February

2, 2016

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

I.
II.
III.
IV.

Qualitative evaluation
Quantitative evaluation
Classification of anemias
Common anemias

4.

I. QUALITATIVE EVALUATION
m Blood smear distribution we analyzed the:
o Shape
o Arrangement
o Color of the cells
o Number of the cells that can be found in the
smear

Hb CC Crystals
10

HB SC Crystals
11

*Specimen: WHOLE BLOOD in EDTA tube; Peripheral Blood Smear (CBC)

To check for the NORMAL MORPHOLOGY
*8-20 platelets/field (Oil Immersion Objective)
*Normal color of RBC (if stained) (pink or bluish color) WRIGHTS Stain
*Poikilocytes variations in shape of cells
*Anisocytes variations in size
*Anisochromasia variations in colors

Basics of Qualitative Evaluation of RBC

1.

Developmental variation
Presence of Macrocytes and Microcytes

*Maturation sequence of the RBC or WBC

*The LARGER the CELLS the MORE IMMATURE

2.

Membrane abnormality
Examples:

Echinocytes
aka Crenated RBC
Condition occurs only in RBC that has been placed
1
under Hypertonic NaCl solution (0.9%)

Burr Cell
RBC with Reversible thorn-like projection and
2
somewhat elongated
Achantocytes
aka Thorn cell, Spur cell
found in patient with abetalipoprotein
3
aka Ovaloytes
Elliptocytes
4
found in Pernicious anemia

Stomatocytes
aka Mouth cell

found in Hereditary Stomatocytes, Alcoholism, &
5

Liver diseases
Spur Cell 3
(same with Achantocytes)
Pernicious anemia (Hypersegmented Neutrophils) [5-10 lobes]

3. Trauma formation of:
aka Fragmenting or Disintegrating RBC
Schistocytes
found in Hemolytic Anemia, Patient with sever
6
burns & suffers with Disseminated Intravascular

Coagulation Syndrome (DIC)
Keratocytes of besis aka Triangle cell, Contracted RBC, Helmet cell
7
results after the blistered or ruptured blister cell
aka Pessary cells, Anulocyte
Ghost cell
8

RBC with thin rim of Hb with clear central area

Seen in Iron Deficiency Anemia

aka Sickle cell, C shape, Crescent shape,

Menischocyte
found in Sickle cell anemia, disease
Refers also as Resistant cell, Irreversible reaction
Dark staining hexagonal crystals with blunt ends
inside the cell membrane leaving the cell relatively
free and colorless
Seen in Hemoglobin C disease especially after
Splenectomy
Dark-hued crystals with parallel sides, one blunt,
pointed, protruding end due to condensed
hemoglobin
Washingtons monument
Seen in Hemoglobin SC disease

Dacrocytes Tear drop cell

5.

m Individual morphology of RBC includes:

o Hemoglobin
o Content
o Shape
o Size of RBC

Abnormal Hemoglobin content

Drepanocytes

Inclusion categorized into 3

a. Developmental

Howell-jolly

Pappenheimer

Basophilic stipplings and Retics(Fine

reticulum of RNA)
b. Abnormal Hb precipitation
c. Presence of parasite enlargement of
normal size RBC in the presence of parasite

Howell-jolly
bodies
12

Pappenheimer

13

Basophilic
stippling
14

Heinz bodies
15

Parasite

16

Bar of Gold Crystals Hemoglobin C

Remnant of the Nucleus

Prussian blue stain & Perls reagent
Conditons: severe Hemolytic anemia, Pernicious
anemia, Megaloblastic anemia, Iron deficiency
anemia
aka Siderocytic granules/bodies or Siderocytes
Condtions: Thalassemia, Sideroblastic anemia
aka Punctate Basophilia
Indication of Lead poisoning
Conditions: Megaloblastic anemia, thalassemia &
Alcoholism
(Heinz-erlich bodies)
denatured Hemoglobin
conditions: Sickle cell anemia, G6PD, Hemolytic
anemia, Post spleenectomy
cause by Plasmodium spp. (Malarial parasite)
P. malariae Ziemmans / Christopher dots
P. falciparum Maurers dots
P. ovale James dots
P. vivax Schuffners dots

*other Parasites: Babesia spp. & Trypanosomes

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

C. Morphological classification

II. QUANTITATIVE EVALUATION

1.

