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1.17 Macrocytic anemia
By Dr. Weilbaecher
62
Pathology
Professional
01/17/2012

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Term
What is anemia?
Definition
decreased RBC count, HGB, HCT, or O2 carrying capacity of blood
Term
Name some examples of spurious anemia?
Definition
hydremia of pregnancy (physiologic), congestive heart failure, overhydration (excessive IV fluids)
Term
Where do you look for pallor in a pt with anemia?
Definition
mucocutaneous membranes (conunctivae, nailbeds, palmar creases)
Term
What are the symptoms of hyperdynamic circulation that accompanies anemia?
Definition
tachycardia, bounding pulse, systolic flow murmur
Term
What is koilonychia?
Definition
concave (spoon shaped) brittle nails that accompanies iron deficiency anemia
Term
Anemia + leg ulcers =
Definition
sickle cell anemia, hemoglobinopathies
Term
What bone deformities are associated with anemia?
Definition
expansion of medullary cavity due to erythroid hyperplasia gives the xray a hair-on-end appearance. Happens in thalessemia and sickle cell anemia
Term
How does the body cause a right shift in the HGB/O2 dissociation curve when pt is anemic?
Definition
d/t incresae in 2,3 DPG which decreases O2 affinity by HGB
Term
How do you determine whether a reticulocyte count is an adequate response of the marrow to anemia?
Definition
"correction of the retic count"
Term
What are two causes of hypoproliferative anemia?
Definition
myelophthisic anemia and aplastic anemia
Term
Name 2 examples of maturation defect anemias.
Definition
megaloblastic, myelodysplastic
Term
What is the corrected RC in hypoproliferative anemia.
Definition
decrased or "normal"
Term
What is the corrected reticulocyte count in maturation defect anemia.
Definition
decreased or "normal".
Term
What is the corrected retic count in hyperproliferative anemia.
Definition
increased
Term
What is the corrected retic count in treated nutritional anemias.
Definition
increased
Term
What are the two major types of macrocytic anemia and how do you differentiate between the two?
Definition
megaloblastic (decreased corrected RC), and nonmegaloblastic (reticulocytosis)
Term
What causes megaloblastic anemia?
Definition
B12/folate deficiency, drugs (folate antagonists like methotrexate, chemotherapy, antiretroviral), myelodysplastic cyndromes
Term
What causes nonmegaloblastic macrocytic anemias?
Definition
hemolysis, hemorrhage, alcoholism, liver disease
Term
What is spurious macrocytosis?
Definition
falsely elevated MCV due to cold agglutinins
Term
What is the pathogensis of megaloblastic anemia?
Definition
defected nuclear maturation caused by impaired DNA synthesis
"nuclear-cytoplasmic dyssynchrony"
Term
What are megaloblasts?
Definition
abnormally large hematopoietic precursors that contain relatively immature appearing nuclei compared to the cytplasm
Term
How does the impaired cell division of megaloblastic anemia lead to anemia?
Definition
buildup of DNA and chromosomal instability and frequent destruction int eh marrow (intramedullary hemolysis) results in peripheral cytopenia due to ineffective hematopoiesis
Term
In a patient developing anemia, what happens first, increased 2,3 BPG or erythroid hyperplasia with reticulocytosis?
Definition
increased 2,3 BPG
Term
B12 is found in what foods?
Definition
those of animal origin (meat, liver, fish, dairy) NOT in vegetables, fruits or cereals
Term
How long do normal body stores of B12 last?
Definition
3-4 years
Term
What cells produce intrinsic factor?
Definition
parietal cells
Term
Where is the B12-IF complex absorbed?
Definition
distal ileum
Term
What protein careies B12 to tissues like the bone marrow and liver for storage?
Definition
transcobalamin II (TC II)
Term
What are three causes of B12 deficiency?
Definition
MC = malabsorption, dietary deficiency, and drug exposure
Term
What causes malabsorption of B12?
Definition
pernicious anemia, gastrectomy, resection of terminal ileum, inflammatory bowel disease, tropical sprue and gluten sensitive enteropathy, blind loop syndrome and fish tapeworm
Term
What is blind loop syndrome?
Definition
bacterial overgrowth which competes for B12
Term
What parasite can lead to B12 deficiency?
Definition
diphyllobothrium latum
Term
What drugs cause B12 deficiency?
