Cross sectional study for spectrum of clinical diagnosis in patients presenting w

macrocytosis

Laila Yaseen,Nida Yaseen, Saqiba Yaseen, Attia Khaliq, Kanza Khalid, Noreen Adil

ABSTRACT

Objective: To determine the frequency of clinical spectrum of diseases in patients with

macrocytosis and to summarize the diagnostic evaluation of patients found to have
macrocytosis on laboratory testing.

Study Design: Cross sectional study.

Place and Duration of Study : Department of Medicine, POF Hospital Wah Cantt, from
August 2021 to January 2022.

Methods: One hundred and five patients found to have macrocytosis with MCV values
>100fL were selected after fulfilling inclusion and exclusion criteria. The informed consent
was taken from all patients. Complete blood counts (CBC), peripheral blood film, serum
vitamin B12 levels, serum folate levels, liver function tests (LFT), renal function tests (RFT)
and thyroid function tests (TFT) were performed during the assessment.

Results: The most common cause of macrocytosis was vitamin B12 deficiency followed by
folate deficiency, combined vitamin B12 and folate deficiency and other causes were found in
few cases.

Conclusion: Vitamin B12 and folate deficiency are the most common preventable causes of
macrocytosis.

Keywords: Anemia, Macrocytosis, Megaloblastic, Non-megaloblastic, Vitamin B12, Folate.

INTRODUCTION

Anemia is a frequently faced problem in primary health care settings¹⁶. According to World
Health Organization (WHO) criteria, anemia refers to hemoglobin less than 13g/dL in males
and less than 12g/dL in females¹. Macrocytosis is defined as MCV greater than 100fL in
adults. Macrocytosis associated with or without anemia is a frequently faced laboratory finding
in routinely ordered investigations². It is usually discovered on a routine blood complete
picture. The prevalence of macrocytosis is 2% to 4%. Males are affected more commonly
than females. It is associated with advanced age. 60% patients have associated anemia³.
Anemia is classified according to its pathophysiological basis either due to decreased
production or increased production due to red blood cells (RBC) loss and according to RBC
size. Anemia with low mean corpuscular volume (MCV) is microcytic anemia and is due to
iron deficiency anemia or thalassemia. Anemia with high MCV is macrocytic anemia and is
commonly due to either megaloblastic anemia or other disorders. MCV indicates RBC size on
a complete blood picture¹⁵. Medical practitioners should be aware of the significance of
macrocytosis as it might lead to the development of anemia. Macrocytosis signifies a wide
range of pathologies. Emphasis should be made on a thorough history (symptoms of anemia
like fatigue, generalized weakness, shortness of breath, palpitations, medication history,
surgical history, dietary habits), general physical examination and systemic examination
(pallor, stomatitis, glossitis, tachycardia, neurological signs) and laboratory findings as it will
not only help in identifying the underlying etiology but will also help in making a proper
management plan for patients with macrocytosis³. The rationale of this study is to timely
identify and evaluate macrocytosis in order to cope up with the preventable causes of
macrocytosis.

METHODOLOGY

It was a quasi-experimental study carried out in the department of Medicine, POF Hospital,
Wah Cantt from August 2021 to January 2022. Sample size was 105. The inclusion criteria
were patients with macrocytosis having MCV >100fL, both indoor and outdoor cases, age
more than 12 years and both gender. The exclusion criteria were MCV<100fL, patients
already taking vitamin B12 and folate supplements, patients who have undergone any
abdominal surgery and age 12 years and below. After permission from the concerned
authorities and ethical committee, 105 patients with macrocytosis were selected through
randomized consecutive sampling. Detailed history was taken and thorough clinical
examination was carried out. Hospital registration numbers and informed consent were taken
from all patients. 66% were males and 39% were females. (105%) I think % is wrong
Complete blood picture, serum vitamin B12 and folate levels, liver function tests, renal
function tests, thyroid function tests, and peripheral blood smear examination were
performed. 3ml of blood was taken for complete blood count and it was analyzed on XN 1000
sysmex analyzer. 3ml serum samples were taken for Vitamin B12, folate, LFT, RFT and TFT.
Vitamin B12 and folate levels were performed on ARCHITECT I 1000 analyzer. LFT and RFT
were performed on cobas c 311 analyzer. TFT were performed on cobas e 411 analyzer.
Peripheral blood smear was analyzed on binocular microscope BX43 by Olympus Japan. The
data were recorded in especially designed proformas. The data were analyzed using SPSS
version 22. Means and standard deviations were calculated for quantitative data like age,
hemoglobin, MCV, serum vitamin B12 and folate levels. The qualitative data like gender,
deranged vitamin B12, folate, LFT, RFT,TFT and morphological abnormalities on peripheral
smear were analyzed by frequencies.