A. Anemia Due to DECREASE RBC; disorder characterized by O2

B. Erythrocytosis

*Due to:

III. CLASSIFICATION OF ANEMIAS

Anemia disorder characterized by the O2 carrying capacity of the RBC (Decrease
RBC count, Hemoglobin, Hematocrit)

A. Classification of Anemia base on Etiology

1.
2.

3.

4.

Relative anemia (Pregnancy, Menstrual period)

Defective Hb synthesis:
Iron Deficiency Anemia (IDA)
Siderocyte
Non-heme iron deposit Pappenheimer Bodies
Thalassemia
Deficiency in vit.B12 & folic acid(Megaloblastic Anemia)
Normal RBC: 6.2 8.2 m

Giant RBC: > 9 m
Impaired Bone marrow function
Examples:
Aplastic anemia bone marrow injury / drugs (Idiopathic)

2.

3.

4.

Macrocytic
Normochromic

Macrocytic
Hypochromic

Blood loss

(due to: Hemorrhage, Bleeding or any Type of Blood Loss

B. Classification of Anemia base on

Physiology
Ineffective erythropoiesis
If the Reticulocyte Production Index (RPI) is
lower than 2.0

Patient with Hypoproliferative Anemia;

Decrease production of Red cell & maturation disorder

Macrocytic Normochromic
Increase of MCV and MCH but normal MCHC
*Due to:
Pernicious Anemia

Myelophthisic anemia (bone marrow replacement)

Ineffective hematopoiesis(Px with Myelodysplastic Anemia) Young Proliferation of cells

Decrease BM stimulation (Px with Renal Failure; Decrease Release of Blood Cells
5. Macrocytic Hypochromic
Constitutional/ congenital anemia
Increase of MCV but decrease of MCH and
(Diamond Black fan type Anemia Fanconis anemia & Familial Aplastic
Anemia); Under HA
MCHC
Acquired Pure Red Cell Aplasia (PRCA) (Thymoma)
*Due to:
Folate Deficiency Anemia
It has PALE RBC or Hemoglobin distribution
Paroxysmal Nocturnal Hemoglobinuria (PNH)
(Presence of Hemoglobinuria); Pre-leukemic; Under HA


Decreased RBC survival
MCV
MCH
MCHC

2 conditions associated with are:

Normocytic
Normochromic
N
N
N

Intrinsic factor (inside cell)

(ex. Enzyme deficiency & Hemoglobinopathy)

Microcytic Normochromic
N

Extrinsic factor (outside cell)

(Could be due to IMMUNE[Antibody Destruction] &

Microcytic
Hypochromic

2.

Chronic inflammation

Microcytic hypochromic anemia
Decrease in MCV, MCH, MCHC
*Due to ATIS: Anemia of Chronic disease

Thalassemia

Iron Deficiency Anemia

Sideroblastic Anemia

NON-IMMUNE[Hypotonic solution] Mechanism

1.

Microcytic Normochromic anemia

Decrease of MCV and MCH but Normal MCHC
*Due to:

6.

Hemolytic anema
Sickle cell anemia
Hemorrhage
Hemodilution
Aplastic anemia
Hemoconcentration

*Drugs Chloramphenicol(drugs against malaria) or

Too much exposure to Radiation

5.

Normocytic Normochromic anemia

Normal MCV, MCH, MCHC
But there is proportionate decrease in RBC,
hemoglobin and hematocrit

Effective erythropoiesis
If the RPI is greater than 3.0

RBC easily destructed just to compensate RBC.

Cause immediate reaction

Kidneys very sensitive to Hypoxia
Ex. Hemolytic anemia (easily Lyse because of Low pH)

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

RBC Indices J
!

I. Aplastic Anemia

Mean Corpuscular Volume (MCV)

W
The description of individual cell size and is the best index for

m Formed due to functional inability of the bone

marrow to replace the RBC
o Normocytic, Normochromic
o Leucopenia
o Thrombocytopenia
o Pancytopenia

m Causes of Aplastic Anemia
o Ionizing Radiation
o Tumor of the Thymus
o Exposure to radicals:

Naphthalene

Arsenical (pesticides)

Benzene

BENZENE in soft drinks has to be

seen in the context of other
environmental exposure.

