Dr. Ahmed Tanjimul Islam. MBBS, PgD, MCPS, MD (Neurology)

1. ACROCYTIC
ANAEMIA
PRESENTED BY
DR. AHMED TANJIMUL ISLAM OVEE
HMO, DEPARTMENT OF HAEMATOLOGY,
CHITTAGONG MEDICAL COLLEGE HOSPITAL

2. Case:
• 60 year old man with Hypothyroidism
on Thyroid replacement therapy
develops Paresthesia, Fatigue,
Anaemia.
Q. What is your 1st clinical diagnosis?
• 1. Iron Deficiency Anaemia
• 2. Anaemia of Chronic Disease
• 3. Pernicious Anaemia
• 4. Folate Deficiency

3. Case:
• 60 year old man with Hypothyroidism
on Thyroid replacement therapy
develops Paresthesia, Fatigue,
Anaemia.
Q. What is your 1st clinical diagnosis?
• 1. Iron Deficiency Anaemia
• 2. Anaemia of Chronic Disease
• 3. Pernicious Anaemia
• 4. Folate Deficiency

4. Macrocytic Anaemia found in
Almost Every Department of
Hospital yet remains the LEAST in
the PRIORITY LIST !

5. • Case to a General Practitionar :

6. • Reffered to Haematologist:
55 yrs , Iron Non responsive Anaemia, Severe
Weakness, Paresthesia.

7. • Reffered to Neurologist:
Difficulty in Walking, Weakness, Ataxia, Paresthesia.

8. • Reffered to Dermatologist:
Vitiligo, Alopecia. Pale lusterless Skin, Weakness

9. • CASE to a GASTROENTEROLOGIST:
Chronic DiarrhoeaRecent onset Weakness, Depression

10. • Reffered to Pediatritian:
Back translucent swelling

11. Case to Obstetritian :

12. • Reffered to Psychiatrist:
SEVERE WEAKNESS
HALLUCINATION
DEPRESSION
PSYCHOSIS

13. PERIPHERAL BLOOD FILM

14. BONE MARROW EXAMINATION

15. ‘MACROCYTIC
ANAEMIA ‘

17. •WHEN IT BECAME A
HEADACHE FOR
MANKIND ?

18. •WHEN IT BECAME A
HEADACHE FOR
MANKIND ?
Answer : 1919-1921

19. Norman Warne 1919
1919

20. Suzzan Lenglen 1920
25 times Wimbledon Champion
1920

21. Alexander Graham Bell . 1921
1921

22. • 1850 : Thomas Edison
• 1926: Murphy (NOBEL PRIZE)
• 1941: Folic Acid
• 1948: Crytaline B12 ( NOBEL PRIZE )
• 1956: Dorothy Hodgkin (NOBEL PRIZE)
Chemical Structure of B12
DOROTHY HODGKIN MURPHY

23. 5%

25. • MEGALOBLASTIC ANAEMIA
• PERNICIOUS ANAEMIA

26. • MEGALOBLASTIC ANAEMIA
• PERNICIOUS ANAEMIA
• VITAMIN B12 DEFICIENCY
• FOLIC ACID DEFICIENCY

30. 0
10
20
30
40
50
60
70
80
90
100
Neurological Paresthesia Weakness Dyspnea

31. SCD
DEMNTIA
PERIPHERAL
NEUROPATHY
PSYCHIATRIC
PERIPHERAL NEUROPATHY
73%
SCD

32. Weakness (<160 m gm)
Dyspnea (<120 mgm)
Paresthesia (<100 mgm)
Megaloblastic Madness (psychiatic)
Neurological Deficit (< 60 mgm)

36. Hypersegmented neutrophil
Macro ovalocytes

40. Messed Up with
Investigation Sheet ?

42. VITAMIN B 12
DEFICIENCY

44. Important for DNA synthesis,
nervous tissue and fat metabolism
in the liver
an intermediate of the citric
acid cycle, porphyrin synthesis
(Heme synthesis)

52. T2 PHASE MRI OF SPINAL CORD
POSTERIOR COLUMN LESION
EASILY CONFUSED WITH ‘MS’

53. FOLIC ACID
DEFICIENCY

60. ‘PERNICIOUS
ANAEMIA’

61. Pernicious Anaemia:
• Autoimmune Destructon of Parietal Cells.
• Antibodies against
1. Parietal Cells,
2. Intrinsic Factor.
• Achlorhydria is Universal.
• Increased incidence of Gastric Cancer.
• Often associated with other Autoimmune diseases
like Hashimoto’s Thyroiditis, Vitiligo.

62. Pernicious Anemia
• Vitiligo

63. Normal Gastric atrophy
PA

64. SCHILLING TEST

67. TREATMENT:

69. CAUTIOUS BLOOD TRANSFUSION
Hb <6 gm/dl
S/S Heart Failure

71. B12 Deficiency: Treatment
• IM B12 1000mcg Daily x 1 wk
– then 1000mcg Weekly x 1 month
– Then 1000mcg Monthly for life for PA
• Oral high dose 1-2 mg daily
– Less reliable than IM
– Only recommended after
full parenteral repletion
• Sublingual, nasal spray and gel formulations
available.

74. Reticco
unt

75. Folic Acid Deficiency dose :

76. DIAGNOSTIC ALGORITHM:
• PBF with RETICULOCYTE
• B12 LEVEL + FOLATE LEVEL
• HOMOCYSTEINE LEVEL
• METHYMELONIC ACID (MMA) LEVEL
• INVESTIGATION FOR OTHER CAUSES
(Alcohol, Hypothyroidism, Liver, Renal, MDS etc)
NORMAL
COBALAMINE 200-900
FOLATE 2.5-20
MMA 70-270
HOMOCYSTEINE 5-16 UM

77. P.A.S BRITISH SOCIETY FOR RESEARCH & AWRENESS

78. PERNICIOUS ANAEMIA AWARENESS

79. FREQUENTLY
ASKED
QUESTIONS

80. •Is Schiling’s Test is a
must test ?

81. IS NORMAL BLOOD COUNT
CAN RULE OUT B12
DEFICIENCY?

82. IS MACROCYTE in
PBF IS A MUST ?

83. WHAT IS THE
PROBLEM WITH
HIGH FOLATE with
LOW B12 ?

84. •WHY IT IS MORE
COMMON IN
DEVELOPED
COUNTRY ?

88. Take Home Message:
• A Slowly Developing Anaemia, Well Compensated.
• Must find Underlying Cause to prevent reversal.
• Response to Therapy Very Rapid.
• Only Folic Acid will not give inprovement in B12
deficiency.
• Neurological complications is Stabilized with
treatment but NOT REVERSED.

89. THANK YOU