Macrocytic anemias

 Macrocytic anemias are characterized by large RBCs with a normal

hemoglobin content.
 The biochemical basis for this is as follows:
 Megaloblastic dyspoiesis (abnormal synthesis) occurs when the DNA
synthesis in the hematopoietic system is disrupted.
 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.
 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

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 B
12 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.
 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.
 B
12 is transported to the bone marrow for use or to the
liver for storage.
How is B12 involved in DNA synthesis? 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.
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
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.
Megaloblastic anemias
 Clinical manifestations occur in two categories –
those found in folic acid or vitamin B12 deficiency, and
those only 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 only, there are neurological
disturbances including numbness and tingling of
extremities, gait abnormalities, and mental
disturbances.
 This is due to a defect in the degradation of

propionyl CoA to succinyl CoA leading to an

accumulation of propionyl CoA:
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.
 Lab findings
 Macrocytic, normochromic anemia (MCV=100-140,
MCHC is normal))
 MCH is increased (due to increased cell size)
Megaloblastic anemias
 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.

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)
Megaloblastic anemias
 Schilling test – is the definative test for the
diagnosis of PA. 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
Schilling test
Schilling test results
Non-megaloblastic macrocytic
anemia
Non-megaloblastic macrocytic
anemia
 Note that the macrocytic RBCs are
not oval, but are round.
 There are no hypersegmented
neutrophils or Howell-Jolly bodies
Differential diagnosis with
increased MCV
Differential diagnosis with
a high MCV
Lab results of megaloblastic vs non-
megaloblastic macrocytosis