1. Anemias where the cells are BIG
MACROCYTIC ANEMIAS
Anemias where the cells are BIG

2. MACROCYTIC ANEMIAS
Macrocytic anemias are characterized by large RBCs with a normal hemoglobin content.
Macrocytic anemias are classified as either megaloblastic or non-megaloblastic
Megaloblastic anemias are associated with defective DNA synthesis and therefore, abnormal RBC maturation in the bone marrow (a nuclear maturation defect).
In megaloblastic anemias, the granulocytic and megakaryocytic maturation are also affected and this leads to pancytopenia

3. MEGALOBLASTIC ANEMIAS
The biochemical basis for this is as follows:
Megaloblastic dyspoiesis (abnormal synthesis) occurs when the DNA synthesis in the hematopoietic system is disrupted or slowed down.
Other rapidly proliferating cells in the body are also affected.
Administration of drugs that interfere with DNA metabolism can be the cause of a megaloblastic anemia.
On rare occasions there is an inherited disorder that affects DNA synthesis

4. MEGALOBLASTIC ANEMIAS
However, the primary defect in DNA replication is usually due to depletion of thymidine triphosphate which leads to retarded mitosis, and therefore retarded nuclear maturation.
The depletion of thymidine triphosphate is usually due to a deficiency of vitamin B12 or folic acid.
Vitamin B12 deficiency is usually due to a deficiency of a factor necessary for B12 absorption while a folic acid deficiency is usually due to an inadequate dietary intake.
Absorption and metabolism of vitamin B12 and folic acid:
Vitamin B12 (cyanocobalamine)
Is found in meats, eggs, dairy products, and liver.
Is absorbed via a binding protein called intrinsic factor (IF)

5. MEGALOBLASTIC ANEMIAS
Vitamin B12 and IF bind to mucosal cells in the ileum and B12 enters.
When B12 is released from the mucosal cell, it binds to transport proteins in the bloodstream (transcobalamine IIII). Type II is the primary transport protein. Therefore a congenital deficiency in type II can lead to a megaloblastic anemia.
B12 is transported to the bone marrow for use or to the liver for storage.

6. VITAMIN B12 ABSORPTION
Mucosal cell

7. HOW IS B12 INVOLVED IN DNA SYNTHESIS?
Vitamin B12 is involved in the following reaction:

8. MEGALOBLASTIC ANEMIAS
Decreased vitamin B12 therefore results in no conversion of N5-methyl THF to THF. Thus, the net result is that dTMP for DNA synthesis is not made.
Humans need 3-5 ug of vitamin B12 per day. Since 70% of dietary B12 is absorbed, the diet needs to contain 5-7 ug/day.

9. MEGALOBLASTIC ANEMIAS
Folic acid (pteroyl glutamic acid)
Is found in most foods, including eggs, milk, yeast, and liver.
Is abundant in green, leafy vegetables and is synthesized by many microorganisms.
Is destroyed by heat
Absorption occurs in the small intestine

10. HOW IS FOLIC ACID INVOLVED IN DNA SYNTHESIS?
Is involved in the following reaction:

11. MEGALOBLASTIC ANEMIAS
Therefore, with decreased folic acid, the net result is the same as that for decreased vitamin B12 – there is decreased conversion of dUMP to dTMP, and thus, dTTP which is required for DNA synthesis.
Defective DNA synthesis may occur when dUTP gets used in place of dTTP because there is a great increase in erroneous DNA copying where dUTP is put in place of dTTP.
Humans need to get about 50 ug/day of folic acid from the diet
Causes of megaloblastic anemia
Vitamin B12 deficiency

12. MEGALOBLASTIC ANEMIAS
85% is due to lack of intrinsic factor (IF) secondary to gastric atrophy – this is called pernicious anemia (PA) and it occurs most often in older adults (over 40), most commonly in individuals of Northern European descent, and more commonly in women. Antibodies against the parietal cells in the G.I. tract and against IF are commonly found in these individuals.
After gastrectomy
Malabsorption syndrome
Inadequate dietary intake (rare)
Defective or absent transport proteins (transcobalamine)

