Week 4: Macrocytic Anemia  Macrocytosis  Vitamin B12  Folic acid  Megaloblastic changes  Pernicious anemia  Schilling test  Hypersegmented PMN  Bone marrow analysis  WBC precursors  Liver disease  Polycythemia and erythremia  PV  Newborn CBC

Bone Marrow Analysis  Aspirate  Particles in fluid part of marrow  Differential count  Biopsy  Solid part of the marrow  Cellularity  Clot section

Aspiration Biopsy

WBC Precursors  Myeloblast  Promyelocyte  Primary azurophilic granules  Meylocyte  Specific granules  Metamyelocyte  Band, stab  Segmented neutrophil, PMN

Promyelocyte Myeloblast Neutrophilic Myelocyte

Segmented neutrophil and lymphocyte

Mast cell and histiocyte Mast cell Megakaryocyte Plasma cell

Histiocyte Fat cell Macrophage

Osteoblasts Giant cell Osteoclasts

Non-Megaloblastic Macrocytosis  Alcoholism  Poor nutrition  Cirrhosis  Liver disease  Reticulocytosis  Hemolytic anemia  Hemorrhage

Megaloblastic Anemia  Hemolytic changes  Waxy pallor  Neurologic changes with B12 deficiency  Glossitis, beefy red or smooth pale tongue

Causes of Megaloblastic Anemia  Folate deficiency  Dietary (green leafy vegetables)  Malabsorption  B12 deficiency  Dietary  Fish tapeworm (

D latum

)  Pernicious anemia  Lack of gastric intrinsic factor (IF) for absorption

B12 Metabolism  Bind to cobalophilin (cobalamine binding protein) in saliva and gastric secretion  Bind to IF (from parietal cell) in the duodenum  Cbl-IF complex bind to receptor (cubilin) at distal ileum for mucosal absorption  1% B12 can be absorbed without IF (megadose of B12 for IF deficiency, no need for IV)

Autoimmune mechanism for PA

Megaloblastic Lab Changes  MCV up to 140 fL  Howell-Jolly bodies and Cabot rings  Hypersegmented PMN  Pancytopenia  BM with low M:E ratio  Megaloblastic morphology (giant bands and metas)  B12 and folate assays  RBC folate (long term indicator)  IF antibody (PA)  Schilling test (obsolete)

Megaloblastic anemia Hypersegmented PMN Megaloblastic BM

Other Apparent Macrocytoses  Cold agglutinin  Prewarm samples  Hyperglycemia  Osmotic changes  Clot  Rouleaux

Polycythemia Vera  A type of myeloproliferative disorder (MPD)  Independent of EPO  High total RBC mass (by radio tagging)

Secondary Polycythemia  Dehydration (decreased plasma volume)  Increased O 2 demand (e.g., emphysema, high elevation)  High EPO (e.g., kidney tumor)