Macrocytic Anemia

Question 1

Anemia is defined as?

Answer 1

dec RBC count, HGB, HCT or O₂ carrying capacity of blood

Question 2

Anemia is NOT what?

Answer 2

specific diagnosis - purely abnormal lab test result that signifies and underlying cause

Question 3

An expansion of plasma volume that results in dilutional anemia is called?

Answer 3

spurious anemia

Question 4

What are some causes of spurious anemia?

Answer 4

1. hydremia of pregnancy (physiologic)
2. congestive heart failure
3. overhydration (excessive IV fluids)

Question 5

Shortness of breath (esp with exertion), fatigue, weakness, palpitations, dizziness, syncope are all symptoms of?

Answer 5

anemia

Question 6

What happens to the mucocutaneous membranes of anemic patients?

Answer 6

pallor

Question 7

What happens cardiovascularly in anemic patients?

Answer 7

hyperdynamic circulation: tachy, bounding pulse, systolic flow murmur

Question 8

What is kolionychia? Which anemia is it associated with?

Answer 8

concave (“spoon-shaped”) brittle nails

iron deficienc anemia

Question 9

Which anemias are leg ulcers indicative of?

Answer 9

sickle cell anemia, hemoglobinopathies

Question 10

What causes bone deformities in some anemic patients?

Answer 10

expansions of medularry cavity due to erythroid hyperplasia

Question 11

How do the bone deformities look on x-ray?

Answer 11

“hair-on-end” appearance

Question 12

What types of anemias will result in bone deformities?

Answer 12

thalassemia, sickle cell anemia

Question 13

Loss of vibratory and position sense in associated with?

Answer 13

B12 megaloblastic anemia

Question 14

What are some initial major adaptations to anemia?

Answer 14

1. cardio: tachy and inc stroke volume
2. HGB-O₂ dissociation curve: right shift due to inc 2,3-DPG - O₂ loses affinity

Question 15

What are some following marrow responses to anemia?

Answer 15

erythroid hyperplasia with reticulocytosis (erythroid production can increase 8-fold)

Question 16

____ reflects ability of the marrow to produce and deliveer RBCs to the peripheral blood (aka?)

is it a part of the routine CBC?

Answer 16

reticulocyte count; effective erythropoiesis

NO

Question 17

What stain is needed to see reticulocytes and how does it work?

Answer 17

supravital stain - precipitates ribosomal RNA as a reticulin network

Question 18

Polychromatic erythrocytes are visible with what smear? What does an increase indicative of?

Answer 18

Wright-Stained smear; polychromasia

Question 19

Reticulocytes are the same cells as?

Answer 19

polychromatic RBCs

Question 20

What does a decrease/normal reticulocyte count with anemia implies?

Answer 20

lack of appropriate marrow response - determine cause

Question 21

What value is normal reticulocytes?

Answer 21

0.5-1.5% (percent of circulating RBCs) or

50-165 x 10³ cells/microliter

Question 22

An inc in retic count implies what?

Answer 22

increase production and delivery of RBCs in response to anemia

may be adequate OR insufficient depending on degree of anemia

Question 23

How do we correct reticulocyte count?

Answer 23

Question 24

Decrease in RBC production resuts in?

Answer 24

hypoproliferative anemia

Question 25

A decrease or "normal" corrected RC is indicative of? (in relation to hypoproliferative anemia)

Answer 25

1. aplastic anemia 2. myelophthisic anemia

Question 26

Define myelophthisic anemia.

Answer 26

replacement of marrow by fibrosis, tumor, etc

Question 27

What's maturation defect?

Answer 27

RBCs produced by die in the marrow - aka **ineffective erythropoiesis**

Question 28

A decrease or "normal" corrected RC is indicative of? (in relation to maturation defect)

Answer 28

1. megaloblastic anemia 2. myelodysplastic syndromes

Question 29

What results when the bone marrow effectively produce and deliver RBCs to peripheral blood?

Answer 29

hyperproliferative anemia

Question 30

What kinds of peripheral destruction can occur in hyperproliferative anemia?

Answer 30

hemolysis or hemorrhage

Question 31

Increased corrected retic count can be indicative of?