Taking the worst example found to

date of a soft drink containing 87.9
ppb (Polybrominated biphenyl)
benzene, someone drinking a
350mL (12oz) can would ingest 31g
(microgram) of benzene, almost
equivalent to the benzene inhaled
by a motorist refilling a fuel tank for
3 minutes.

According to the World Health

Organization (WHO), this exposure
can cause Reproductive and
developmental problems, damage
the highest levels of these
compounds are found in soils,
sediments, and food such as dairy
products, meat, fish, and shellfish

Chlordane

m Congenital / Hereditary
o Diamond black fan type
o Viral heap
o Oncogenic virus

m Idiopathic
m Decrease Osmotic Fragility Testing (OFT)

classifying anemias.

W
W

Expresses the volume occupied by a single red cell.

Reference range: 82-92 fl (femtoliter)

Mean Corpuscular Hemoglobin (MCH)

W
A measure of the average weight of hemoglobin in the RBCs.
W
Is of value in diagnosing severely anemic patients
W
RR: 27-32 pg (picogram)

Mean Corpuscular Hemoglobin Concentration (MCHC)

W
The measure of the average concentration of hemoglobin in

W
W

the RBCs.
Most valuable in evaluating the therapy for anemia because
the two most accurate hematologic determinations are used
for calculating this test.

RR: 32-38%

D. 4 Classification of Anemia according to

Cause
1)

Due to decrease RBC production

*Problem in Bone Marrow/Renal disease; APLASTIC ANEMIA

2)

Due to hemolysis of RBC

*HEMOLYTIC ANEMIA observe characteristic of RBC is
SPHEROCYTE(Microcytic cells; No Central Pallor; aka as Fragile cell

3)

Due to nuclear maturation abnormality

4)

Due to cytoplasmic maturation abnormality

*No proper maturation of RB; ex. PERNICIOUS

ANEMIA(Multinucleated/Hypersegmented neutrophil)
*Thalassemia; patient with problem in Iron Deficiency Anemia
Problem in Cytoplasm because of No Proper Maturation
*Poikilocyte problems: Target cell, Bulls eye, Mexican Hat cell,
Codocytes

IV. COMMON ANEMIAS

i.
ii.
iii.
iv.
v.
vi.
vii.

Aplastic Anemia
Hemolytic Anemia
Sickle Cell Anemia
Thalassemia
Severe Iron Deficiency Anemia
Pernicious Anemia
Folic Acid Deficiency Anemia

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

B.

II. Hemolytic Anemia

m Formed due to excessive destruction and shortening
of the life-span of the RBC, it can be an acquired or
congenital type

m Causes:
a. Due to the presence of the antibodies

*(Multiple Blood Transfusion)

2)

*Hemolytic disease of the New Born

5)

Chemicals
*Benzene, Lead, Aniline dyes

6)

Mechanicals
*Extraneous exercise

7)

Physical age
Burns, too much exposure

Normocytic, Normochromic
Very high retics count
Increase of NRBC
Increase of Osmotic Fragility Index
Presence of Poikilocytosis
Inclusion bodies: Howell-jolly bodies J

m 2 common types of Hemolytic Anemia
1. PCH (Paroxysmal Cold Hemoglobinuria)
Associated with exposure to cold temperature
due to the presence of cold agglutinin
antibodies also called Donath Landsteiner
hemolysin that fixed in the RBC at cold
temperature and causes lysis in body
temperature.
They exhibit tea colored urine sample
m
m
m
m
m
m

2.
-

Hexose monophosphate
shunt transfer of
glucose to the cell
s Ex. G6PD
Enzyme involve in
methemoglobin
formation Glutathione
synthetase

Infection
Drugs
*Antimalarial drugs such as salicylate &
Chloramphenicol; may lead to HA

Due to toxins/poisons
Due to drugs
Due to inherited intracorpuscular anomaly
affected are the enzymes

m 2 Main Division that Causes HA
A. Intrinsic/Corpuscular defect the problem
is the RBC itself

1) Defect in the cell membrane
o Examples:
o PNH (membrane defect)
o Hereditary spherocytosis
o Achantocytosis
o Elliptocytosis
o Zeives syndrome

2) Defect intracellular enzyme (Nonspherocytic HA) enzyme involve
in:
o Anaerobic glycolysis
s Hexokinase
s Phosphohexose
isomerase
s Phosphoglycerate
kinase
s Pyruvate kinase
o

Paroxysmal Cold Hemolysis (PCH)

*During cold temperature; Lysis of RBC

3)
4)

b.
c.
d.

