1. A 41 years old professor in AM College presented with lethargy, generalized weakness and consulted psychiatrist for the treatment of depression: CBC Hb 9 g/dl mcv 109 fl platelet count 130x10 9 /l 1. What is your likely diagnosis 2. Outline further investigations to reach at a conclusive diagnosis 3. What is treatment of this condition

2. A Jehova witness presented with pallor and breathlessness : CBC Hb 6.5 g/dl TLC 6x10 9 /l platelet count 180x10 9 /l She was advised blood transfusion but due to religious faith she declined. How will you u manage her?

3. Maj Gen Dr Muhammad Ayyub MBBS, PhD (London), MRCPath (London), FRCPath (UK) Prof & HOD AM College

5. Objectives Body stores and daily requirements of vitamin B12 and folate Absorption of vitamin B12 and folate from the gut Causes of vitamin B12 and folate deficiency Hematological consequences of vitamin B12 and folate deficiency Neurological sequelae of vitamin B12 deficiency Diagnosis and management of megaloblastic anemia Diagnosis and management of Pernicious Anemia

6. Requirements for Red Blood Cell Production Erythropoeitin Proteins, required for globin synthesis Iron Vitamin B12 and folic acid Vitamin B6 Vitamin C Thyroid hormones, estrogens and androgens

7. Vitamin B 12 and Folate

10. Macrocytic anemia with hypersegmented neutrophil

11. Macro-ovalocyte in megaloblastic anemia

13. Megaloblastic Anemia – Bone Marrow

14. Bone marrow - megaloblasts

17. Important for DNA synthesis, nervous tissue and fat metabolism in the liver an intermediate of the citric acid cycle, porphyrin synthesisporphyrin synthesis (Heme synthesis)

21. Absorption and transport of vitamin B12

24. B 12 /

27. Early graying of hair Blue eyes Pernicious Anemia (PA)

28. Pernicious Anemia Red beefy tongue

29. Pernicious Anemia Vitiligo

30. Normal Gastric atrophy PA

31. Atrophic Gastritis

37. The patient was a 45 year old woman. She had a swollen tender tongue, parasthesias of both feet and hands, decreased proprioception and vibratory sensation, ataxia and leg weakness.

38. Subacute Combined Degeneration of Spinal Cord

49. (120-160) (35-46) (80-100) (27-33) (9-15) (4.8-10.8) (150-400 106 g/l 32% 125 f 35.8 pg 14.9% 3.2 100 Hb Hct MCV MCH RDW WBC Plt CBC:

54. Retic count