Megallo

Question 1

Megaloblastic anemia is characterized by RBCs that are (smaller or larger?) than normal.

Answer 1

Larger

Question 2

In Megaloblastic anemia , There are enough of the megaloblasts.

T/F

Answer 2

F

also aren’t enough of them.

Question 3

When RBCs aren’t produced properly, it results in megaloblastic anaemia.
Because the blood cells are too large, they may not be able to ___________________________

Answer 3

exit the bone marrow to enter the bloodstream and deliver oxygen.

Question 4

An increase in MCV can be due to a number of reasons but careful review of the _________ and _______ can narrow the diagnostic possibilities.

Answer 4

patient’s history and blood smear

Question 5

The differential can be divided into two broad categories based on RBC morphology.

____ macrocytosis

______ macrocytosis

Answer 5

Round

Oval

Question 6

Round macrocytosis: as a result of abnomal ———— in the ________. Round macrocytosis

Common etiologies include:
1.________.
2. _____ Disease.
3. _____ Disease.
4. _________ (“_________ of the red cell”).

Answer 6

deposition of lipids

erythrocyte membrane

Alcoholism; liver; kidney; Hypothyroidism

myxedema

Question 7

Oval macrocytosis (macroovalocytes) is a sign of problem with cell _________.

Answer 7

DNA replica tion.

Question 8

Oval macrocytosis

The developing red cell has difficulty in undergoing _______ but RNA continues to be translated and transcribed into protein leading to _______ while the ______ lags behind.

Often _____________ are skipped leading to a larger than normal cell.

Answer 8

cell division

growth of the cytoplasm

nucleus; one or more cell division

Question 9

macrocytic anaemia

MCV > _____fl

Answer 9

100

Question 10

macrocytic anaemia

Impaired ____ formation due to lack of —— or _______ in ultimatly active form
Therefore the, _________ is delayed to that of the cytoplasm

Answer 10

DNA

vit.B12 or folate

maturation of nucleus

Question 11

Causes of megaloblastic anaemia
The two most common causes of megaloblastic anemia are deficiencies of _________ and ______

Answer 11

vitamin B12 and folate.

Question 12

Which is affected more by cooking?

Vitamin B12 or folate

Answer 12

Folate is destroyed by cooking

Little effect on vitb12

Question 13

Usual therapeutic form of vitamin B12

Usual therapeutic form of folate

Answer 13

Hydroxycobalamin

Folic acid

Question 14

Major intracellular physiological form of

Vitamin B12 and folic acid

Answer 14

Methy and deoxyadenosylcobalamin

Reduced polyglutamate derivatives

Question 15

VITAMIN B12 AND FOLATE-
METABOLIC PATHWAYS
Both vitamin B12 and folate are key components in the synthesis of DNA due to their role in conversion of ______ and ________

Answer 15

uridine to thymidine.

Question 16

VITAMIN B12 AND FOLATE-
METABOLIC PATHWAYS
vitamin B12 and folate role in conversion of uridine to thymidine.

When ________ loses a methyl group to form ________, vitamin B12 “_____” the methyl group to _____ converting it to _____.

Tetrahydrofolate is eventually converted to ________ which is required for thymidine synthase.

Answer 16

methyltetrahydrofolate

tetrahyrodrofolate; shuttles

homocysteine; methionine

methylenetetrahydrofolate

Question 17

Vitamin B12 other role is a co-factor in the conversion of _________ to _______

Answer 17

methymalonyl-CoA to succinyl-CoA.

Question 18

ABSORPTION AND METABOLISM OF
FOLATE

Folate:
The body stores very (little or large?) folate (for several _____) and maintenance of folate stores is dependent on adequate _______.

Folate is found in ____________, and ______

Folate is absorbed in the ______ and circulates in a ____ form or (loosely or tightly?) bond to ______.

Answer 18

Little ; weeks; dietary intake

green leafy vegetables, and liver.

small bowel ; free

Loosely ; albumin

Question 19

ABSORPTION AND METABOLISM OF VITAMIN B12 AND
FOLATE

Vitamin B12:
In contrast to folate the body stores copious amounts of vitamin B12 (for ___-___).
Absorption of vitamin B12 is complex and can be interrupted by a variety of mechanisms.

