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Iron deficient and megaloblastic anemias Atanas Stanchev MD University Hospital”Alexandrovska” Clinic of Hematology
Anemia
Red cells development
Normal red cell Size  7µм MCV 82-98fl MCH 27-32pg MCHC 31 0 -34 0 g/l
Anemia   is a symptom of disease that requires investigation to determine the underlying aetiology . Anemia is strictly defined as a decrease in red blood cell (RBC) mass . I n practice, anemia is usually discovered and quantified by measurement of the RBC count, hemoglobin (Hb) concentration, and hematocrit (Hct)
Normal value 40-75   mol/l 40-75   mol/l TIBC 20 – 180   g/l 30 – 180   g/l Ferritin 10.7 - 23   mol/l 12.5 – 26.5  mol/l Iron 34 – 46% 40 – 54% Hct 4.2 – 5.4 T/l 4.6 – 6.6  T/l Er. 1 20-1 6 0 g/l 140-180 g/l Hb Women Men Parameter
Definition for anemia (WHO) ,[object Object],[object Object],[object Object],Classification ,[object Object],[object Object],[object Object]
Iron deficiency anemia
[object Object],[object Object],[object Object],[object Object],[object Object]
Dietary iron enters the   enterocyte after being reduced to the ferrous state by duodenal   cytochrome b (Dcytb) and being transported by the divalent metal transporter (DMT1). Hephaestin facilitates iron export by ferroportin.   Hepatocytes take up either free or transferrin-bound iron and release   it back into the circulation via the action of ferroportin. Ferroportin   also releases iron from macrophages. Ferroportin-mediated release of   iron is inhibited by hepcidin.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Causes for Iron deficiency ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Treatment ,[object Object],[object Object],[object Object],[object Object]
Reticulocytosis on day 3-4 , max. on day 10
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
Megaloblastic anemia
[object Object],[object Object],[object Object],[object Object]
The assimilation of cobalamin. On entering the stomach, dietary cobalamin (Cbl) forms a   complex with R binding protein. As this protein is digested in the small intestine, cobalamin is transferred to   intrinsic factor (IF). This complex passes through the intestine until it reaches specific receptors on the mucosa   of the distal ileum. The internalized Cbl is then transferred to transcobalamin II (TC II), which circulates in the   plasma until it binds to receptors on cells throughout the body and is internalized.
Folate  is essential for the de novo synthesis of purines, serving as an intermediate carrier of 1-carbon fragments used in the   biosynthesis of these compounds. Its active form is tetrahydrofolate (THF)..
COBALAMIN DEFICIENCY I.  Inadequate intake: vegetarians (rare) II. Malabsorption A. Defective release of cobalamin from food : ( Gastric achlorhydria ;  Partial gastrectomy ;  Drugs that block acid secretion ) B. Inadequate production of intrinsic factor (IF) : (  Pernicious anemia ;  Total gastrectomy ;  Congenital absence or functional  abnormality of IF (rare) ) C. Disorders of terminal ileum : ( Tropical sprue ;  Nontropical sprue ;  Regional enteritis ;  Intestinal resection ;  Neoplasms and  granulomatous disorders (rare) ;  Selective cobalamin  malabsorption  ) D. Competition for cobalamin : ( Fish tapeworm (Diphyllobothrium  latum) ;  Bacteria: "blind loop" syndrome ;  Drugs:  p - aminosalicylic acid, colchicine, neomycin ) III. Other A. Nitrous oxide B. Transcobalamin II deficiency (rare)
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
This marrow section demonstrates so-called nuclear-cytoplasmic   dissociation; The slow nuclear   maturation is related to a decrease in DNA synthesis related to an insufficient supply of reduced folate to   synthesize thymidylate. DNA synthesis inhibitors can produce this picture, as can folate and B12 deficiency.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
Bone marrow aspirate in megaloblastic anaemia showing early, intermediate and late megaloblasts and a giant metamyelocyte [arrow] .
