Evaluation of Macrocytic Anemias.

Macrocytic anemia, defined as a mean cell volume (MCV) ≥100 fL in adults, has a narrow differential diagnosis that requires evaluation of the peripheral blood smear as well as additional laboratory testing taken in conjunction with clinical information that includes patient history and physical examination findings. This review is an update on the approach to a patient with macrocytic anemia with attention paid to the differentiation of megaloblastic and non-megaloblastic macrocytic anemias. Critical to the determination of the diagnosis is the judicious use of laboratory testing and the evaluation of those findings in conjunction with the patient medical, surgical, and medication history.

Hydroxyurea increases plasma concentrations of microparticles and reduces coagulation activation and fibrinolysis in patients with sickle cell anemia.

Microparticles (MPs) are present in healthy subjects and their concentration increases in patients at high risk of thrombosis. We evaluated 10 patients with sickle cell anemia (SCA) treated with hydroxyurea (HU) and 13 SCA patients without this treatment. MP concentrations were determined by flow cytometry. Coagulation was evaluated using the thrombin-antithrombin complex (TAT) and D-dimers. Total MP concentrations were increased in the HU-treated group (265 × 10(6)/ml vs. 67.45 × 10(6)/ml; p = 0.0026), as well as MPs derived from RBC (67.83 × 10(6)/ml vs. 26.31 × 10(6)/ml; p = 0.05), monocytes (51.31 × 10(6)/ml vs. 9.03 × 10(6)/ml; p = 0.0084), monocytes with tissue factor (TF) expression (2.27 × 10(6)/ml vs. 0.27 × 10(6)/ml; p = 0.0058), endothelium (49.42 × 10(6)/ml vs. 7.23 × 10(6)/ml; p = 0.007) and endothelium with TF (1.42 × 10(6)/ml vs. 0.26 × 10(6)/ml; p = 0.0043). Furthermore, the concentrations of TAT (7.56 vs. 10.98 µg/l; p = 0.014) and D-dimers (0.65 vs. 1.29 µg/ml; p = 0.007) were reduced with HU. The MP elevation may suggest a direct cytotoxic effect of HU. Another explanation is a cell surface increase secondary to a megaloblastic process, resulting in increased vesicle release. In our opinion, the known benefits of HU on SCA patients, along with the reduction in coagulation activation, surpass its potential detrimental effect on MPs. Future studies should elucidate the role of MPs and demonstrate their significance in different contexts.

[Pronounced pancytopenia with concomitant jaundice in a 66-year-old woman]. / Ausgeprägte Trizytopenie mit Ikterus bei einer 66-jährigen Patientin.

HISTORY AND ADMISSION FINDINGS: A previously healthy 66-year-old women presented with onset of general weakness, shortness of breath and significant weight loss. Due to appearance of jaundice, biliary obstruction had been ruled out by a CAT scan previous to the patients presentation in our practice. INVESTIGATIONS: The laboratory tests already arranged by the patients general practitioner showed a pronounced pancytopenia with megaloblastic anemia and hyperbilirubinemia. The bone marrow aspiration revealed a hypercellular bone marrow with megaloblastic erythropoiesis. The diagnosis of pernicious anemia was confirmed by the low cobalamin (vitamin B12) serum level and the presence of atrophic gastritis. TREATMENT: Pernicious anemia was treated with intramuscular injection of Cyanocobalamin (1000 µg) which resulted in an immediate reticulocytosis and a widely normalized blood cell count and bilirubin level four weeks after initiation of treatment. CONCLUSION: The differential diagnosis of megaloblastic anemia covers a wide spectrum of diseases with different etiology. This case report demonstrates an example of a pernicious anemia with atypical and foudroyant clinical course.

Reversible bone marrow dysplasia in patients with systemic lupus erythematosus.