Vitamin B12 is synthesized by ____ and the major dietary source is _____.

Answer 19

2-6 years

microbes

animal protein.

Question 20

Vitamin B12

When animal protein is ingested, vitamin B12 is freed from the protein and binds to “________”.
This complex travels to the _______ where ______ destroy the _______.
This allows _______ to bind to vitamin B12.
This latest complex is absorbed only in the ___________ of ________.

Vitamin B12 binds to ____________ and is delivered to tissues

Answer 20

R proteins; duodenum

pancreatic enzymes; R protein

intrinsic factor (IF)

last 1-2 feet; terminal ileum

transcobalamin II

Question 21

CONSEQUENCES OF VITAMIN B12 OR FOLATE
DEFICIENCY

When vitamin B12 or folate is deficient, ______ synthase function is impaired and ___ synthesis is interrupted leading to megaloblastic changes in ____________ cells.

Answer 21

thymidine; DNA

all rapidly dividing

Question 22

CONSEQUENCES OF VITAMIN B12 OR FOLATE
DEFICIENCY

The inability to synthesized DNA leads to _________________.
There is often ________ in the marrow but most of these immature cells ____ before reaching maturity.

This process, ______________, leads to the classic biochemical picture of hemolysis-elevated ____ and indirect _____.

Answer 22

ineffectual erythropoiesis

erythroid hyperplasia; die

intramedullary hemolysis; LDH; bilirubinemia

Question 23

The LDH level is often in the ________’s in patients with megaloblastic anemia.

Answer 23

1,000

Question 24

In Megaloblastic Anaemia, The lack of DNA synthesis affects the neutrophils leading to nuclear ______________.

Answer 24

hypersegmentation

Question 25

Megaloblastic Anaemia The anemia is of (gradual or sudden?) onset and is often very (well or poorly?) tolerated despite (low or high?) hematocrits. Often a mild _______ is seen but ________ can be severe.

Answer 25

Gradual; well ; low pancytopenia; thrombocytopenia

Question 26

Other rapidly dividing tissue are influenced by the megaloblastic process. In the GI tract this can lead to ________ of the ________ and further ________. This also leads to the classic sign of ______________.

Answer 26

atrophy of the luminal lining malabsorption tongue smoothing

Question 27

AETIOLOGIES OF FOLATE DEFICIENCY Decreased intake- The average intake of folate in the diet is only ____-___ ug/day which is (more or less?) than the estimated daily requirement. Thus, for most people a ______ or ____ will lead to folate deficiency.

Answer 27

2-300; less poor diet or decrease eating

Question 28

AETIOLOGIES OF FOLATE DEFICIENCY Increased requirements-Patients who are _______, have _____ anemia, or ______ have increased needs for folate which can cause them to rapidly develop folate deficiency if intake is not kept up.

Answer 28

pregnant; hemolytic; psoriasis

Question 29

AETIOLOGIES OF FOLATE DEFICIENCY Malabsorption T/F

Answer 29

T

Question 30

AETIOLOGIES OF FOLATE DEFICIENCY Drugs - Patient with underlying mild folate deficiency are more susceptible to trimethoprim/sulfa, ______ and _______toxicity. _________ and ________ lead to increase consumption of folate.

Answer 30

pyrimethamine and methotrexate Oral contraceptive and anticonvulsants

Question 31

AETIOLOGIES OF FOLATE DEFICIENCY Alcohol- Alcohol affects several aspects of folate metabolism. Alcoholics have __________. In addition, folate metabolism is interfered with leading to a functional folate deficiency. Alcoholics have an inability to ________ and can have _______ with normal ________

Answer 31

poor intake of folate mobilize folate stores depleted tissue stores serum levels of folate

Question 32

AETIOLOGIES OF VITAMIN B12 DEFICIENCY Inadequate intake is (common or rare?) but seen in very strict _____. Abnormal gastric events include being unable to _____________ due to lack of _______ or enzymes. This is a recently recognized group of patients which may compose a very large subset of patients with vitamin B12 deficiency. 10-30% percent of patients with ___________ will develop vitamin B12 deficiency.

