Macrocytic Anaemia Updates
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Transcript of 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