macrocytic anaemia updates

MACROCYTIC ANAEMIA

PRESENTED BYDR. AHMED TANJIMUL ISLAM OVEE

HMO, DEPARTMENT OF HAEMATOLOGY,CHITTAGONG MEDICAL COLLEGE HOSPITAL

Case:• 60 year old man with Hypothyroidism on

Thyroid replacement therapy develops Paresthesia, Fatigue, Anaemia.

Q. What is your 1st clinical diagnosis?

• 1. Iron Deficiency Anaemia• 2. Anaemia of Chronic Disease• 3. Pernicious Anaemia• 4. Folate Deficiency

Case:• 60 year old man with Hypothyroidism on

Thyroid replacement therapy develops Paresthesia, Fatigue, Anaemia.

Q. What is your 1st clinical diagnosis?

• 1. Iron Deficiency Anaemia• 2. Anaemia of Chronic Disease• 3. Pernicious Anaemia• 4. Folate Deficiency

Macrocytic Anaemia found in Almost Every Department of Hospital yet remains the LEAST in the PRIORITY LIST !

• Case to a General Practitionar :

• Reffered to Haematologist: 55 yrs , Iron Non responsive Anaemia, Severe

Weakness, Paresthesia.

• Reffered to Neurologist: Difficulty in Walking, Weakness, Ataxia, Paresthesia.

• Reffered to Dermatologist: Vitiligo, Alopecia. Pale lusterless Skin, Weakness

• CASE to a GASTROENTEROLOGIST:Chronic DiarrhoeaRecent onset Weakness, Depression

• Reffered to Pediatritian: Back translucent swelling

Case to Obstetritian :

• Reffered to Psychiatrist:

SEVERE WEAKNESS

HALLUCINATIONDEPRESSIONPSYCHOSIS

PERIPHERAL BLOOD FILM

BONE MARROW EXAMINATION

‘MACROCYTIC ANAEMIA ‘

•WHEN IT BECAME A HEADACHE FOR MANKIND ?

•WHEN IT BECAME A HEADACHE FOR MANKIND ?

Answer : 1919-1921

Norman Warne 1919

1919

Suzzan Lenglen 192025 times Wimbledon Champion

1920

Alexander Graham Bell . 1921

1921

• 1850 : Thomas Edison• 1926: Murphy (NOBEL PRIZE)• 1941: Folic Acid• 1948: Crytaline B12 ( NOBEL PRIZE )• 1956: Dorothy Hodgkin (NOBEL PRIZE) Chemical Structure of B12

DOROTHY HODGKIN MURPHY

5%

• MEGALOBLASTIC ANAEMIA

• PERNICIOUS ANAEMIA

• MEGALOBLASTIC ANAEMIA

• PERNICIOUS ANAEMIA

• VITAMIN B12 DEFICIENCY

• FOLIC ACID DEFICIENCY

Neurological Paresthesia Weakness Dyspnea0

10

20

30

40

50

60

70

80

90

100

SCDDEMNTIAPERIPHERAL NEU-ROPATHYPSYCHIATRIC

PERIPHERAL NEUROPATHY 73%

SCD

Weakness (<160 m gm)

Dyspnea (<120 mgm)

Paresthesia (<100 mgm) Megaloblastic Madness (psychiatic)

Neurological Deficit (< 60 mgm)

Hypersegmented neutrophilMacro ovalocytes

Messed Up withInvestigation Sheet ?

VITAMIN B 12 DEFICIENCY

Important for DNA synthesis, nervous tissue and fat metabolism in the liver

an intermediate of the citric acid cycle, porphyrin synthesis

(Heme synthesis)

T2 PHASE MRI OF SPINAL CORD

POSTERIOR COLUMN LESIONEASILY CONFUSED WITH ‘MS’

FOLIC ACID DEFICIENCY

‘PERNICIOUS ANAEMIA’

Pernicious Anaemia:• Autoimmune Destructon of Parietal Cells.

• Antibodies against 1. Parietal Cells, 2. Intrinsic Factor.

• Achlorhydria is Universal.

• Increased incidence of Gastric Cancer.

• Often associated with other Autoimmune diseases like Hashimoto’s Thyroiditis, Vitiligo.

Pernicious Anemia

• Vitiligo

Normal Gastric atrophy

PA

SCHILLING TEST

TREATMENT:

CAUTIOUS BLOOD TRANSFUSIONHb <6 gm/dlS/S Heart Failure

B12 Deficiency: Treatment• IM B12 1000mcg Daily x 1 wk

– then 1000mcg Weekly x 1 month– Then 1000mcg Monthly for life for PA

• Oral high dose 1-2 mg daily– Less reliable than IM

– Only recommended after full parenteral repletion

• Sublingual, nasal spray and gel formulations available.

Reticcount

Folic Acid Deficiency dose :

DIAGNOSTIC ALGORITHM:• PBF with RETICULOCYTE

• B12 LEVEL + FOLATE LEVEL

• HOMOCYSTEINE LEVEL

• METHYMELONIC ACID (MMA) LEVEL

• INVESTIGATION FOR OTHER CAUSES (Alcohol, Hypothyroidism, Liver, Renal, MDS etc)

NORMAL

COBALAMINE 200-900

FOLATE 2.5-20

MMA 70-270

HOMOCYSTEINE 5-16 UM

P.A.S BRITISH SOCIETY FOR RESEARCH & AWRENESS

PERNICIOUS ANAEMIA AWARENESS

FREQUENTLY ASKED QUESTIONS

•Is Schiling’s Test is a must test ?

IS NORMAL BLOOD COUNT CAN RULE OUT B12 DEFICIENCY?

IS MACROCYTE in PBF IS A MUST ?

WHAT IS THE PROBLEM WITH

HIGH FOLATE with LOW B12 ?

•WHY IT IS MORE COMMON IN DEVELOPED COUNTRY ?

Take Home Message:• A Slowly Developing Anaemia, Well Compensated.

• Must find Underlying Cause to prevent reversal.

• Response to Therapy Very Rapid.

• Only Folic Acid will not give inprovement in B12 deficiency.

• Neurological complications is Stabilized with treatment but NOT REVERSED.

THANK YOU