Extrinsic/Extracorpuscular defect eternal

factor that can cause hemolytic anemia
1) Acquired autoimmune HA

PNH (Paroxysmal Nocturnal Hemoglobinuria)

Associated with complement mediated
hemolysis
Due to a decrease of activity of acetylcholinesterase enzyme that is found in the cell
membrane
Hams Acidified Serum Test
aka Marchiafava-Micheli Syndrome

GEN CAMATO

February 23, 2016

ERYTHROCYTE STUDIES
HEMATOLOGY 2

III. Sickle Cell Anemia

IV. Thalassemia

m due to the presence of HbS variant that causes

sickling of RBC under reduce Oxygen tension
m it may cause vaso-occlusive crisis
m Blood picture:

Presence of sickle cell

Poikilocytes

Thrombocytosis

Neutrophilia

Anisocytosis

Decrease OFI

Inclusion bodies

Normocytic Normochromic

m Due to abnormal production rate of one of the

polypeptide chain of hemoglobin molecule. It can be
the alpha or the beta
m Also known as:

Cooleys anemia

Hereditary leptocytosis (predominant cell Is

target cell)

Mediterranean anemia
m Beta and Alpha thalassemia common in Southeast
Asia
m 2 classification of Thalassemia

Beta thalassemia

Alpha thalassemia

Beta thalassemia
m Cause by point mutation that results in premature
chain termination or abnormal transcription of RNA
that leads to the formation of reduce/absence of
-globin chain
m -thalassemia major predominance of hbF
m -thalassemia minor predominance of HbA2
m Sickle cell can be categorized as:
1. Homozygous SC presence of 2 Hbs
2. Heterozygous SC carrier, they have the sickle
cell trait

Thalassemia major/Homozygous thalassemia

m Results from either a decrease or an absence in chain production by both gene alleles

With a decrease in beta chain production, chain production is high which results in
increased Hb F.

Excess of alpha-chains due to lack of

matching beta chains

Clinical symptoms

m Test for Sickle Cell Anemia

A. Scriver and Waugh method

Simple test for Sickle cell

B.

Daland and DaSilva

Best method

Chemical deoxygenizers

2% Ascorbic Acid

2% Na Methabiosulfate

2% Na dithionite

C.

Shermans method

Uses 2 mL formol saline solution

1 mL mineral oil (to prevent the entrance of

oxygen; for adhesion)

1 mL blood

Stand for 1 hour

% =

#
100
100

HbS + HbA *should not be in the circulation J

INTERPRETATION:
* if 40% is observed after an hour the patient has SC anemia
* 1% of SC after an hour Sickle cell trait
* <40%, wait for 6 hours, then observed again

Jaundice
Splenomegaly
Prominent frontal bones (cheek, jaws)
Chronic marrow hyperplasia
Stunted growth
Delayed puberty
Hemochromatosis
Cardiac failure (major cause of death)
Due to myocardial siderosis by 30 years
of age

* Microcytic/Hypochromic anemia

* Extreme poikilocytosis and anisocytosis (target cells, ovalocytes,

howell-jolly bodies, normoblasts, siderocytes, cabot rings)

* Reticulocyte count is less elevated than what would be expected

b/c of destruction of erythroid precursors in the marrow

* Osmotic fragility test is decrease

* Serum iron is increased

* Indirect bilirubin is increased
* MCV is decreased with an increased RDW

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

Thalassemia minor/Heterozygous
-thalassemia

Hb H disease/ Alpha-Thalassemia
Major

m Results from the absence or decrease in beta-chain

production at one gene allele

From severe microcytic/hypochromic

anemia to normal clinical findings

Slight haemolytic jaundice and

splenomegaly
m Hematologic Profile:

