MEGALOBLASTIC

ANEMIAS
 Introduction
Megaloblasts are nucleated RBC precursors in the BM which maybe seen
in rarely in severe deficiency states

Macrocytic anemia is more appropriate

Anemia caused by vitamin B12 (cobalamin) deficiency and folate

deficiency is similar

2
Vitamin B12 deficiency

Take longer time to develop

Neurological manifestations may come early

Folate deficiency
Can develop in relatively short duration
Pregnancy
Acute & severe infection
Severe hemolysis

3
It’s nuclear maturation defect which leads to d e f e c t i n D N A
synthesis.

Megaloblast, the morphologic hallmark of the syndrome, is a product of

impaired DNA formation which in turn is due to deficiencies of Vitamin
B12 (cobalamin, Cbl) or Folic Acid (FA).

Other causes of impaired DNA or RNA formation, such as antimetabolite

drugs and myelodysplastic syndrome, can also lead to megaloblastic
anemia.

4
Causes
Cobalamin deficiency or abnormality in it’s metabolism
Folate deficiency or abn. metabolism
Treatment with Antifolate drugs eg. Methotrixate

5
6
 VITAMIN B12 DEFICIENCY
General consideration
It’s belongs to family of Cobalamin
It serves as cofactor for two Rxn

7
1. For conversion of homocystein to methionin (as methylcobalamin)
It reduces the plasma concentration of homocysteine which is probably
toxic to endothelial cells; and, perhaps more importantly, it
demethylates (CH3)THF

Demethylation is a critical step in DNA synthesis

2. For conversion of methylmalonyl coA to succinyl coA
This pathway might be important in myelin formation and in the
neurologic abnormalities seen with B12 but not FA deficiency

2nd rxn important for kreb’s cycle (ATP formation)

8
9
Source:
Animal origin

All Vit B12 comes from diet & is present in all foods of animal origin

Daily absorption is 5 µg

NB: cobalamin deficiency is characterized by elevations in the serum

levels of both homocysteine and MMA (methylmalonyl coA), while only
homocysteine levels are elevated in folate deficiency.

10
 Absorption
Cobolamin initally combined with salivary glycoprotien which is digested
by pancreatic trypsin & transferred to IF.

After being ingested,

Vit B12 is bounded to IF (Protien secreted by gastric parietal cells)

Another cobalamin binding protien called R factor compete with IF for

Vit B12 (which can’t be absorbed)

11
The Vit B 12–IF complex:

Travels through the intestine & absorbed in the terminal ileum and
Transported through plasma & stored in liver

Liver contain 2000 – 5000µg of stored Vit B12.

The body has sufficent store of Vit B12

So that Vit B12 deficiency develops more than 3 yrs after Vit B12
absorption ceases.

12
 Causes
Dietary deficiency
Rare – except strict vegiterians
Its present in all foods of animal origin, extrimly rare
Decreased production of IF
Pernicious Anemia: most common cause (immunological destruction of
parietal cells in stomach which produce IF)
Gasterectomy

13
Competition for Vit B12 in gut

Blind loop syndrome (bacterial over growth)

Fish tape worm (rare) – Diphyllobotherium latum
Pancreatic Insufficiency
Cobolamin initally combined with salivary glycoprotien which is
digested by pancreatic trypsin & transferred to IF.
Decreased ileac absorption
Surgical resection
Crohn’s disease
14
Small bowel is the site of rapid motility so the organisms commonly found are
simply passing through.
Interruption of this flow, as with a stagnant segment (stricture,
obstruction, diverticulum, blind loop), results in colonic
concentrations of bacteria with a predominance of anaerobes.

This bacterial overgrowth pattern may be responsible for malabsorption and is

best treated with antibiotics directed against anaerobes.

There is speculation that overgrowth may play a role in irritable bowel

syndrome.
15
 Clinical Features
Anorexia, Diarrhea, Glossitis
Sx of anemia
Neurologic Sx:
Paresthesia
Next Posterior column impaired (difficlty in balance)
Loss of position & vibration sense
Progressive spastic & ataxic weakness

16
 Lab Investigations
Classic Presentation
Anemia with MCV > 100fL (usually >115)
Low –normal or low ARC
Macro-ovalocytes
?megaloblasts
Hypersegemented neutrophils

Masked by iron deficiency/ thalassemia

17
Neurologic manifestation
Cyanobalamin deficiency
Without anemia
Only hypersegemented neutrophils

18
Elevated MCV

Peripheral blood smear

Hyper segmented Neutrophils: >5% of peripheral neutrophils have ≥5
lobes of nucleus
Macrocytosis

BM morphology
Cytoplasm maturation with retarded nuclear development

19
Coalmine serum level (N >240pg/ml)
Pts with low-normal or even normal serum Cbl values may be truly Cbl
deficient & respond to replacement Rx.
Measurement of the serum concentrations of the metabolic
intermediaries homocysteine & methylmalonic acid appears to be:
More sensitive for the diagnosis of these deficiencies than serum vitamin levels,
AND
Is helpful in clarifying the Dx when serum Cbl or folate concentrations are
equivocal, or are low in the pregnant subject

20
Other tests
Schilling test (3 stages)
Antibodies
Intrinsic factor
Parietal cell

21
 Schilling Test
Step 1: One µg of radioactive crystalline B12 is taken orally.

Step 2: Gastric acid & pepsin free vitamin B12 from food proteins.

