This document discusses nutritional anemias, specifically iron deficiency anemia and megaloblastic anemia. It provides details on the causes, pathogenesis, clinical features, diagnostic criteria and bone marrow findings for each type. Iron deficiency anemia results from inadequate iron intake or absorption and causes a hypochromic microcytic anemia. Megaloblastic anemia is caused by vitamin B12 or folate deficiency and is characterized by large, oval macrocytes and nuclear-cytoplasmic dyssynchrony in bone marrow cells. Pernicious anemia, a type of megaloblastic anemia, involves autoimmune destruction of gastric parietal cells leading to vitamin B12 malabsorption.

1. DR.VANDANA
JR II
Deptt.of pathology

2.  “Decrease in total number of circulating red
cells with decrease in hemoglobin when
compared with normal for that age group and
sex”
 WHO criteria
Group Hb (g/dl)
Adult male <13
Adult female <12
Infant and children upto
12 yrs
<12
Pregnant women <11

3. CLASSIFICATION
1.ETIOLOGIC CLASSIFICATION
2.MORPHOLOGIC CLASSIFICATION

4. Etiologic classification
Anemia due to impaired
red cell production
Hemolytic anemias due to
increased red cell destruction
* Deficiency of
essential nutrients
-Fe
-B12,folate
- vit c
* Defect in stem
cell/erythroid precursor
-Aplastic anemia
-Pure red cell aplasia
• Miscellaneous
-anemia of chronic disorder
-marrow suppression due to drug
1.Intracorposcular defect
a.enzyme deficiency-
G-6-PDdefncy
PNH
secondary to liver disease
b. membrane defect
HS,HO
c.Hemoglobinopathies
Thallesemia,SCD,HbD,E etc
2.Extracorposcular defect
.immune hemolytic anemia
.fragmentation syndrome
.hypersplenism

5. Morphologic Classification :
On the basis of red cell size
Microcytic
Normocytic
Macrocytic
On basis of degree of hemoglobinisation
Normochromic
Hypochromic

6. NUTRITIONAL ANEMIAS
 Occurs due to deficiency of substances which are
essentially required by bone marrow for development
of red cells.
 They broadly include
1.IRON DEFICIENCY
2.MEGALOBLASTIC anemia
vitB12 deficiency
folic acid deficiency
multiple deficiency
pernicious anemia

7. Iron Deficiency Anemia
Iron is an essential mineral that is needed to form
hemoglobin, an oxygen carrying protein inside
red blood cell.
Iron requirement: 1 to 1.5 mg./day
Only 10-15% of ingested iron is
absorbed ,so for men- 5 to 10 mg/day
for women- 7 to 20 mg/day

8. Causes of iron deficiency anemia
1.Dietary deficiency
2.Malabsorption
 gluten induced enteropathy
 atrophic gastritis
 following gastrectomy
3.Increased blood loss
 G.I . causes
Peptic ulcer,hemorrhoids,aspirin,UC,hiatus hernia,amoebic colitis,hook
worm infestation,diverticulosis,malignancy.
 Uterine Causes
menorrhagia,repeated pregnancy
 Urinary tract causes
hematuria,chronic dialysis
 Miscellaneous
Pulmonary hemosiderosis
4.Increased physiological demand
infancy,pregnancy,adolescence,lactation.

9. IRON ABSORBTION

10. IRON METABOLISM

11. PATHOGENESIS
 Whatever its basis, iron deficiency induces a hypochromic
microcytic anemia.
In state of negative iron balance,
 reserves in the form of ferritin and hemosiderin may be
adequate to maintain normal hemoglobin and hematocrit levels
as well as normal serum iron and transferrin saturation.
 Progressive depletion of these reserves first lowers serum iron
and transferrin saturation levels, without producing anemia.
 In this early stage, there is increased erythroid activity in the
bone marrow.
 Anemia appears when iron stores are completely depleted,
accompanied by low serum iron, serum ferritin, and transferrin
saturation.

12.  Pallor,fatigue,palpitation,breathlesness,irritability.
 Growth in infancy is impaired
 Alopecia,angular stomatitis ,atrophic glossitis
 Finger Nails
Platynychia(thin ,flattened)
Koilonychia(spoon shaped)
 Pica
 Restless leg syndrome
 Dysphagia (Plumer –Vinson syndrome)

13. Diagnosis of IDA
CBC
 Hb & Hct
 RBC count
 MCV (<80fL/cell)
 MCH (<27pg/cell)
 MCHC(<33%)
 RDW(>15)
 TLC & differential (unchanged)
 Platelet count (>4.5lakh)
 Reticulocyte count

14. Peripheral smear
 Hypochromic
microcytic picture
 Anisocytosis
 Pencil shaped
poikilocytes
 Occasional Target cells

15. 2.Bone marrow Features
 Erythroid hyperplasia (but less compared to degree of
anemia)
 Normoblast - micronormoblastic reaction ,and the late
micronormoblast demonstrate persistent basophilia
and fraying of cytoplasmic border
 In late normoblast lack of hemoglobin is visualized as
pale areas in cytoplasm
 Mild to mod.degree of dyserythropoeisis in form of
nuclear budding and karyorrhexis
 Myelopoiesis and megakaryopoiesis are normal

