Megaloblastic anemias

Megaloblastic anemia
Megaloblastic anemias constitute a diverse
group of entities with1. Impaired DNA synthesis
2. Megaloblastic changes in blood & BM due to
nuclear : cytoplasmic asynchrony
Etiologies : Vit B12 def. including Pernicious anemia,
Folate def.

PATHOGENETIC CLASSIFICATION OF NON

MEGALOBLASTIC MACROCYTIC ANEMIA
Associated with accelerated erythropoiesis
Hemolytic anemia
Post haemorrhagic anemia

Alcoholism
Liver disease
MDS
Myelophthistic anemia
Acquired sideroblastic anemia
Hypothyroidism
CDA(TYPES I &III)
DIAMOND BLACKFAN SYNDROME

Intracellular substances: Folate and

Cobalamin
Folate

Pteridine ring, glutamate side chain

Enzymatically active form is tetra-hydrofolate (THF)
Intermediate in transfer of one carbon units
Involved in purine, pyrimidine metabolism, and sadenosyl methione (S-Adomet) generation

Cobalamin
Cobalt-tetrapyrrole ring
Cobalamin forms
Methylcobalamin
Adenosylcobalamin
Cyanocobalamin

Cobalamin deficiency traps folate

dTMP

dUMP

Glycine

Methylene-THF

DHF

Pyridoxal-5-phosphate

P
mthfr

Serine
THF

Methyl-THF

Folic acid

Methyl-cobalamin

Cystiene

Homocystiene

Methionine

Cobalamin deficiency Inhibits Methionine synthesis

It also traps Methyl-THF, and activates more methylene THF to be converted to Meth-THF
Internal THF deficiency ensues,yield of less polyglutamated forms.
Excess homocysteine is converted to Cysteine, which is toxic to cells

Folate and cobalamin help amino-acid

synthesis
M Methyl-cobalamin
S-Ado-Meth is regulator
of folate
metabolism,inhibits
mthfr
S-Ado-met is also a
methyl donor and hence
has a role in amino-acid
synthesis
Folate and Cobalamin
deficiency inhibit aminoacid synthesis

Methyl-THF

Homocystiene

S-Adohomocyctiene

Methylated
product

THF

Folic acid

Methionine

S-AdoMet

Methyl-acceptor

Metabolic effects of B12 & folic acid

Methyl malonyl CoA

Succinyl malonyl CoA

B12

accumulates

MMCoA mutase

Abnormal fatty acids

Histidine

FIGLU

myelin breakdown &

neurologic complications

glutamate + formimino FH4

FH4

Dietary sources
- Food folate
- Folic acid

Folate absorption
Intestinal
transporter

Intestinal
transporter

Proximal jejunum
Saturable absorption

Meth-THF

Meth-THF

Blood
vessel

Folic acid

THF

Mucosal cell

Folic acid
THF
Meth-THF

Terminal ileum
Non-saturable absorption

Meth-THF
Folate receptor

Tissues

Rapid absorption

Folate stores

In liver and red cells

Polyglutamate form
Total content:5-20 mg,exhausted in 4 mths
Normal loss through sweat,saliva.urine.faecus

Dietary sources
- Animal produce

Cobalamin absorption

R-B12
complex

IF
Proteases
Cubulin receptor

Duodenum

TC-II
Ileal mucosa

Gastric mucosa

Tissue

Pancreas

Blood
vessel

Meth-THF

TCII-R

Cobalamin stores

Liver is the principle site

Also present in kidney,heart and brain
Storage form is adenosyl-cobalamin
Major routes of loss through biliary excretion
and desquamation of intestinal epithelial cells

Folate vs Cobalamin
Folate
RDA 400ug adults; 600ug
pregnant women
Fresh vegetables, fruits,
dairy, meats.
Absorption in proximal and
distal small intestine
Does not involve specific
binding proteins for
absorption and transport
Storage form is limited, RDA
essential. Development of
deficiency rapid.

Cobalamin
RDA 2.5ug in adults
Present in animal sources
Milk cheese eggs
Absorption in distal small
intestine
Requires specific binding
proteins (IF, TC-II)
Stored in body, excretion is
limited. Development of
deficiency is slow.

Folate vs Cobalamin
Folate
Deficiency due to

Cobalamin
Deficiency due to

Poor dietary intake

Increased requirement
Alcoholism
Anti-folate drugs
Extensive intestinal resection

Poor intake (vegans)

IF deficiency (pernicious
anemia)
Inflammatory bowel disease
Ileum resection
Gastrectomy
Fish tapeworm

Combined deficiency
Tropical sprue
Gluten sensitive enteropathy

Pernicious anemia
Autoimmune des. of gastric mucosa leading to chronic
atrophic gastritis parietal cell loss decreased IF
release B12 def

I Ab blocks binding of B12 to IF

II Ab blocks binding of IF-B12 to ileal R
III Ab not specific
Auto-reactive T cell mediated injury

Pernicious anemia

Similar blood and bone-marrow findings

Atrophy of fundic glands
Intestinal metaplasia
Atrophic glossitis
CNS lesions (SACD of dorso-lateral tracts)

Consequences of folate and cobalamin

deficiency
Manifest deficiency
Megaloblastic anemia
Altered DNA synthesis
Nuclear cytoplasmic asynchrony

Neurological dysfunction
Altered myelin synthesis
Subacute combined degeneration

Mucosal abnormalities (Glossitis)

Subclinical deficiency
Hyper-homocystienemia
Atherosclerosis

Hematological findings
Affects all three series of cells
Anemia, Dyserythropoiesis
Leukopenia
Thrombocytopenia

Affects cellular maturation

Megaloblasts in marrow
Macrocytes in peripheral smear
Hypersegmented neutrophils

Peripheral smear

Macrocytes

Hypersegmented
neutrophils

Biochemical findings
Vit B12 def.

S.Vit B12 (N 160900ng/l)

Homocysteine,S. methyl
malonic acid

IF antibodies
Folic acid def

S. folic acid

FIGLU in urine
(intermediate product in
conversion of histidine to
glutamate)

Tests for diagnosis

Test

Cobalamin def

Folate def

Discriminating
capacity

S.cobalamin

N or

Fair to good

S.folate

N or

Very good

Red cell folate

or n

poor

S.Methylmalonyl
acid

Very good

De-oxyuridine
suppression test

abnormal

abnormal

Very good

Schillings test
Schillings test : radioactive B12 is used to assess status
of IF and VitB12 ; to distinguish PA from other causes of
B12 def.
Stage I
Oral dose radiolabelled, 1ug
Parenteral dose 1000 microg
24 hr urine N >10%, PA
Stage II : repeat with IF supplements

Megaloblastic anemia: Bone Marrow

BM : hypercellular, may
completely replace the
fatty marrow
M:E is reversed
Megaloblasts larger in
size, open seive-like
chromatin and well
hemoglobinized
cytoplasm
Giant metamyelocytes
and band forms
Megakaryocytes large
and bizarre multilobate
nuclei

Reversal of symptoms
New reticulocytes: 2-3 days
LDH and s.bilirubin decline
Neutrophil hypersegmentation persists for 2
wks or more
WBC and platelets: 1 wk
Peak retic:10 days (hb increases)
Fully normal:8 weeks,neurological
manifestations first few wks