MACROCYTIC ANEMIA Prepared by

Darien Liew Daojuin

MEGALOBLASTIC ANEMIA 3 July 2017
INTRODUCTION
Macrocytic anemia can be divided into
megaloblastic and non-megaloblastic
types, depending on bone marrow
findings.
TERMINOLOGIES
Macrocytosis Macrocytosis is a term used to describe erythrocytes
that are larger than normal, typically reported as mean cell volume
(MCV) greater than 100 fL.
Megaloblastic anemia characterised by the presence of large and
immature nuclei in the bone marrow of erythroblasts. These cells have
delayed nuclear maturation due to defective DNA synthesis.
Megaloblastic changes are most apparent in rapidly dividing cells
such as blood cells and gastrointestinal cells.
MEGALOBLASTIC ANEMIA
The common feature in megaloblastosis is a
defect in DNA synthesis in rapidly dividing
cells. To a lesser extent, RNA and protein
synthesis are impaired.
Unbalanced cell growth and impaired cell
division occur since nuclear maturation is
arrested. More mature RBC precursors are
destroyed in the bone marrow prior to
entering the blood stream (intramedullary
hemolysis).
The most common causes for
megaloblastosis are vitamin B12 and folate
deficiencies, medications, and direct
interference of DNA synthesis by HIV
infections and myelodysplastic disorders.
METABOLISM OF VITAMIN B12 Prepared by
Darien Liew Daojuin
AND FOLATE 3 July 2017
VITAMIN B12
Also known as cobalamine.
Source meat, fish, eggs and milk,
but not in plants.
Not usually destroyed by cooking.
Average daily diet contains 5-30g
of vitamin B12, only 2-3g is
absorbed.
B12 storage contains 2-3mg, mainly
in the liver. It may take 2-3 years to
have symptoms manifestation after
absorptive failure.
STRUCTURE AND FUNCTION
Cobalamins consist of a planar group
with a central cobalt atom (corrin ring)
and a nucleotide set at right-angle.
Vitamin B12 was first crystallized as
cyanocobalamin, but the main natural
cobalamins have deoxyadenosyl-,
methyl- and hydroxocobalamin groups
attached to the cobalt atom.
 Methionine a sulfur containing amino
acid, required for protein synthesis

FUNCTION OF B12 and other vital metabolic processes.

B12 has two functions:

1. The main function of B12 is the methylation of homocysteine to methionine with the
demethylation of methyl THF polyglutamate to THF. THF is a substrate for folate
polyglutamate synthesis. (see next slide) Inadequate function of methionine synthase
can lead to an accumulation of homocysteine, which has been associated with increased
risk of cardiovascular disease

2. Deoxyadenosylcobalamin is a coenzyme for the conversion of methylmalonyl CoA to

succinyl CoA (enters the citric acid cycle). Measurement of methylmalonic acid in urine
was used as a test for vitamin B12 deficiency but it is no longer carried out routinely.
BIOCHEMICAL RELATION BETWEEN FOLATE (THF)
AND VITAMIN B12
 B12 Pathway for Methionine
synthesis and B6 Pathway for
Cysteine Synthesis
Folate Pathway for DNA Synthesis

Cysteine residues forms

disulfide bridges which
stabilises the protein
primary structure, increases
the proteolytic resistance
 ABSORPTION OF VITAMIN B12
1. Peptic digestion releases dietary
vitamin B12, allowing it to bind a
salivary protein called
haptocorrin.
2. On entering the duodenum,
haptocorrinB12 complexes are
processed by pancreatic
proteases; this releases B12, which
attaches to IF secreted from the
parietal cells of the gastric fundic
mucosa.
3. The IFB12 complexes pass to the
distal ileum and attach to cubulin,
a receptor for IF, and are taken
up into enterocytes. 4. The
absorbed vitamin B12 is
transferred across the basolateral
membranes of enterocytes to
plasma transcobalamin, which
delivers vitamin B12 to the liver
and other cells of the body.
TRANSPORT OF VITAMIN B12
Vitamin B12 is transported from the enterocytes to the bone marrow
and other tissues by the glycoprotein transcobalamin II (TCII).
Although TCII is the essential carrier protein for vitamin B12, the
amount of B12 on TCII is low. However, it has a rapid clearance and is
able to deliver cobalamin to all cells of the body.
Vitamin B12 in plasma is mainly bound to TCI (7090%), but the
functional role of this protein is unknown. About 1% of an oral dose of
B12 is absorbed passively without the need for intrinsic factor.
(thermolabile)
FOLIC ACID
Folic acid monoglutamate (B9) is not itself present in
nature but occurs as polyglutamates. Folates are
present in food as polyglutamates in the reduced
dihydrofolate or tetrahydrofolate (THF) forms.
Polyglutamates are broken down to monoglutamates in
the upper gastrointestinal tract, and during the
absorptive process these are converted to methyl THF
monoglutamate, which is the main form in the serum.
The methylation of homocysteine to methionine
requires both methylcobalamin (B12) and methyl THF
as coenzymes.
Intracellular polyglutamates are the active forms of
folate and act as coenzymes in the transfer of single
carbon units in amino acid metabolism and DNA
synthesis.