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Irion defitient and megaloblastic anemias

  • 1. Iron deficient and megaloblastic anemias Atanas Stanchev MD University Hospital”Alexandrovska” Clinic of Hematology
  • 4. Normal red cell Size 7µм MCV 82-98fl MCH 27-32pg MCHC 31 0 -34 0 g/l
  • 5. Anemia is a symptom of disease that requires investigation to determine the underlying aetiology . Anemia is strictly defined as a decrease in red blood cell (RBC) mass . I n practice, anemia is usually discovered and quantified by measurement of the RBC count, hemoglobin (Hb) concentration, and hematocrit (Hct)
  • 6. Normal value 40-75  mol/l 40-75  mol/l TIBC 20 – 180  g/l 30 – 180  g/l Ferritin 10.7 - 23  mol/l 12.5 – 26.5  mol/l Iron 34 – 46% 40 – 54% Hct 4.2 – 5.4 T/l 4.6 – 6.6 T/l Er. 1 20-1 6 0 g/l 140-180 g/l Hb Women Men Parameter
  • 7.
  • 9.
  • 10. Dietary iron enters the enterocyte after being reduced to the ferrous state by duodenal cytochrome b (Dcytb) and being transported by the divalent metal transporter (DMT1). Hephaestin facilitates iron export by ferroportin. Hepatocytes take up either free or transferrin-bound iron and release it back into the circulation via the action of ferroportin. Ferroportin also releases iron from macrophages. Ferroportin-mediated release of iron is inhibited by hepcidin.
  • 11.
  • 12.
  • 13.
  • 14.  
  • 15.  
  • 16.
  • 17.  
  • 18.  
  • 19.
  • 20. Reticulocytosis on day 3-4 , max. on day 10
  • 21.
  • 22.
  • 24.
  • 25. The assimilation of cobalamin. On entering the stomach, dietary cobalamin (Cbl) forms a complex with R binding protein. As this protein is digested in the small intestine, cobalamin is transferred to intrinsic factor (IF). This complex passes through the intestine until it reaches specific receptors on the mucosa of the distal ileum. The internalized Cbl is then transferred to transcobalamin II (TC II), which circulates in the plasma until it binds to receptors on cells throughout the body and is internalized.
  • 26. Folate is essential for the de novo synthesis of purines, serving as an intermediate carrier of 1-carbon fragments used in the biosynthesis of these compounds. Its active form is tetrahydrofolate (THF)..
  • 27. COBALAMIN DEFICIENCY I. Inadequate intake: vegetarians (rare) II. Malabsorption A. Defective release of cobalamin from food : ( Gastric achlorhydria ; Partial gastrectomy ; Drugs that block acid secretion ) B. Inadequate production of intrinsic factor (IF) : ( Pernicious anemia ; Total gastrectomy ; Congenital absence or functional abnormality of IF (rare) ) C. Disorders of terminal ileum : ( Tropical sprue ; Nontropical sprue ; Regional enteritis ; Intestinal resection ; Neoplasms and granulomatous disorders (rare) ; Selective cobalamin malabsorption ) D. Competition for cobalamin : ( Fish tapeworm (Diphyllobothrium latum) ; Bacteria: "blind loop" syndrome ; Drugs: p - aminosalicylic acid, colchicine, neomycin ) III. Other A. Nitrous oxide B. Transcobalamin II deficiency (rare)
  • 28.
  • 29.
  • 30.
  • 31.
  • 32.  
  • 33. This marrow section demonstrates so-called nuclear-cytoplasmic dissociation; The slow nuclear maturation is related to a decrease in DNA synthesis related to an insufficient supply of reduced folate to synthesize thymidylate. DNA synthesis inhibitors can produce this picture, as can folate and B12 deficiency.
  • 34.
  • 35.
  • 36.
  • 37. Bone marrow aspirate in megaloblastic anaemia showing early, intermediate and late megaloblasts and a giant metamyelocyte [arrow] .
  • 38.