RBC count is increased and Hb and Hct are

reduced

RBC indices are below normal and RDW is

increased

Smear shows moderate poikilocytosis,

target cells, and basophili stippling

Osmotic fragility is decreased

Serum iron levels are normal to high

m Thalassemia in which three of the four alpha-globin

genes are absent (--/-)
m Patients who have this disorder have a chronic
haemolytic anemia
m Hematologic characteristics include: decreased MCV
and MCH, hypochromia and target cells on the
blood smear, moderate anisocytosis and
poikilocytosis, reticulocyte count of 4%-5%,
moderate Heinz bodies (Hb H precipitates)

Alpha-Thalassemia Minor

Beta-Thalassemia

m Result from a partial or total decrease in the

production of alpha chains
m Mild alpha-thalassemia, is a deletion of only one
gene; represented as /
m Severe alpha-thalassemia is a deletion of two alpha
globin genes, and is represented as --/
m HYDROPS FETALIS ,with Hb BARTS- most severe
form of alpha-thalassemia. Individuals of this form
have a diploid genotype of --/-- which represents the
absence of all alpha chains
m The absence of all alpha chains is incompatible with
life and infants who have this disorder are stillborn
or die soon after birth
m Display of electrophoretic pattern:

Hb A, Hb F, and Hb A2= NONE

Hb Barts: greater than 80%

m Clinically mild and resembles beta-thalassemia

minor.
m Genetically, patients are lacking two of the four
alpha-globin genes
m --/ or /-
m Patients have mild anemia, microcytosis, and normal
serum iron
m Electrophoretic pattern shows:
I.
Diagnosis is made by finding 5%6% of Hb Barts in cord blood
II.
Adults show no evidence of an Hb
imbalance

m

SILENT CARRIER OF ALPHA-THALASSEMIAS- represents a

disorder that has only one defective alpha-globin gene (/ ) and is not associated with any hematologic
abnormalities

HEMOGLOBIN CONSTANT SPRING (Hb CS) is an alphachain variant with 31 extra amino acids

Alpha chains are functionally normal but

synthesized more slowly, and therefore present
a clinical picture of thalassemia

Hb CS migrates slower than HbA2 at an alkaline

pH
-Thalassemia facial bone abnormalitites. These chsnges include
bossing of the sku;;; hypertrophy of the maxilla, exposing the
upper teeth; depression of nasal bridge; and periorbital puffiness.
-Thalassemia major. Note the pallor, short stature, massive
hepatosplenomegaly, and wasted limbs in this undertransfused
case of -thalassemia major.

March 8, 2016

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

m Three Stages of IDA

Iron depletion stage

beginning of iron deficiency. A

negative iron balance develops,
and iron is mobilized from iron
stores. When this process begins,
storage iron decreases, plasma
ferritin decreases, GI absorption
increases to a limited extent, &
amount of plasma ferritin (TIBC)
increases

Iron deficient erythropoiesis stage

occurs when tissue iron stores are

depleted. When transferrin
saturation falls, below 15%, the
percent of marrow sideroblasts
decreases; serum iron is
decreased, & levels of RBC
photoporphyrin increase

V. Severe Iron Deficiency Anemia

m Due to depletion of iron storage in the body, needed

for normal Hemoglobin production
m Causes:
1. Due to poor diet that leads to poor iron intake
2. Due to faulty absorption
3. Excessive iron loss
4. Due to excessive iron demand
m Iron Metabolism-Associated disorders

Most commonly occur as a result of an iron

deficiency but can result from a block in the
enzyme that inserts iron (ferrochelatase)
into the heme ring.

Iron and its metabolism is vital to the body

because a Hb molecule is non functioning
without iron and two thirds or more of the
total body iron is in the RBCs and their
precursors

Each milliliter of RBCs contains 1 mg of iron

Storage iron is present in macrophages or

normoblasts as ferritin or hemosiderin

Recycle Hb is transported to normoblasts by

plasma transferrin

Only 0.9 1.3 mg of iron per day is lost

from the body

m Iron Deficiency Anemia

Results when iron loss exceeds iron intake

for a long time and the bodys iron stores
are depleted.