RESULTS

A total of 105 patients were included. Sixty-six (66%) were males and thirty-nine (39%) were
females. Mean age of the sampled patients (n=105) was 52.2 ± 18.1 years with minimum age
13 years and maximum 87 years. 20 patients out of 105 were below 35 yrs, 11 patients were
between 35-44 yrs, 26 patients were between 45-54 yrs, 23 patients were between 55-64 yrs,
11 patients were between 65-74 yrs and 14 patients were above 75 yrs. Mean hemoglobin
was 10.6 ± 2.73g/dL with minimum 5 gm/dl and maximum 18 g/dL, mean MCV was 104.7 ±
5.75 fL with minimum 101 fL and maximum 126 fL , mean serum vitamin B12 level were
225.4 ± 126.4 ng/L with minimum 83.00 ng/mL and maximum 380.00 ng/L and mean serum
folate levels were 8.80 ± 1.38ng/mL with minimum 2.00 ng/mL and maximum 10.00 ng/mL.
Vitamin B12 deficiency was identified as the etiological factor in 80% cases, folate deficiency
was identified in 20% cases and combined vitamin B12 and folate deficiency was identified in
18% cases. Other causes identified were liver disease 3%, chronic renal failure 2%,
hypothyroidism 2% and other hematological issues were present in 5% cases. Anemia was
observed in 93% of cases and no cause was identified in 11% cases. We found that vitamin
B12 deficiency has significantly higher frequency among all the causal factors in patients with
macrocytosis. Macrocytosis needs to be investigated either diagnosed with or without anemia
as it may be the first clue to the underlying pathology.

DISCUSSION

Macrocytosis is due to abnormal RBC development,abnormal RBC membrane composition,

reticulocytosis or combination of all of them. These abnormalities of RBC nuclear maturation
and development occurs as a result of impaired DNA synthesis. Macrocytic anemia may be
megaloblastic or non-megaloblastic. Megaloblastic anemia is associated with abnormal
development of RBC. It is most commonly seen in vitamin B12 and folate deficiency. Vitamin
B12 comes from the diet and is present in all foods of animal origin. Vitamin B12 deficiency is
seen in strict vegetarians⁴. Pernicious anemia which is an autoimmune disorder whereby
autoantibodies destroy gastric parietal cells that produce intrinsic factor and cause atrophic
gastritis or bind to and neutralize intrinsic factor or both cause vitamin B12 deficiency.
Abdominal surgery like gastrectomy that will eliminate the site of intrinsic factor production
and surgical resection of the ileum which will eliminate the site of vitamin B12 absorption will
also cause its deficiency. Blind loop syndrome will cause competition for vitamin B12 by
causing bacterial overgrowth in the lumen of the intestine. Vitamin B12 deficiency is also seen
in severe Crohn disease and prolonged use of proton pump inhibitors and metformin⁵.
Folic acid is present in most fruits and vegetables especially citrus fruits and green leafy
vegetables. Folate deficiency may be dietary, due to decreased absorption like in Celiac
disease or due to increased requirement like in pregnancy or chronic hemolytic anemia. Folic
acid deficiency is seen in patients taking phenytoin, methotrexate, sulfasalazine and
trimethoprim-sulfamethoxazole⁴. Reticulocytosis is seen in hemolysis, blood loss or
transiently during recovery phase once the cause of anemia is corrected. Non-megaloblastic
causes include hypothyroidism, pregnancy, chronic liver disease, chronic kidney disease and
hematological disorders like myelodysplastic syndrome and myeloproliferative disorders. In
megaloblastic anemia peripheral blood film shows macro-ovalocytes and hypersegmented
neutrophils. On a complete blood picture macrocytosis is labelled when MCV is more than
100fL⁷. During workup of macrocytosis serum vitamin B12, folate levels, peripheral blood film,
reticulocytes count, liver function tests, thyroid function tests, renal function tests have got
important role⁶.

Treatment of macrocytic anemia needs treatment of the underlying cause. If there is

megaloblastic anemia then vitamin B12 and folate needs to be replaced. Oral vitamin B12
and folate supplements along with diet enriched with vitamin B12 and folate is required.
Pregnant women especially with a history of neural tube defects and people on anti-epileptic
drugs should regularly take folic acid supplementation⁹. If macrocytic anemia is evaluated
properly and cause especially megaloblastic anemia is identified and treated in time then not
only the anemia is resolved but permanent neurological defects are also prevented¹⁰.
Symptoms of anemia resolve quickly with early treatment⁸.