Source Folate is found in green vegetables, such as

spinach and broccoli, and offal, such as liver and
kidney. Cooking causes a loss of 6090% of the
folate. The minimal daily requirement is about 100 g.
CAUSES OF B12 AND FOLATE (B9)
DEFICIENCY
VITAMIN B12 DEFICIENCY
Prepared by
Darien Liew Daojuin
3 July 2017
PERNICIOUS ANEMIA
One of the most common cause of
B12 deficiency is Pernicious Anemia
(PA).

Pernicious anaemia (PA) is an

autoimmune disorder in which there
is atrophic gastritis with loss of
parietal cells in the gastric mucosa
with consequent failure of intrinsic
factor production and vitamin B12
malabsorption.
PATHOGENESIS
AUTOIMMUNE REACTION

PA is a result of autoimmune reaction against the gastric parietal cells

and intrinsic factor itself, resulting in gastric mucosal atrophy. Patients
with PA have an increased risk for the development of gastric
carcinoma.
There are three types of autoantibodies found in the serum and
gastric juice
1. Parietal canalicular antibodies binds to mucosal parietal cells.
(90% of patients)
2. Blocking antibodies disrupts the binding of B12 to IF
3. IF-B12 complex antibodies prevent the compex from binding to
cubulin.
PATHOGENESIS
RELATION TO OTHER AUTOIMMUNE DISEASE

Pernicious anemia probably is an autoimmune

disorder with a genetic predisposition. The
disease is more common than is expected in
families of patients with pernicious anemia,
and it is associated with human leukocyte
antigen (HLA) types A2, A3, and B7 and type
A blood group.

PA frequently occurs concomitantly with

Hashimoto thyroiditis, Addison disease, T1DM.
CLINICAL PRESENTATION
PERNICIOUS ANEMIA

General (typical anemia signs & Gastrointestinal Symptoms

symptoms) 1. Smooth tongue with loss of
1. Pallor papillae
2. Fatigue 2. Red patches are observed on the
3. Dsypnea edges of the dorsum of the
4. Weight loss tongue.
3. Patients may report burning or
soreness, most particularly on the
Cardiac Symptoms anterior third of the tongue. These
1. Cardiac output is usually symptoms may be associated with
increased with hematocrits less changes in taste and loss of
than 20%, and the heart rate appetite.
accelerates. 4. Constipation or having several
2. Congestive heart failure and semisolid bowel movements daily
coronary insufficiency can occur. (due to megaloblastic changes of
the cells of the intestinal mucosa)
CLINICAL PRESENTATION
PERNICIOUS ANEMIA

Neurological symptoms Genitourinary Symptoms

1. Symmetric numbness, tingling and Urinary retention and impaired
burning in feet or hands micturition may occur because of spinal
(paresthesia, peripheral cord damage. This can predispose
neuropathy) patients to urinary tract infections.
2. Unsteady gait
3. Loss of propioception,
particularly in toes.

These neurologic symptoms are due to

myelin degeneration and loss of nerve
fibers in the dorsal and lateral columns
of the spinal cord and cerebral cortex.

Also, subacute combined degeneration

of the spinal cord.
PHYSICAL EXAMINATION
PERNICIOUS ANEMIA

Typically, patients with pernicious anemia are Loss of position sense in the
described as having a stereotypic appearance: second toe and loss of
they have a lemon-yellow waxy pallor with vibratory sense for a 256-
premature whitening of the hair, and they appear Hz tuning fork, but not for a
flabby, with a bulky frame that is generally
incongruent with the severe anemia and 128-Hz fork, are the
weakness. earliest signs of
posterolateral column
disease. If untreated, this
Some significant findings may include can progress to spastic
Beefy red smooth tongue
ataxia from demyelinization
Dark complexion, blotchy skin pigmentation of the dorsal and lateral
Tachycardia, flow murmurs, congestive heart failure columns of the spinal cord.
Abnormal mental health, vision deterioration
Retinal hemorrhages and exudates
Hepatosplenomegaly
 B12 DEFICIENCY
SUBACUTE COMBINED DEGENERATION OF THE SPINAL CORD
Also known as Lichtheim's disease.

Insidious onset (subacute) with peripheral

neuropathy.

Combination of
1. symmetrical posterior/dorsal column loss,
causing sensory and LMN signs, and
2. symmetrical corticopsinal tract loss, causing
motor and UMN signs.

Loss of proprioception, leading to ataxia,

stiffness and weakness if untreated.

The classical triad is

Extensor plantar reflex (UMN) Positive
Babinski sign
Absent knee jerks (LMN)
Absent ankle jerks (LMN)
METABOLIC CAUSES
B12 DEFICIENCY

In pancreatic insufficiency, the alkaline environment in the small

intestine is insufficient for release of cobalamin from R-proteins and
binding to intrinsic factor.