This step is not required when crystalline B12 is utilized as the test dose.
B12 attaches to "R" binders (R) produced by the stomach, which have a
higher affinity for B12 than IF, also produced by the stomach.

Step 3: Pancreatic proteases degrade the "R" binders, allowing formation of the
B12–IF complex, the specific form absorbed by the terminal ileum.

22
Step 4: One hour after the test dose, a 1000 µg "flushing" dose of non-
radioactive B12 is given to saturate B12 binders (transcobalamines).

Step 5: If present, bacteria in "blind loops" in the duodenum or jejunum

preferentially utilize vitamin B12, allowing none to be available at the site of
absorption.

Step 6: With blood and tissue B12 binding sites blocked by the "flushing" dose,

the B12–IF complex is absorbed by the terminal ileum, and the B12 is excreted in
the urine.
Step 7: Which is assayed for its content of radioactivity.
23
24
The test can be repeated with the addition of missing factors (eg, intrinsic
factor, pancreatic extract), or following the use of nonabsorbable
antibiotics (blind loops and/or bacterial overgrowth present), or gluten-
free diet (celiac disease)

25
26
 Treatment
Identify the underlying cause

Cobalamine 1000µg (1 mg)/daily; IM

Given every 3–7 days (twice weekly) for 6 doses then
monthly OR
1000microgram(1mg) daily for 1wk
1mg/wk for 1month
1mg/month then after
Cause not known or PA → give for life monthly

27
Folic acid 5 mg daily; Po; for 3–4 months
Response
Reticulocytosis occur (5–7 days)
Hematology picture normalize 2 months
CNS Sx reversible if it’s short duration (< 6 month)

28
 FOLIC ACID DEFICIENCY
General consideration
It’s present in most fruits & vegetables
Daily requirement - 50–100µg/day
Total body store ~5000µg; enough to supply for 2–3months

29
 Causes
Dietary deficiency
Decrease absorption
Rare – drugs
Increase requirement
Pregnancy
Chronic hemolytic anemia
Exfolative skin deseases
Inhibition of reduction to active form
Methotrexate
Trimetoprim
30
Deitary: by far the most common cause
Alcholic person who don`t eat fresh fruits & vegitable
Those over cooks there food are candidate for folate deficiency

Decrease absorption - rarely seen b/c absorption occur from entire GIT;
Tropical sprue
Drugs like phentoin, cotrimoxazol, sulfasalzin

31
During Thymidylate Synthesis
Folate ---oxidized---DHF Polyglutamate (inactive
form)---DHF Reductase---THF (active form)

During thymidylate synthesis, folate becomes oxidized to inactive dihydrofolate

polyglutamate.
Regeneration of active tetrahydrofolate requires the enzyme
dihydrofolate reductase, which is inhibited by methotrexate.
Trimetoprim- is a weak inhibitor of dihydrofolate reductase and in high dose
has been implicated in megaloblastic pancytopenia.
32
Alcohol abuse produces:
A sharp fall in serum folate within two to four days by
Impairing its enterohepatic cycle and
Inhibiting its absorption
Thus, alcoholics on a low folate intake can develop megaloblastosis
within 5 to 10 weeks.
This period is shorter than the 4 to 5 months required in normals in part
because alcoholics start with lower stores due to previous dietary
habits.
33
 Clinical Features
Similar to vitamin B12 except neurologic abn.

34
 Lab Investigations
Similar to Vitamin B12

Serum Vitamin B12 level normal

R B C f o l a t e l e v e l <150 ng/ml i s d i a g n o s t i c

35
 Treatment
Folic acid 1–5 mg/d orally; For 1–4 months

Response:
Rapid improvement & sense of wellbeing
Reduction in LDH in 2days
Reticulocytosis in 3–4days (peak in 1wk)
Total correction of hematologic abn. (rise in HBG & reduction in MCV) in
8wks
Delay in cases of iron deficiency 36
Folic acid can partially reverse some of the hematologic abnormalities of
Cbl deficiency, although the neurologic manifestations will progress for
reasons that are not entirely clear.
T h u s , i t i s i m p o r t a n t t o r u l e o u t C b l d e f i c i e n c y b e f o re
t re a t i n g a p t w i t h m e g a l o b l a s t i c a n e m i a w i t h f o l i c
acid.

If initiation of treatment is urgently required, blood samples should be

obtained for the appropriate assays, and the patient should be treated with
BOTH folic acid and vitamin B12 until the test results are known.
37