After laboratory evaluation macrocytosis may still remain unexplained in 10% cases. These
cases require close follow up with six monthly complete blood picture as they may develop
primary bone marrow disorder or worsening cytopenias later on¹¹. The aim of this study is to
identify and evaluate the underlying causes of macrocytosis detected on routine investigations
a similar study, Chang et al studied hematinic deficiencies in Taiwan cohort with macrocytosis.
was a case control study which included 60 patients with macrocytosis. Patients with
macrocytosis had a significantly higher frequency of hemoglobin (50.0%), vitamin B12 (40.0%)
and folic acid deficiency (5.0%)¹. Veda et al found alcoholism as a causative factor in 36.5%
cases, vitamin B12 deficiency in 24.1% cases, drug induced in 12.9% cases and folate deficien
in 4.4% cases in a cross-sectional study conducted on a cohort of 178 adult patients with
macrocytosis. Anemia was also observed in 53.3% cases².

In another trial, Iqbal et al found vitamin B12 deficiency in 78.5% cases and folate deficiency in
43.4% cases in a retrospective cohort study of 220 patients with macrocytic anemia at the Agh
Khan University Hospital¹⁴.
There are, however, other studies that have observed the contradictory results of causes of
macrocytosis. Savage et al found drug therapy and alcohol and liver disease as the most
common cause of macrocytosis in 300 consecutive hospitalized patients in a New York City
teaching hospital¹². McNamee et al conducted a cross-sectional study involving 1,207 adults an
found elevated Gamma-glutamyl transfrase (25.0%) and smoking (24.6%) association with
macrocytosis rather than alcoholism (6.3%), folate (10.5%) and vitamin B12 deficiency (3.4%)¹
Mischoulon et al conducted a study on 223 patients at Massachusetts General Hospital and
found that macrocytosis did not predict folate or vitamin B12 deficiencies. Among 39 patients w
folate deficiency and among 25 patients with low vitamin B12 levels, none had macrocytosis¹ ⁷.

CONCLUSION

Macrocytosis indicates different preventable and treatable underlying clinical conditions. As

medical practitioners we should realize the importance of early identification of causes
associated with macrocytosis and their treatment. The results, however, need further evaluatio
by large randomized controlled trials.

CONFLICT OF INTEREST

This study has no conflict of interest to be declaired by any author.

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combined serum vitaminB12 and folate deficiency

 Frequency Percent

Valid

3 2.8

present 18 16.7

absent 87 80.6

Total 108 100.0

minimum and maximum ages

Frequency Percent Valid Percent

Valid 3 2.8 2.8

<35 20 18.5 18.5

35-44 11 10.2 10.2

45-54 26 24.1 24.1

55-64 23 21.3 21.3

65-74 11 10.2 10.2

>75 14 13.0 13.0

Total 108 100.0 100.0

males and females

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

male 66 61.1 61.1 63.9

female 39 36.1 36.1 100.0

Total 108 100.0 100.0

renal function tests

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

normal 103 95.4 95.4 98.1

 deranged 2 1.9 1.9 100.0

Total 108 100.0 100.0

liver function tests

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

normal 102 94.4 94.4 97.2

deranged 3 2.8 2.8 100.0

Total 108 100.0 100.0

thyroid function tests

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

normal 103 95.4 95.4 98.1

deranged 2 1.9 1.9 100.0

Total 108 100.0 100.0

other hematological issues on peripheral blood film

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

present 5 4.6 4.6 7.4

absent 100 92.6 92.6 100.0

Total 108 100.0 100.0

no cause identified

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

no cause identified 11 10.2 10.2 13.0

any cause identified 94 87.0 87.0 100.0

Total 108 100.0 100.0

presence of vitamin B12 deficiency

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

present 80 74.1 74.1 76.9

 absent 25 23.1 23.1 100.0

Total 108 100.0 100.0

presence of folate deficiency

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

present 20 18.5 18.5 21.3

absent 85 78.7 78.7 100.0

Total 108 100.0 100.0

presence of anemia

Frequency Percent Valid Percent Cumulative Percent

Valid 3 2.8 2.8 2.8

present 93 86.1 86.1 88.9

absent 12 11.1 11.1 100.0

Total 108 100.0 100.0

Descriptive Statistics

N Minimum Maximum

age in years

105 13.00

hemoglobin g/dL

105 5.00

mean corpuscular volume above 100fL

105 101.00
serum vitamin B12 levels ng/L

105 83.00

serum folate levels ng/mL

105 2.00

Valid N (listwise)

105