test, LDH: Lactate dehydrogenase

11. Thank You