MACROCYTIC ANEMIA

Rahmawati Minhajat

Tutik Harjianti

A. Fachruddin B

Div. of Hematology & Medical OncologyDept. of Internal Medicine, Medical Faculty

Hasanuddin University

Division of Hematology & Medical Oncology Dept. of Internal Medicine

Deficiency of Cyanocobalamin

B12 : all of it made from diet

A food ingredients may from animal.

Absorbtion : 5 ug / days

Cofactor at 2 important reaction in a body

Division of Hematology & Medical Oncology Dept. of Internal Medicine

The role of Cyanocobalamin

Methyl-Cobalamin is a cofactor for methionine-synthetase at rx change of homosystein metyonin.

Adenosyl-Cobalamin is a cofactor at rx change of methyl-malonyl CoA succinyl-CoA

Division of Hematology & Medical Oncology Dept. of Internal Medicine

2. Peripheral blood smear:

macro-ovalocyte & hypersegmented neutrophil

3. Level of Vit B12

Division of Hematology & Medical Oncology Dept. of Internal Medicine

Macrocytic Normocytic

Division of Hematology & Medical Oncology Dept. of Internal Medicine

The Cause

1. Deficiency vit B12 (diet)

2. The decrease production of intrinsic factor

(Anemia perniciosa, post-gastrectomy)

2. The decrease absorbtion of vit B12 at the ileum

(Post-op, Crohn ds)

3. Helmynthyasis (tape-worm)

4. Deficiency Transcobalamin II

Division of Hematology & Medical Oncology Dept. of Internal Medicine

Physiology

Vit B12 come in from IT binding with intrinsic factor (made from parietal mucosa gaster cell)

abs in ileum terminal by spesific receptor come in to the plasma liver .

There are 3 protein transporter in the plasma :

Trans-cobalamin I, II & III (by leukocyte). Only

Trans-cobalamin II that can transport vit B12

into the cell.

Division of Hematology & Medical Oncology Dept. of Internal Medicine

Phatogenesis

Hepar consist 2.000 5.000 ug vit B12

Need : 3 5 ug / hari

Defs vit B12 will be happen in 3 years after no more absorpsi.

Defs caused by diet less vit B12 vary rare ( vegetarian )

Example :

Gastrectomy the area produce factor intrinsik will decrease

Over-growth bactery in intestinal

Reseksi ileum the area of absorpsi vit B12 will decrease

Helmenthyasis

Crohns disease ileum destruction

the area of absorpsi vit B12 will decrease

Anemia Perniciosa

Often cause defs B12

Abnormality Auto-Imun herediter

Seldom show before 35 years old

Scandinavia / Eropa Utara

A black skin teenager, a hispanic woman

Anemia Perniciosa

Clinic illustration :

Likely anemia caused by defs vit B12,

- Gastritis atrophic

- Abnormal Auto-Imun ( rheumatoid arthritis

Graves disease, defs IgA )

- After several years some patient

Gastritis Atrophic => Carcinoma Gaster

CLINIC MANIFESTATION OF

DEFS. VIT B12

Megaloblastic anemia

May a hard anemia ( hematokrit < 10 % )

A change mucosa cell : glossitis, anorexia, diare.

Neurologic disturb:

1. Perifer parestesi

2. Cerebral difunction

Lab. Abnormal

1. Megaloblastic Anemia

2. MCV between 110 140 fl (increase)

at some patients : MCV normal

3. Blood Perifer : anisocytosis &

poikilocytosis. Specif : macro-ovalocytes.

Blood Perifer

4.Morfologi eritrosit is abnormal

Likely Hemolytic Anemia

5. Hypersegmentation of neutrophyls

6. Decreased Reticulocyte amount

Bone Marrow Asp

In-efective Erythropoesis ( abnormally RBC production)

erythroid hyperplasia ( as respons )

Abnormal megaloblastic Cell in BM and different shapes :

* Large abnormal size,

* nuclear maturation & cytoplasm are not

synchronize.

Maturasi cytoplasm is normal,

DNA synthesis is bother

Myeloid : Giant cell (meta-myelocyte)

Other Abnormal Lab :

In-efective erytropoesis in BM may happen destruction of erythroid cell that in the

development period increased level of LDH ( lactic-dehydrogenase ) and Bilirubin indirect

Diagnosis

1. Level of vit B12 serum is low

( normal : 150-350 pg / mL )

2. Schilling test ( for dx A Perniciosa /

the decrease absorpsi vit B12 oral )

THERAPY

* Anemia Pernisiosa (oral absorpsi disfunction)

Intra-muscular Inj. Vit B12 ( IM )

Dosis : 200 ug

1st week : every day (replacement tx)

2nd 4th week : every week

Once a month

Respons Therapy

Reticulocytosis 5 7 days.

Abnormalitas hematologic disappear after 2 months.