OBJECTIVE: Several reports of bone marrow dysplasia in patients with systemic lupus erythematosus (SLE) have been published. However, the reports are restricted primarily to descriptions of the erythroid lineage; no follow-up studies have been reported, and the clinical significance of the dysplasias is unknown. Therefore, in the present study, the dysplasias noted in bone marrow aspirates obtained from SLE patients were characterized. PATIENTS AND METHODS: The smears of bone marrow aspirates obtained from 17 SLE patients who had bone marrow aspiration due to cytopenia (WBC < 1,500/microl, or Hb < 10.5 g/dl, or platelet count < 10 x 10(4)/microl) were examined retrospectively. Of the 17 patients, 4 had a repeat bone marrow aspiration during follow-up. Clinical and laboratory data were obtained from the medical records. RESULTS: Of the 17 SLE patients, 12 had dysplasias, including: erythroid cell multinuclearity (trinuclear or more) (5 patients), megaloblastoid changes (4), pseudo-Pelger abnormalities (6), annular nuclear myeloid cells (2), separated nuclear megakaryocytes (4), and micromegakaryocytes (5). In the 4 patients who had follow-up bone marrow aspiration, these dysplasias were correlated with disease activity; some abnormalities disappeared with remission of SLE. Diffuse proliferative glomerulonephritis (3 patients) and cerebral lupus/neuropsychiatric lupus (4 patients) were seen only in patients with dysplasia. CONCLUSION: This study found that bone marrow dysplasia can be observed in all lineage cells of SLE patients, and that the dysplasia is reversible during the course of the disease. The presence of dysplasias appears to be associated with disease severity.

DNA ploidy and cell cycle analyses in the bone marrow cells of patients with megaloblastic anemia using laser scanning cytometry.

BACKGROUND: Megaloblastic anemias are characterized by several hematopoietic cells with dysplastic nuclear morphology. The analyses of DNA ploidy and cell cycle of these cells are important to understand the property of such diseases. METHODS: As laser scanning cytometry (LSC) is a useful tool to evaluate the morphology of the cells fixed on the slide glass together with the quantitative analysis of the fluorescence information of each cell by rapid scanning of the specimens, the authors examined the DNA ploidy and cell cycle of six cases with megaloblastic anemia using LSC. RESULTS: Giant neutrophilic series such as giant metamyelocytes and giant band cells were found to have extraordinarily higher DNA ploidy, while hypersegmented neutrophils represented the normal diploid pattern like normal neutrophils. As to megaloblasts, cell cycle analysis showed that the proportion of the cells in S phase was increased as compared with the case of normal erythroblasts. CONCLUSIONS: The present study clearly demonstrates the abnormal aspects of the hematopoietic cells with megaloblastic anemia from the viewpoint of the DNA ploidy and cell cycle analyzed by the use of LSC.

A new disease categorization of low-grade myelodysplastic syndromes based on the expression of cytopenia and dysplasia in one versus more than one lineage improves on the WHO classification.

Multilineage dysplasia was advanced by the World Health Organization to increase prognostic accuracy in myelodysplastic syndromes (MDS) classification. We performed a structured cytomorphological examination of bone marrow (BM) in 221 low-grade MDS patients, this in conjunction with strict guidelines for cytopenias. A dysplasia scoring system was developed utilizing dysplastic changes, which were associated with worse outcome on univariate and multivariate analysis corrected for the International Prognostic Scoring System (IPSS). Dysplasia >or=10% in one BM lineage and one cytopenia constituted the low-risk category UCUD or Unilineage Cytopenia and Unilineage Dysplasia. The high-risk category comprised patients with cytopenia in >or=2 lineages and dysplasia in >or=2 BM lineages, namely MCMD or Multilineage Cytopenia and Multilineage Dysplasia. Intermediate-risk patients had one cytopenia and multilineage dysplasia, or cytopenia in >or=2 lineages and unilineage BM dysplasia, designated UCMD/MCUD or Unilineage Cytopenia and Multilineage Dysplasia/Multilineage Cytopenia and Unilineage Dysplasia. This system utilizing cytopenia-dysplasia scoring at diagnosis enabled comprehensive categorization of low-grade MDS cases that predicted for overall as well as leukemia-free survival. Cytopenia-dysplasia categorization added additional prognostic values to the lower risk IPSS categories. This suggests that a standardized dysplasia scoring system, used in conjunction with cytopenia, could improve diagnostic and prognostic sub-categorization of MDS patients.