Answer 31

hyperproliferative anemia treated nutritional anemia

Question 32

MCV 80 – 100 fL \*MCV being an average\*

Answer 32

normocytic

Question 33

MCV \<80 fL

Answer 33

microcytic

Question 34

MCV \>100 fL

Answer 34

macrocytic

Question 35

What are the 2 major types of macrocytic anemias?

Answer 35

megaloblastic vs non-megaloblastic anemia

Question 36

What are some causes for megaloblastic anemia?

Answer 36

1. **B12, folate deficiency** 2. **drugs** - folate antagonists (methotrexate), chemotherapeutic agents, antiretroviral drugs

Question 37

What are some causes of non-megaloblastic anemias?

Answer 37

1. hemolysis, hemorrhage (reticulocytosis) 2. alcoholism, liver disease

Question 38

What's the pathogenesis of megaloblastic anemia?

Answer 38

Question 39

What's the source of B12?

Answer 39

**foods of animal origin**: meat, liver, fish, dairy (NOT found in veg, frits, cereals) normal body **stores last 3-4 years**

Question 40

How is B12 absorbed in the body?

Answer 40

Question 41

What are the causes of B12 deficiency?

Answer 41

1. **malabsorption** 2. **dietary deficiency** (rare in U.S.) - strict vegans and their breast-fed infants 3. **drugs**- nitrous oxide exposure

Question 42

What can lead to malabsorption of B12?

Answer 42

1. **pernicious anemia** - lack of intrinsic factor 2. **surgical**: gastrectomy (total or partial), resection of terminal ileum 3. **inflammatory bowel disease** 4. **tropical sprue and gluten** - sensitive enteropathy 5. **blind loop syndrome** - bacterial overgrowth competing for B12 6. **fish tapeworm** (diphyllobothrium latum)

Question 43

* an **autoimmune chronic atrophic gastritis** * results in **hypo-/achlorhydria** * average age = **60 years** * most common in persons of **N. european descent** * increased risk of **gastric carcinoma** * significant assocation with other autoimmune diseases (grave"s, hashimoto's)

Answer 43

pernicious anemia (PA)

Question 44

Define autoimmune chronic atrophic gastritis.

Answer 44

anti-parietal and anti-intrinsic factor antibodes destroy gastric parietal cells and intrinsic factor production

Question 45

* found in leafy greeen veg, fruits, cereals, dairy products, and liver * heat labile and destroyed by cooking (unlike what?) * where absorbed?

Answer 45

folate B12 in upper SI (duodenum and jejunum)

Question 46

What's the most common cause of folate deficiency?

Answer 46

inadequate dietary intake since body stores in liver only lasts 3-4 months

Question 47

What are some clinical signs and symptoms of folate deficiency?

Answer 47

similar to those in B12 deficiency except lack of neurological features typically seen in B12 deficiency

Question 48

* symptoms: weakness and sore tongue; **glossitis** may be painful, smooth, and atrophic or beefy red; **angular cheilosis** * physical exam: **pallor with mild jaundice** ("lemon-yellow" skin) * **neurological impairment:** may present with this with no anemia or macrocytosis

Answer 48

megaloblastic anemia

Question 49

What causes the neurological impairments sometimes seen in megalobastic anemia? reversible or irreversible?

Answer 49

B12 deficiency! (unreleated to degree of anemia) irreversible

Question 50

What are the neuropathologic changes that can occur in B12 deficiency?

Answer 50

* **demyelination of dorsal and lateral columns of spinal cord** - affecting both sensory and motor pathways - **subacute combined degeneration** * **peripheral neuropathy**: parethesias ("pins and needles") in LE; reduced vibration and position sense in extremities * **uncoordinated gait**: difficulty walkng and loss of balance

Question 51

What's the B12/Folate pathophysiology?

Answer 51

Question 52

What are the 3 key reactins B12 is essential for?

Answer 52

Question 53

What's the peripheral blood morphology in megaloblastic anemia?

Answer 53

* RBC: **macro-ovalocytes** * WBC: **hypersegmented neutrophils**- one of first to appear and among last to disappear after therapy * platelets: **decreased - thrombocytopenia**

Question 54

What's the bone marrow morphology in megaloblastic anemia?

Answer 54

* erythroid hyperplasia with megalobastic change (nuclear/cytoplasmic dysynchrony) * giant bands and metamyelocytes