Answer 32

Rare; vegans dissociated vitamin B12 from food ; stomach acid partial gastrectomy

Question 33

AETIOLOGIES OF VITAMIN B12 DEFICIENCY Deficient intrinsic factor most commonly occurs due to ___________ by ______ (_______ anemia). Abnormal small bowel events include _____ insufficiency, ______ syndromes (bacterial absorbing vitamin B12-IF complexes) and patients infested with ___________.

Answer 33

destruction of parietal cells; autoantibodies pernicious; pancreatic; blind loops ; Diphyllobothrium latum

Question 34

AETIOLOGIES OF VITAMIN B12 DEFICIENCY Abnormal mucosal events including ______ syndromes and surgical removal of the ________. Drugs -________, ____s

Answer 34

malabsorption terminal ileum. Metformin, PPIs

Question 35

Causes of B12 Deficiency Pernicious Anaemia: Auto antibodies to intrinsic factor in <___% cases Blocks attachment of ____ to ___ Chronic gastritis Autoantibodies against ______ cells blocks attachment of ______ to _____

Answer 35

70 Cobalamin to IF parietal Cbl-IF to ileal receptors

Question 36

B12 deficiency symptoms _______(shinny tongue) _______ gait Anaemia and related symptoms ______ atrophy Malabsorption _______

Answer 36

Atrophic glositis Shuffling Vaginal; Jaundice

Question 37

Personality changes is a B12 deficiency symptom T/F

Answer 37

T

Question 38

Hypohomocysteinemia is a B12 deficiency symptom T/F

Answer 38

F Hyperhomocysteinemia

Question 39

Neurologic symptoms is a _____ deficiency symptom

Answer 39

B12

Question 40

General Morphological features of Megaloblastic anaemia Peripheral blood finding haemoglobin- ____eased Haematocrit- ____eased RBC count- ___eased MVC - > ____fl MCH – _____ MCHC –_______

Answer 40

decr decr decr; 100; increased; normal

Question 41

General Morphological features of Megaloblastic anaemia Peripheral blood finding _______penia Total WBC count –________ Platelet count –________ ________penia, esp. if anaemia is severe

Answer 41

Recticulocyto normal/low normal/low Pancyto

Question 42

Peripheral smear RBC: ______ ovalocyte _____cytic ____chromic in severe anaemia in addition to macrocytosis, marked ______cytosis, ____philic stipplind, _____ bodies, ______may be found. ___________erthyroblast with fine open nuclear chromatin (megaloblast) may be seen in peripheral blood in severe anaemia

Answer 42

Macro macro; normo anisiopoikilo; baso; howell jolly cabot’s ring Late or intermediate

Question 43

________ is the earliest sign in vit. B12 def. and be detected even before the onset anaemia

Answer 43

Macrcytosis

Question 44

Peripheral smear in Megaloblastic Anaemia WBC: ___________ count ____________neutrophils – is one of the earliest signs of megaloblastic haemopoeisis and can be detected even in the absence of anaemia PLATELET: _____________ count (severe anaemia) ______ platelet may occur

Answer 44

Normal to reduced Hypersegemented Normal or decreased Giant

Question 45

Bone marrow Markedly (hypo or hyper?) cellular marrow Myeloid : erythroid ratio is _______ or _____ Megaloblastic erthyroid hyperplasia Giant ___________

Answer 45

Hyper decreased or reversed metamyelocyte

Question 46

MEGALOBLAST Cell and nuclear size and amount of cytoplasm (deeply ________) are ____eased Nuclear chromatin is _____ like or ____ (____) Nuclear-cytoplasm ______/_____ Abnormal (small or large?) precusor (promegaloblast and earl megaloblast) are increased in bone marrow as a result of _______ arrest Abnormal mitosis (____eased)

Answer 46

basophilic royal blue; incr sieve; stippled; open asynchrony; dissociation Large; maturation; incr

Question 47

Granulocytic series also display megaloblastic changes Most prominent changes –___________ with ______ shaped nuclei and finer nuclear chromatin, and in band forms Megakaryocytes are often (small or large?) with multiple nuclear ____ and ____ of cytoplasmic granules.