Megaloblastosis: from morphos to molecules.

OBJECTIVE: Megaloblastosis (i.e., megaloblastic transformation of erythroid precursor cells in the bone marrow) is the cytomorphological hallmark of megaloblastic anemia resulting from vitamin B12 and folate deficiency. It is characterized by a finely stippled lacy pattern of nuclear chromatin, which is believed to be an expression of deranged cellular DNA synthesis. However, the molecular basis of these cytomorphological aberrations still remains obscure. The current presentation describes the results of our studies on some molecular events associated with the development of megaloblastosis. METHODS: Transmission electron microscopy was used to study megaloblasts as well as DNA fibers extracted from megaloblastic and normoblastic bone marrows with and without treatment with proteinase K during the extraction procedure; cellular DNA synthesis in bone marrow cultures was studied by incorporation of 3H-thymidine and deoxyuridine suppression test, while histone biosynthesis in bone marrow cells was studied by in vitro incorporation of 3H-tryptophan, 3H-lysine and 3H-arginine into histones. RESULTS: Derangement of DNA synthesis occurred due to an impaired de novo pathway of thymidylate synthesis in both vitamin-B12- and folate-deficient human megaloblastic bone marrows as well as in the bone marrows of rhesus monkeys and rats with experimentally induced folate deficiency. Interestingly, folate-deficient monkeys developed frank megaloblastic bone marrows, but folate-deficient rats did not. On the other hand, megaloblastic changes in the bone marrow of human patients with myelodysplastic syndrome and erythroleukemia were not associated with this DNA synthetic abnormality. Biosynthesis of predominantly arginine-rich histones in megaloblastic bone marrows was markedly reduced as compared to normoblastic bone marrows, which was consistently associated with elongation and despiralization of chromosomes and finely stippled nuclear chromatin in megaloblasts. CONCLUSION: The impaired biosynthesis of predominantly arginine-rich nuclear histones appeared to be a common molecular event (a denominator) underlying the development of megaloblastosis with or without abnormal DNA synthesis.

On the pathogenesis of erythroleukaemia (H0493).

In erythroleukaemia megaloblastic changes can co-exist with leukaemic changes in the marrow. The cause of the disease must therefore be such as can cause megaloblastosis and at the same time be mutagenic. Failure of the thymidylate synthelase reaction, the commonest cause of megaloblastic anaemia, can be eliminated in erythroleukaemia because (a) the dU suppression test is normal in the disease and (b) failure of the thymidylate synthelase reaction is not mutagenic. The deamination of both cytosine and adenine is mutagenic but the deamination of cytosine alone is apparent and the nucleotide of cytosine is the prime mutagenic nucleotide in leukaemia and cancer. Megaloblastic changes can result from an inadequate supply of any one of the four nucleotides that enter into the composition of DNA and it is suggested that an inadequate supply of the mutagenic nucleotide of cytosine, possibly through impaired synthesis, could cause both the megaloblastic and leukaemic changes in erythroleukaemia.

RAEB-t in young adults--a rare entity.

Refractory anemia with excess blasts in transformation (RAEB-t) in young adults is a rare entity. RAEB-t presenting with megaloblastic erythropoiesis should be differentiated from nutritional B12 and folic acid deficiency and from acute erythroleukemia. We report two cases in the present article.

Pernicious anemia: the African experience (3 cases reports). / Anémie de Biermer: expérience africaine (à propos de 3 observations).

We report three cases of pernicious anemia diagnosed in women in Africa. All three women had macrocytic anemia with megaloblasts evident on medullogram. The patients had neurological signs of combined sclerosis and the presence of megaloblasts confirmed the diagnosis of pernicious anemia. All were successfully treated parenterally with vitamins. This disease seems to be underdiagnosed in Africa given the number of cases reported in previous studies.

Congenital dyserythropoiesis characterized by marked macrocytosis, vitamin B12- and folate-independent megaloblastic change and absence of the defining features of congenital dyserythropoietic anaemia types I or III.