Definition
nitrous oxide
Term
What antibodies are present in pernicious anemia?
Definition
anti-parietal cell and anti-intrinsic factor
Term
What is the average age of pernicious anemia?
Definition
60 years
Term
Pernicious anemia increases you risk of ....
Definition
gastric carcinoma; also there is significant association with other autoimmune diseases (Graves disease, and hashimoto's thyroiditis)
Term
What race is at risk for pernicious anemia?
Definition
N european descent
Term
What foods have folate?
Definition
leafy green vegetables, fruits, cereals, dairy products and liver (heat labile and destroyed by cooking, unlike B12)
Term
Where is folate absorbed?
Definition
upper SI (duodenum and jejunum)
Term
How long do the body's stores of folate in the liver last?
Definition
3-4 months
Term
What's the most common cause of folate deficiency?
Definition
inadequate dietary intake (malnutrition, alcoholism)
Term
What causes increased folate requirement?
Definition
pregnancy, infancy, diseases with rapid cellular proliferation (hemolytic anemia with compensatory erythropoiesis, leukemia, myeloproliferative synd.
Term
What drugs cause folate deficiency?
Definition
folate antagonists (methotrexate), anticonvulsants (dilantin), trimethoprim
Term
What are the symptoms of megaloblastic anemia on physical exam?
Definition
weakness and sore tongue, glossitis may be painful, smooth, and atrophic or beefy red; angular cheilosis, lemon-yellow skin, neurologic impairment
Term
What neurological deficits occur with B12 deficiency?
Definition
1) subacute combined degeneration (dorsal and lateral column demyelination) 2) peripheral neuropathy (paresthesias and reduced vibration and position sense) 3) uncoordinated gait
Term
What is the purpose of B12 in DNA synthesis?
Definition
once CH3-folate gets into the cell, B12 helps it turn into tetrahydrofolate
Term
How does B12 deficiency lead to nerve demyelination?
Definition
B12 turns homocysteine into methionine which allows nerve myelination
Term
Why does B12 cause an increase in methymalonic acid?
Definition
B12 converts methymalonyl CoA into succinyl CoA. otherwise methymalonyl CoA turns into methymalonic acid (MMA)
Term
What is the peripheral blood morphology of megaloblastic anemia?
Definition
macro-ovalocytes RBCs, hypersegmented neutrophils (> or = 6 lobes), thrombocytopenia
Term
What is the first sign to appear and the last sign to disappear in a peripheral blood smear of a pt with megaloblastic anemia?
Definition
hypersegmented neutrophils
Term
Nuclear/cytoplasmic dyssynchrony are seen in bone marrow of patients with ________.
Definition
megaloblastic anemia
Term
What doyou seen in bone marrow of patients with megaloblastic anemia?
Definition
erythroid hyperplasia with megaloblastic change (nuclear cytoplasmic dysnchrony), giant bands and metamyelocytes
Term
What are the abnormal chem lab values in patients with megaloblastic anemia?
Definition
increased LDH and indirect bilirubin d/t hemolysis
Term
T/F Low RBC folate is diagnostic of folate deficiency.
Definition
false; RBC folate usually reflects folate status at time RBCs were produced however it may also be decreased in B12 deficiency
Term
What tests do you order for pernicious anemia?
Definition
antiparietal cell antibodies (good sensitivity, poor specificity), antiintrinsic factor antibodies (poor sensitivity, good specificity), schilling's test, serum or urine methylmalonic acid
Term
What happens to folate levels in B12 deficiency?
Definition
normal or increased serum, normal or decreased RBC folate
Term
T/F Serum homocysteine is increased in both B23 and folate deficiency.
Definition
true
Term
How long does it take for replacemnt therapy with B12 or folate to work?
Definition
retic response in 2-3 days; max retic in 5-7 days; normal bone marrow in 2-4 days; hypersegmented PMNs disappear in 2 weeks; hemoglobin becomes normal in 2-3 months
Term
How does chronic liver disease cause macrocytic anemia?
Definition
addition of lipids to red cell membrane cuasing an increased surface area
Term
Macrocytosis with oval cells means=
with round cells=
Definition
oval= megaloblastic; round= nonmegaloblastic
Term
NRBCs are due to a ______ macrocytic anemia.
Definition
megaloblastic
Term
Macrocytic anemia + no WBC or platelet abnormalities =
Definition
non megaloblastic
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