13. CAUSES OF B12 DEFICIENCY

14. MEGALOBLASTIC ANEMIAS
Folic acid deficiency
Inadequate diet is the major cause and this occurs most often in the poor, elderly, and alcoholics.
When there is increased requirement such as in pregnancy, hemolytic anemia, leukemia, etc.
Malabsorption – may be due to diseases of the upper small intestine such as ileitis, tropical sprue, and gluten sensitive enteropathy.
When there is increased loss such as in patients undergoing hemodialysis
Drug inhibition – examples are oral contraceptives, anticoagulant drugs, alcohol, and isoniazid

15. MEGALOBLASTIC ANEMIAS
Clinical manifestations occur in two categories – those found in folic acid or vitamin B12 deficiency, and those mainly found in B12 deficiency
In both types of deficiency the symptoms include pallor, weakness, lightheadedness, a smooth, sore tongue, and diarrhea alternating with constipation
In vitamin B12 deficiency, and occasionally folic acid defefiency, there are neurological disturbances including numbness and tingling of extremities, gait abnormalities, and mental disturbances.
Older theories suggest that the B12 deficiency leads to a defect in the degradation of propionyl CoA to succinyl CoA leading to an accumulation of propionyl CoA:

16. MEGALOBLASTIC ANEMIAS
When there is a build up of propionyl CoA (3 carbons), it is used in place of acetyl CoA (2 carbons) as a primer for fatty acid synthesis.
Fatty acids with odd numbers of carbons get incorporated into neural membranes
This leads to disruption of membrane function with subsequent demyelination of nerve fibers.
Newer theories suggest that the defiency of methionine leads to decreased production of S-adenosyl-methionine (SAM), a key intermediate in methylation reactions of myelin and this leads to demyelination
Lab findings
Macrocytic, normochromic anemia (MCV= , MCHC is normal))
MCH is increased (due to increased cell size)

17. MEGALOBLASTIC ANEMIAS
Hemoglobin and RBC counts are decreased
WBC and platlet counts are decreased
On a peripheral smear, a triad of things is commonly seen: oval macrocytes, Howell Jolly bodies (nuclear DNA fragments), and hypersegmented neutrophils (5 or more lobes). In addition:
Anisocytosis is usually moderate
Poikilocytosis is striking with nucleated RBCs, polychromatophilia, and cabot rings (spindle remnants).
RBC dimorphism is seen with concomitant IDA.
The absolute reticulocyte count is decreased because of ineffective erythropoiesis.

18. PERIPHERAL SMEAR OF MEGALOBLASTIC ANEMIA
Oval Macrocyte
Howell Jolly Body
Cabot ring

19. PERIPHERAL SMEAR OF MEGALOBLASTIC ANEMIA
Hypersegmented neutrophil

20. MEGALOBLASTIC ANEMIAS
The bone marrow will show hypercellularity, yet there are decreased numbers of all cell types in the peripheral blood because ineffective hematopoiesis is occurring and many cells are dying prematurely in the bone marrow.
In folic acid deficiency – there will be decreased serum and RBC folate
In B12 deficiency – there will be decreased serum vitamin B12
Specific tests for PA
Gastric analysis – if there is no free HCl after histamine stimulation, this may indicate PA since the same cells that secrete HCl, also secrete intrinsic factor (IF)
Test for antibodies to IF

21. MEGALOBLASTIC ANEMIAS
Schilling test – is the definative test for the diagnosis of PA. ( Know this test!)
The test measures the amount of an oral dose of radioactively labeled B12 that is absorbed in the gut and excreted in the urine.
This is followed by an injection of unlabeled vitamin B12 to saturate all vitamin B12 receptors in the tissue and plasma. Thus any amount absorbed in the gut will be in excess, and will be filtered in the kidneys to appear in the urine.
If there is no radioactivity in the urine, this means that there is either malabsorption or PA.
The test is repeated, but this time the radioactively labeled B12 is accompanied by a dose of IF.
If absorption is now normal, this means that the patient has PA

22. SCHILLING TEST

23. SCHILLING TEST RESULTS

24. NON-MEGALOBLASTIC MACROCYTIC ANEMIA

25. NON-MEGALOBLASTIC MACROCYTIC ANEMIA
Note that the macrocytic RBCs are not oval, but are round.
There are no hypersegmented neutrophils or Howell-Jolly bodies

26. DIFFERENTIAL DIAGNOSIS WITH INCREASED MCV

27. DIFFERENTIAL DIAGNOSIS WITH A HIGH MCV

28. LAB RESULTS OF MEGALOBLASTIC VS NON-MEGALOBLASTIC MACROCYTOSIS