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Medicine 5th year, 7th lecture/part two (Dr. Sabir)
 

Medicine 5th year, 7th lecture/part two (Dr. Sabir)

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The lecture has been given on Mar. 27th, 2011 by Dr. Sabir.

The lecture has been given on Mar. 27th, 2011 by Dr. Sabir.

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    Medicine 5th year, 7th lecture/part two (Dr. Sabir) Medicine 5th year, 7th lecture/part two (Dr. Sabir) Presentation Transcript

    • MEGALOBLASTIC ANEMIAS Dr. Sabir
    • MARROW FAILURE
      • Metabolically highly active, 2º to rapid cell turnover
        • White cell life span 12-24 hours
        • Platelet life span 7 days
        • Red blood cell lifespan 120 days
      • Any slowing of DNA production  marrow failure
    • MEGALOBLASTIC ANEMIA
      • Hemoglobin production probably normal
      • Defect in nuclear replication & division
      • Affects all marrow elements
    • MEGALOBLASTIC ANEMIA
      • Trademark cell: Oval macrocyte, (MCV > 100 fl)
      • Hypersegmented neutrophils - 98%
      • Pancytopenia, esp if anemia severe
      • Reticulocytopenia
      • LDH elevated (90%)
      • Serum Fe normal or elevated
      • Serum B 12 or folate low
      • Marrow  classic megaloblastic changes
    •  
    •  
    •  
    • MEGALOBLASTIC ANEMIAS Causes
      • 1. Vit . B 12 deficiency
      • 2. Folic acid deficiency
    • VITAMIN B 12 AND FOLIC ACID-PHYSIOLOGIC CONSIDERATIONS
      • V itamin B 12 F olic acid
      • Sources meat, fish green vegetables, yeast
      • Daily requirement 2-5 ug 50-100 ug
      • Body stores 3-5 mg (liver) 10-12mg (liver)
      • Places of absorption ileum duodenum and prox i mal
      • jejunum
    • MEGALOBLASTIC ANEMIAS Causes of Vit.B 12 deficiency(1)
      • 1. Malabsorption
      • a) Inadequate production of intrinsic factor
      • - pernicious anemia
      • - gastrectomy, partial or total
      • b) Inadequate releasing vit. B 12 from food
      • (partial gastrectomy, abnormality of stomach function,
      • chronic pancreatic insufficiency)
      • c) Terminal ileum disease (sprue, celiac disease, ilea l resection, Crohn ’s
      • disease)
      • d) Competition for intestinal B 12 :
      • - bacterial overgrowth: jejunal diverticula, intestinal stasis and
      • obstruction due to strictures, blind-loop syndrome
      • - Fish tapeworm
    • MEGALOBLASTIC ANEMIAS Causes of Vit.B 12 deficiency(2)
      • 2. Inadequate intake
      • - vegetarians
      • 3. Inadequate ut i lisation
      • Drugs: PAS, Neomycin, Colchicin e , Nitrous oxide
    • MEGALOBLASTIC ANEMIAS- Causes of Folic acid deficiency
      • 1. Inadequate intake
      • - diet lacking fresh food; chronic alcoholism, total parenteral nutrition,
      • 2. Malabsorption
      • - small bowel disease ( tropical sprue, celiac disease,)
      • - alcoholism
      • 3. Increased requirements:
      • - pregnancy and lactation
      • - infancy
      • - chronic hemolysis
      • - malignancy
      • - hemodialysis
      • 4. Defective utilisation
      • Drugs: folate antagonists (methotrexate, trimethoprim), purine analog ue s (azathioprine), p y rimidine analog ue s (zidovudine), RNA reductase inhibitor (hydroxyurea), miscellaneous (phenytoin)
    • MEGALOBLASTIC ANEMIAS clinical features
      • 1. Symptoms of anemia
      • 2. Symptoms associated with vit. B 12 or Folic acid deficiency
      • neurologic manifestations (exclusiv e ly in v it. B 12 deficiency)
      • - megaloblastic madness or psychosis,
      • - subacute, combined degeneration of the spinal cord
      • ( proprioceptive and vibratory sensation, spinal ataxia)