Four patients with congenital dyserythropoiesis characterized by marked macrocytosis, little or no anaemia, and vitamin B12- and folate-independent megaloblastic erythropoiesis are reported. Their erythroblasts also showed various dysplastic changes but not those diagnostic for congenital dyserythropoietic anaemia (CDA) types I or III. The haematological features of the four patients, who included two siblings, resemble those of a previously reported patient and together these patients form a recognizable subgroup within those cases of CDA not belonging to CDA types I-III. In two of the cases studied, and possibly a third, the inheritance was as an autosomal recessive character.

Congenital dyserythropoietic anaemia.

A case of congenital dyserythropoietic anaemia presented with recurrent jaundice and painful splenomegaly. There was binuclearity, internuclear chromatin bridges, megaloblastic changes in erythrocyte precursors and positive acidified serum test with normal serum.

Clinching the diagnosis: macrocytic anemia.

Macrocytosis is a common laboratory finding. Whether this change requires further attention is dictated by clinical circumstances and concomitant cytopenias or aberrant erythrocyte and leukocyte morphology. The utility of these changes for dictating further investigation and the appropriate "modus operandi" in diagnostic strategies for the adult and the younger patient are outlined.

Diabetes insipidus associated with dysplastic pancytopenia.

This case report describes a 60-year-old man who presented with a three-year history of generalized malaise, decreased libido, polyuria, and polydipsia. He had been previously investigated for pancytopenia, and found to have a hypoplastic bone marrow. A diagnosis of central diabetes insipidus was established; the patient was also found to have a number of other defects in his hypothalamic-pituitary function. Hematologic studies again revealed peripheral pancytopenia associated with a hypoplastic megaloblastic bone marrow. Computed axial and nuclear magnetic resonance tomography failed to establish the nature of the morphologic lesion in the hypothalamus. A possible relationship between the hematologic and endocrine disturbance is discussed.

Anemia in alcoholics.

In order to develop a diagnostic approach to the common problem of anemia associated with alcoholism, 121 chronic alcoholics admitted to a general medical service with a low hematocrit were evaluated. Multiple contributing causes of anemia were present in most patients. Megaloblastic marrow change was found in 33.9% of patients, sideroblastic change in 23.1%, absent iron stores in 13.2%, aggregated macrophage iron in 81.0%, and acute blood loss in 24.8%. The MCV was of little value in predicting the presence of megaloblastic change unless markedly elevated (greater than 110 fl). In 15 of 41 patients with megaloblastic marrow morphology (36.6%) the MCV was normal or low. Among 40 patients with MCV values between 100 and 110 fl, megaloblastic change was not present in the bone marrow smears of 24 (60.0%). Neutrophil hypersegmentation was 95% specific but only 78% sensitive for megaloblastic change; in contrast, the presence of macroovalocytosis was 90% sensitive but only 68% specific. Serum lactic dehydrogenase, plasma folate, and erythrocyte folate levels had such low sensitivities and specificities for megaloblastic change as to be of little predictive value. Hematologic responses to folic acid were often inadequate in patients with megaloblastic morphologic changes, apparently because of associated acute and chronic illness. Our findings are consistent with the hypothesis that 2 mechanisms account for the development of megaloblastic hematopoiesis in alcoholics: induction of folate deficiency and a direct toxic effect of alcohol on erythroid precursors independent of folate depletion, as reflected by the presence of normal plasma and erythrocyte folate levels in several patients with megaloblastic change. In no patient was sideroblastic change the sole apparent cause of anemia. Megaloblastic hematopoiesis and aggregated macrophage iron frequently accompanied sideroblastic change. Examination of the blood smear revealed siderocytes in one-third of patients with sideroblastic marrows and dimorphic erythrocyte morphology in the majority. Dimorphic blood smears, however, were neither sensitive nor specific for sideroblastic change. Serum iron concentrations were usually not elevated in the group with sideroblastic abnormalities. In predicting marrow iron stores, serum iron and iron-binding capacity concentrations were often non-diagnostic or misleading. Serum ferritin levels less than 100 ng/ml, however, showed 100% sensitivity and 95% specificity for absent marrow iron stores despite the frequent presence of abnormal liver function. On the basis of our findings, practical guidelines have been formulated for the evaluation and therapy of anemia in alcohol