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Week 4: Macrocytic Anemia

Macrocytosis Vitamin B12 Folic acid Megaloblastic changes Pernicious anemia Schilling test Hypersegmented PMN. Bone marrow analysis WBC precursors Liver disease Polycythemia and erythremia PV Newborn CBC. Week 4: Macrocytic Anemia. Bone Marrow Analysis. Aspirate

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Week 4: Macrocytic Anemia

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  1. Macrocytosis Vitamin B12 Folic acid Megaloblastic changes Pernicious anemia Schilling test Hypersegmented PMN Bone marrow analysis WBC precursors Liver disease Polycythemia and erythremia PV Newborn CBC Week 4: Macrocytic Anemia

  2. Bone Marrow Analysis • Aspirate • Particles in fluid part of marrow • Differential count • Biopsy • Solid part of the marrow • Cellularity • Clot section

  3. Aspiration Biopsy

  4. WBC Precursors • Myeloblast • Promyelocyte • Primary azurophilic granules • Meylocyte • Specific granules • Metamyelocyte • Band, stab • Segmented neutrophil, PMN

  5. Myeloblast Promyelocyte Neutrophilic Myelocyte

  6. Segmented neutrophil and lymphocyte

  7. Mast cell and histiocyte Megakaryocyte Plasma cell Mast cell

  8. Histiocyte Fat cell Macrophage

  9. Osteoclasts Osteoblasts Giant cell

  10. Non-Megaloblastic Macrocytosis • Alcoholism • Poor nutrition • Cirrhosis • Liver disease • Reticulocytosis • Hemolytic anemia • Hemorrhage

  11. Megaloblastic Anemia • Hemolytic changes • Waxy pallor • Neurologic changes with B12 deficiency • Glossitis, beefy red or smooth pale tongue

  12. Causes of Megaloblastic Anemia • Folate deficiency • Dietary (green leafy vegetables) • Malabsorption • B12 deficiency • Dietary • Fish tapeworm (D latum) • Pernicious anemia • Lack of gastric intrinsic factor (IF) for absorption

  13. B12 Metabolism • Bind to cobalophilin (cobalamine binding protein) in saliva and gastric secretion • Bind to IF (from parietal cell) in the duodenum • Cbl-IF complex bind to receptor (cubilin) at distal ileum for mucosal absorption • 1% B12 can be absorbed without IF (megadose of B12 for IF deficiency, no need for IV)

  14. Autoimmune mechanism for PA

  15. MCV up to 140 fL Howell-Jolly bodies and Cabot rings Hypersegmented PMN Pancytopenia BM with low M:E ratio Megaloblastic morphology (giant bands and metas) B12 and folate assays RBC folate (long term indicator) IF antibody (PA) Schilling test (obsolete) Megaloblastic Lab Changes

  16. Hypersegmented PMN Megaloblastic anemia Megaloblastic BM

  17. Other Apparent Macrocytoses • Cold agglutinin • Prewarm samples • Hyperglycemia • Osmotic changes • Clot • Rouleaux

  18. Polycythemia Vera • A type of myeloproliferative disorder (MPD) • Independent of EPO • High total RBC mass (by radio tagging)

  19. Secondary Polycythemia • Dehydration (decreased plasma volume) • Increased O2 demand (e.g., emphysema, high elevation) • High EPO (e.g., kidney tumor)

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