Iron deficiency develops when there is an

increased need for ironm such as in rapid
growth in infancy, childhood, or during
pregnancy

Most common in children who are between

the ages of 6 and 24 months

Develops when there is excessive chronic

loss of blood

m clinical Signs and Symptoms IDA

Numbness and tingling of extremities

Atrophy of the epithelium of the tongue

with soreness

Cracks or ulcers at the corners of the mouth

Concave or spoon-shaped nails

Pica

m Laboratory Diagnosis IDA

Peripheral Blood:

microcytic/hypochromic RBCs with

marked anisocytosis and slight
poikilocytosis

Reticlocytes are decreased

MCV is low and RDW is increased

Serum iron is decreased; TIBC is

increased (NV: 250-400 mg/dL)

Intracellular protoporphyrin IX is
increased

Bone Marrow:

Normoblasts are smaller than

normal

Storage iron is absent

Sideroblasts are decreased to

lower than 20%
7

By the IDA stage

a clinical anemia becomes

detectable as
normocytic/normochromic anemia,
then gradually progressing to a
microcytic/hypochromic anemia

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

m Blood picture:

Microcytic hypochromic

Anisocytosis

Poikilocytosis

Decrease of OFI

Thrombocytosis

Increase Total Iron Binding Capacity (TIBC)

m Primary Familial Hemochromatosis

Condition of iron excess that results from

an abnormality in a gene on chromosome 6

Increase in absorption by intestinal mucosal

cells

Increase serum iron level, increase

transferrin saturation, iron-loading in
macrophages and hepatocytes

m SIDEROBLASTIC ANEMIA

disorder of iron excess that is associated

with defective synthesis of heme because of
multiple enzyme defects, and a resulting
iron overload in the mitochondria of
normoblasts.

Patients RBC morphology: hypochromic

and often microcytic

Increased serum iron levels, decreased

TIBC, and greatly increased transferrin

Increased sideroblasts greater than 50%

Disorder

Serum Iron

Iron
Deciency
Anemia

Decreased

Anemia of
chronic
disorders

Decreased

Sideroblas4c
anemia

Increased

Thalassemia

Normal to
increased

TIBC

% Satura4on

Ferri4n

Bone
Marrow Iron

Increased

Decreased

Decreased

Decreased

Normal to
decreased



Decreased



Normal to
decreased

m UIBC (unsaturated iron binding capacity)

A measure of the reserved iron binding

capacity of transferrin

Formula: TIBC serum iron

m Percent saturation

It is also known as the transferrin

saturation; an index of iron storage

It is the ratio of serum iron to TIBC

Formula:
% =

Normal to
decreased

Normal to
increased

Normal to
increased

Increased

Increased

Increased

Normal to
Increased

Normal to
increased

Normal to
increased

!!"# (!"/!")

100

Increased:

Iron overdose

Hemochromatosis

Sideroblastic anemia
Decreased:

IDA (lowest % saturation)

Malignancy

Chronic infection

Anemia of chronic disease

Reference value:

20 50%

m Serum transferrin

Transferrin is the principal iron transport

protein

Formula:
TIBC (/) x 0.7 = /

It refers to the amount of iron that could be

bound by saturating transferrin and other
minor-iron binding proteins present in the
serum plasma sample
IDA has high TIBC; non-iron anemias has
low TIBC
Anemia of chronic infection has low or
normal TIBC

!"!#$ !"#$ (!"/!")

m TIBC

All TIBC methods require addition of excess

iron to saturate transferrin
Excess iron is then removed by adding
magnesium carbonate to measure the
bound iron
Reference value:

245 425 g/dL (adult male and

female)

10 250 g/dL (>40 years old)

100 250 g/dL (new born and

child)
Formulas: TIBC = UIBC + serum iron
Increased:

IDA

Hepatits

Iron-supplemented pregnancy
Decreased:

Non-IDA

Nephrosis

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

VI. Pernicious Anemia

VII. Folic Acid Deficiency Anemia

m Is a conditioned nutritional deficiency of B12

caused by failure of the gastric mucosa to secrete IF
m Also called macrocytic or megalocytic anemia or
Addisonians anemia
m There is 3x increase of RBC production in bone
marrow but the rate of release remains constant
m PA is an inherited disorder, most commonly
occurring in persons older than 40 years.
m 2 types of autoantibodies have been identified in PA
patients
1. Autoantibody that is directed against the
parietal cells
2. Autoantibodies can develop that are
directed against IF or vit. B12 complex

m Most common cause due to:

1. Inadequate dietary intake of folic acid
2. Alcoholism
3. Anorexic patient
4. Those patient who do not eat fresh foods
and vegetables
5. Overcooking of food may attribute to this
deficiency

m Sources. Folate is primarily acquired from the diet
in such food as eggs, milk, leafy vegetables, yeast,
liver, and fruits. A smaller percentage is formed by
intestinal flora.
m Minimum daily dietary requirement has been set at
50 mg. Dietary ingestion just barely meets the
minimum daily requirement. The bodys reserve
lasts for only 3 months.
m Storage. Liver tissue is the main storage site of folic
acid
m Normal serum reference values are 5-21 ug/L, and
150-600 ug/L for RBC folate
m Deficiency in Folic Acid:

Can occur within weeks, as compared with

years for a Vitamin B12 deficiency

A megaloblastic anemia caused by folate

deficiency is most commonly due to
insufficient dietary intake

A womans demand for folate increases

during pregnancy, and pregnant women
should receive folate supplements of
approximately 500 mg/d

Leukopenia and thrombocytopenia; less

common with folate deficiency
m Causes of Deficiency: FOLATE

LIVER DISEASE associated with alcoholism;

differential diagnosis is necessary to
distinguish this from anemia of liver
disease; which has a normal folate but is
macrocytic with a normoblastic marrow

DEFECTIVE ABSORPTION can result from

malabsorption syndromes; adult celiac
disease

INADEQUATE UTILIZATION of folate in the

body can be blocked with chemotheraphy
drugs (methotrexate) which are folic acid
antagonists. In addition to inhibit tumor
growth, chemotherapeutic drugs also
produce megaloblastic anemia.

m Other causes of PA

Gastrectomy

Removes the source of IF and

results in megaloblastic anemia if
vit. B12 supplements are not
provided

Defective absorption of vit. B12

into the intestinal mucosal cell can
result in a secondary vit. B12
deficiency even if dietary intake is
normal

Fish tapeworm

Bacterial infestation in a blind loop

of the intestine
m Blood picture:

Macrocytic Normochromic

Leukopenia

Thrombocytopenia

Pancytopenia

Inclusion bodies

Shift to the right

Anisocytosis

Poikilocytosis

m Laboratory diagnosis base on characteristics

1. Study the peripheral blood smear
2. Consider achlorhydria after histamine
stimulation
3. Megaloblastic dysplasia of the BM
4. Low concentration of Vit. B12 in urine
5. Low conc. Of Vit. B12 in serum
6. BM aspirate, serum, urine are the specimen
needed for the determination of pernicious
anemia

GEN CAMATO

ERYTHROCYTE STUDIES
HEMATOLOGY 2

m There is increased requirement of folate in the

following conditions:
1. Pregnancy
2. Patient with Hemolytic Anemia
3. Patient with exfoliative skin disease
4. Patient who do not meet the normal diet
requirement of folate

m Blood picture:

Similar to pernicious anemia however their

morphological classification is different

Macrocytic Hyperchromic

m LABORATORY PROFILES FOR DNA DISORDERS

DISORDER
CHARACTERISTICS

Megaloblas*c Anemia
-Marrow has enlarged precursor cells
-Blood smear shows: macrocytes
mixed with microcytes, moderate
anisocytosis and poikilocytosis,
dacryocytes, basophilic sJppling,
howell-jolly bodies, cabots rings, and
a few NRBCs

Vitamin B12 Deciency

Folic Acid Deciency

-Pancytopenia
-Low RBC count
-Low haemoglobin, haematocrit
-MCV > 100 fL
-increased to normal MCH
-Leukopenia with hypersegmentaJon
of neutrophils
-Mild thrombocytopenia
-Increased serum iron

-Same characterisJcs as
megaloblasJc anemia

-Serum Vit B12 assay value <100 ng/L

(NV: 200-900 ng/L)
-Increased urinary methylmalonic
acid
-Schilling test* can indicate an IF
dysfuncJon or PA

-Leukopenia and thrombocytopenia

are less common than with Vit B12

-Serum folate <3 ug/L (NV: 5-21 ug/L)

-RBC folate <150 ug/L (NV: 150-600
ug/L)
-Urinary forminomonoglutamic acid
level is increased

10

LABORATORY PROFILE