In the Zollinger-Ellison syndrome, the acid environment also prevents

binding of cobalamin to intrinsic factor. In both conditions, the
diminished binding to intrinsic factor interferes with cobalamin
absorption.
OTHER CAUSES OF
B12 DEFICIENCY

Chronic vitamin B12 malabsorption is also seen after gastrectomy

(owing to loss of intrinsic factorproducing cells) or ileal resection
(owing to loss of intrinsic factorB12 complexabsorbing cells), and in
disorders that disrupt the function of the distal ileum (such as Crohn
disease, tropical sprue, and Whipple disease).
Particularly in older persons, gastric atrophy and achlorhydria may
interfere with the production of acid and pepsin, which are needed to
release the vitamin B12 from its bound form in food.
Nitrous oxide exposure can cause megaloblastosis by oxidative
inactivation of cobalamin. Prolonged exposure to nitrous oxide can
lead to severe mental and neurological disorders.
PPI AND H2 RECEPTOR ANTAGONIST
Proton-pump inhibitors (e.g., omeprazole and lansoprazole), used for
therapy of Zollinger-Ellison syndrome and gastroesophageal reflux disease
(GERD), markedly decrease stomach acid secretion required for the release
of vitamin B12 from food but not from supplements. Long-term use of proton-
pump inhibitors has been found to decrease blood vitamin B12 levels.
However, vitamin B12 deficiency does not generally develop until after at
least three years of continuous therapy.
Histamine2 (H2)-receptor antagonists (e.g., cimetidine, famotidine, and
ranitidine), used to treat peptic ulcer disease, has also been found to
decrease the absorption of vitamin B12 from food. It is not clear whether the
long-term use of H2-receptor antagonists could cause overt vitamin B12
deficiency.
Individuals taking drugs that inhibit gastric acid secretion should consider
taking vitamin B12 in the form of a supplement because gastric acid is not
required for its absorption.
INHERITED CAUSES
Imerslund-Grsbeck syndrome is an inherited vitamin B12
malabsorption syndrome that causes megaloblastic anemia and
neurologic disorders of variable severity in affected subjects.

Similar clinical symptoms are found in individuals with hereditary IF

deficiency (also called congenital pernicious anemia) in whom the
lack of IF results in the defective absorption of vitamin B12.

Additionally, mutations affecting vitamin B12 transport in the body

have been identified.
SUMMARY
TREATMENT
VITAMIN B12 DEFICIENCY

1. Hydroxocobalamin 1000 g 5 to 6mg, given intramuscularly,

over the course of 3 weeks.
2. Followed by 1000 g of Hydroxocobalamin every 3 months for
the rest of patients life.
3. Alternatively, oral vitamin B12 2mg/day. 1-2% of an oral dose is
absorbed by diffusion, does not require intrinsic factor.
FOLATE DEFICIENCY
Prepared by
Darien Liew Daojuin
3 July 2017
FOLATE DEFICIENCY
The main cause is poor intake, which
may occur alone or in combination with
excessive utilization or malabsorption.
CLINICAL PRESENTATION
The onset of the anemia of folate deficiency is insidious, being associated
with nonspecific symptoms such as weakness and easy fatigability. The
clinical picture may be complicated by the coexistent deficiency of other
vitamins, especially in alcoholics.
Because the cells lining the gastrointestinal tract, like the hematopoietic
system, turn over rapidly, symptoms referable to the alimentary tract, such
as sore tongue, are common.
Unlike in vitamin B12 deficiency, neurologic abnormalities do not
occur.
The diagnosis of a megaloblastic anemia is readily made from
examination of smears of peripheral blood and bone marrow. The
anemia of folate deficiency is best distinguished from that of vitamin B12
deficiency by measuring serum and red cell folate and vitamin B12 levels.
INVESTIGATION
TREATMENT
FOLATE DEFICIENCY

1. Give 5mg of folic acid daily, for about 4 months to replace body
stores. Folic acid should not be given without B12 in a B12
deficiency patient, as it can worsen the neuropathy.
2. Treat underlying cause.
3. Prophylactic folic acid (400 g daily) for all women planning for
pregnancy to reduce neural tube defects, and also through
pregnancy.
4. Women who have had a child with NTD should take 5mg folic acid
daily before and during subsequent pregnancy.
REFERENCES
Harrisons Principles of Internal Medicine, 19 Edition
Kumar and Clark, 8th Edition
Davidsons Principles and Practice of Medicine, 22nd Edition
Essential Haematology, 6th Edition
http://bestpractice.bmj.com.ezproxy.lib.monash.edu.au/best-
practice/monograph/823/diagnosis/tests.html
http://lpi.oregonstate.edu/mic/vitamins/vitamin-B12
http://www.aafp.org/afp/2009/0201/p203.pdf
http://emedicine.medscape.com/article/204066-overview#a5