      • gastrointestinal comp l aints (vit.B 12 and folic acid deficiency)
      • - loss of appetite
      • - gloss i tis (red, sore, smooth tongue)
      • - diarrhea or constipation
      • Combined degeneration refers to the combined
      • demyelination of both pyramidal (lateral
      • columns) and posterior (dorsal) columns, the
      • signs and symptoms being predominantly in the legs
    • Clinical features of SCD
      • Sensory peripheral neuropathy with numbness
      • and paraesthesia in the feet are the usual presenting symptoms.
      • Less commonly, the disease presents as a spastic paraparesis.
      • The signs are of:
      • posterior column (loss of vibration and position senses, with positive Romberg);
      • upper motor neuron lesion (weakness, hypertonia and hyperreflexia, with absent abdominal reflexes and upgoing toes);
      • peripheral neuropathy (absence of all jerks), reduced touch sense and deep tenderness in the calves
    •  
    • MEGALOBLASTIC ANEMIAS Diagnosis(1)
      • 1. Blood cell count:
      • macrocytic anemia ( MCV>100fl )
      • thrombocytopenia
      • leucopenia (granulocytopenia)
      • low reticulocyte count
      • 2. Blood smear:
      • macroovalocytosis , anisocytosis, poikilocytosis
      • hypersegmentation of granulocytes
    • MEGALOBLASTIC ANEMIAS Diagnosis(2)
      • 3. Laboratory features
      • indirect hyperbilirubinemia
      • elevation of lactate dehrogenase (LDH)
      • serum iron concentration- normal or increased
      • 4. Bone marrow smear
      • hypercellular
      • increased erythroid /myeloid ratio
      • erythroid cell changes (megaloblasts, RBC precursor abnormally large with nuclear- cytoplasmic asynchrony)
      • myeloid cell changes (giant bands and metamyelocytes , hypertsegmentation)
      • megakariocytes are decreased and show abnormal morphology
    • MEGALOBLASTIC ANEMIAS Diagnosis
      • 1. Diagnosis of megaloblastic anemia
      • 2. Establishing a type of deficiency (vit. B 12 and/or folic acid)
      • 3. Establishing a cause of deficiency
    • VIT B 12 DEFICIENCY ANEMIA DIAGNOSIS
      • 1. Establishing megaloblastic anemia
      • 2. Clinical symptoms of vit. B 12 deficiency
      • 3. Low serum vit. B 12
    • PERNICIOUS ANEMIA DIAGNOSIS
      • 1. Establishing vit.B 12 deficiency anemia
      • 2. Absence of [H +] secretion (achlorhydria) with maximal histamine stimulation
      • 3. Radiolabeled vit. B 12 absorption test (Schilling test) : very reduced absorption of the B 12 -isotope, corrected to normal only when coadministered with a source of gastric IF.
      • 4. Intrinsic factor, parietal cell and IF-vit.B 12 complex antibodies
    • SCHILLING TEST
    • FOLIC ACID DEFICIENCY ANEMIA DIAGNOSIS
      • 1. Establishing megaloblastic anemia
      • 2. History: causes of folate deficiency
      • 3. Absence neurologic symptoms
      • 4. Low serum and red blood cell folic acid
    • MEGALOBLASTIC ANEMIAS TREATMENT(1)
      • PERNICIOUS ANEMIA
      • 1. Vitamin B 12 i m 1000 μg 3 times/ week for 2 weeks, then 100 0 μg every 3 month s (without neurological involvement)
      • With neurological signs: 1000 µg on alternate days until no further improvement, then 1000µg every 2 months
      • 2. Reticulocytosis begins 2 or 3 days after therapy started and maximal number reached on day 5 to 8.
      • Serum iron monitoring, after 7-10 days of vit.B12 treatment, as it may fall, for which iron is indicated
    • MEGALOBLASTIC ANEMIAS TREATMENT(2)
      • FOLIC ACID DEF . ANEMIA
      • 1. Oral folic acid 5mg / day, for 3 months
      • 2. Reticulocytosis after 5-7 days
      • 3. Correction of anemia is over after 1-2 months
      • 4. Maintenance therapy if necessary