Answer 47

giant metamyelocyte; horseshoe Large; lobes; paucity

Question 48

Biochemical findings in Megaloblastic Anaemia ___ease in serum unconjugated bilirubin ____ease LDH ______ serum iron and ferritin

Answer 48

Incr Incr Normal

Question 49

Diagnosing Vit. B12 & folate deficiency measuring serum levels of B12 or folate is very adequate to diagnosis deficiency. T/F

Answer 49

F Inadequate

Question 50

Diagnosing Vit. B12 & folate deficiency It turns out that simply measuring serum levels of B12 or folate is very inadequate to diagnosis deficiency. B12 deficiency. - there would be elevated ______ level. -also _______ acid accumulates.

Answer 50

homocysteine methylmalonic

Question 51

Both homocysteine and methylmalonic acid assays are widely available and should be the first line tests for B12 deficiency. T/F

Answer 51

T

Question 52

Serum folate levels are also very unreliable. T/F

Answer 52

T

Question 53

serum homocysteine will also accumulate in folate deficiency T/F

Answer 53

T

Question 54

Serum homocysteine is a more sensitive marker of tissue folate stores. T/F

Answer 54

T

Question 55

Management of B12 deficiency When vit.B12 is suspected a trial of B12 is essential Failure to respond can only be determined after careful follow-up over a period of _______, particularly if the patient is still _______ Standard therapy for all cases of vitb12 deficiency is _________ injection of B12 Usually in the form of ____ In patient with inadequate intake, may be given by ____. Underlying conditions should be treated.

Answer 55

several months; non-anaemic intramuscular; hydroxycobalamin supplements; mouth

Question 56

Vitamin B12 treatment After initiation therapy, reticulocyte count begins to increase around ____ day –peak at ___ or ____ day gradually returns to normal by the end of ______ Hematocrit steadily rises and normalise in about ________ Blood transfusion is indicated in ______________ patients or in patients with CCF.

Answer 56

3rd; 6th or 7th 3rd week. 1-2month severe anaemic symptomatic

Question 57

__________________ are given to patients if B12 deficiency has not been excluded. Why?

Answer 57

Both B12 and folate This is to prevent neurological damage, e.g subacute combined degeneration of the spinal cord.

Question 58

Elevated levels of homocysteine are associated with an decreased risk of atherosclerosis or venous thrombosis.

Answer 58

F Increased

Question 59

Increased levels of homocysteine (reflecting lack of folic acid) in pregnant women is a risk factor for _________

Answer 59

neural tubes defects.

Question 60

Patients with alcoholism and folate deficiency can take up to _____ to respond to folate therapy.

Answer 60

three weeks

Question 61

Which is better, IM Injection or oral B13 therapy?

Answer 61

Oral therapy with 1-2000 ug/day has been tested and has been found to be just as reliable as IM therapy and is becoming more widely used.

Question 62

megaloblastic anemia often present with severe anemia, therefore transfusion therapy is often indicated. T/F With reason

Answer 62

F Although patients with megaloblastic anemia often present with severe anemia, transfusion therapy is rarely indicated. Since the anemia is rapidly reversible with therapy there is little justification for exposing the patient to the risk of transfusion except if the patient is having life- threatening symptoms such as severe ischemia.

Question 63

Megaloblastic anemia maybe caused by all of the following, except: a. Phenytoin b. Methotrexate c. Pyrimethamine d. Amoxycilline

Answer 63

D

Question 64

A 1 year old child presented with severe macrocytic anemia with sub-nephrotic range proteinuria. His vitamin B12 levels are low. The diagnosis: a. Imerslund-Grasbeck disease b. Thiamine deficiency c. Roger syndrome d. Pearson syndrome

Answer 64

A

Question 65

The earliest specific indicator of folate deficiency is: a. Serum folate level b. Red cell folate level c. Anemia d. Elevated homocysteine level

Answer 65

A

Question 66

Hypothyroidism causes pancytopenia T/F

Answer 66

F Hypothyroidism does not causes pancytopenia.

Question 67

7. The earliest neurological sign of megaloblastic anemia is: a. Loss of position sense b. Loss of vibration sense c. Dysdiadochokinesia d. Romberg’s sign positive

Answer 67

A

Question 68

Cobalamin deficiency is characterized by all of the following, except: a. Angular cheilitis b. Glossitis c. Cognitive impairment d. Jaundice

Answer 68

A That’s for iron deficiency

Question 69

megaloblastic anemia May be caused by nitrous oxide inhalation T/F

Answer 69

T By causing vitamin B12 deficiency