17.  Prussian blue staining of BMA and BMB shows that
the fragments are completely devoid of iron
 In normoblast tiny iron granules present normally are
not seen in IDA

18. Biochemical findings
Serum Iron (50-170 μg/dL Female)
(65- 176μg/dL Male )
TIBC (Total iron binding capacity)
(240- 450 μg/dL)
Plasma transferrin saturation (<10% )
(20-50%)
Serum ferritin level
(>100 µg/L)
Red cell protoporphyrin
(<30 µg/dL)

19. Following iron therapy
 Day 7 –Reticulocyte is increased
 Gradually marrow reaction reverts to Normoblastic

20. Newer MARKERS
 CHr (reticulocyte hemoglobin content)
 sTfR (soluble transferrin receptor) cells
 %HYPO (percentage of hypochromic red blood cells)
 Hepcidin
 ZPP(zinc protoporphyrin)
 SQUID (superconducting quantum interference
devices)- bone marrow iron stores, serum iron,
transferrin saturation (TSAT), iron-binding capacity,
and serum ferritin

21. CHr (reticulocyte hemoglobin content)
Realtime snapshot of iron directly available for Hb
synthesis
By flow cytometry light scatter
N range (26-32pg)
<26 in iron deficient erythropoiesis
Response to EPO can be assesed
Little affected by inflammation

22. sTfR(soluble transferrin receptor)
Present on external surface of plasma membrane
Iron-transferrin complex binds to receptor
complex internalised & iron released
Proteolytic cleavage releases truncated sTfR
 Inverse relation to iron status
 Not an acute phase reactant
 N range 1.8-4.6 mg/L

23. HEPCIDIN
 Regulator of iron metabolism
 Binds to ferroportin & degrade it leading to decreased
iron absorption & export
 Decrease in IDA

24. Serum ferritin level assesssement
B.M. iron stain B.M. iron N/increased B.M.
iron increased
B.M. iron nil HbF + Hb Electrophoresis
Normal HbF HbF increased /
and electrophoresis Abnormal Hemoglobins
Ring Sideroblasts+
Mirocytic Hypochromic Anemia
Serum Ferritn
reduced
Seum Ferritin
normal/inceased
Serum ferritin
inceased
Iron deficiency
anemia
Anemia of chronic
disorders
Thalassemia &
other
hemoglobinopathie
s
Sidroblastic
Anemia

25. MEGALOBLASTIC ANEMIA
Impaired DNA synthesis.
DICHOTOMY between nuclear and cytoplasmic
maturation.

26. Causes of MA
Vitamin B12 Deficiency
Daily requirement 2-3microgram
Folic Acid Deficiency
Daily requirement 50-2oomicrogram
Decreased intake
Inadequate diet, vegetarianism
Impaired absorption
Intrinsic factor deficiency
Pernicious anemia
Gastrectomy
Malabsorption states
Diffuse intestinal disease, e.g., lymphoma,
systemic sclerosis
Ileal resection, ileitis
Competitive parasitic uptake
Fish tapeworm infestation
Bacterial overgrowth in blind loops and
diverticula of bowel
Increased requirement Pregnancy,
hyperthyroidism, disseminated cancer
Decreased intake
Inadequate diet—alcoholism, infancy
Impaired absorption
Malabsorption states
Intrinsic intestinal disease
Anticonvulsants, oral contraceptives
Increased loss
Hemodialysis
Increased requirement Pregnancy,
infancy, disseminated cancer, markedly
increased hematopoiesis
Impaired use
Folic acid antagonists
Unresponsive to Vitamin B12 or Folic Acid
Therapy

29. VitB12 and Folate deficiency
Retardation of DNA synthesis RNA synthesis normal
Normal cytoplasmic maturation
Cells are larger as division is delayed
Cell division delayed
Daughter cells have more cytoplasm
and deranged nuclear chromatin
Nucleus does not mature
Dichotomy between nuclear and
cytoplasmic maturation widens
With cell division ,some cells die or
Ineffective erythropoiesis omit terminal differentiation
Fewer and oversized cells
produced have shorter life spans
Macrocytosis
Anemia

30. Clinical features
 Pallor
 Dyspnea and tachycardia
 Beefy red tongue(B12 deficiency)
 Oral soreness and aphthous stomatitis
 NEUROLOGICAL( B12 deficiency-SACD of
posterolateral columns of spinal cord)–poor gait
,memory loss,loss of position sense,blindness (optic
atrophy),psychiatric disturbance.

31. Hematological findings
 Identical in both vit b12 and FA deficiency
Anemia.
Leucopoenia(mostly of neutrophils)
Thrombocytopoenia(50,000-1lac/microL)
Retic count decreased
mod. to severe cases- pancytopenia
MCV,MCH,RDW are increased
MCHC is normal

32. Peripheral smear
Hypersegmented
neutrophils
 1st hematologic
abnormality to appear
 Have 6-10 nuclear
segments
 Should be>5% of all
peripheral blood
neutrophils
Macro-ovalocytes
 Large egg shaped red
cells(mcv>100fl)
 Pathognomic of MA

33.  Extreme anisopoikilocytosis
 Few tear drop cells
 Howell Jolly bodies(nuclear remnants in RBC)
 Cabot rings ( microtubules which are remnant of
mitotic spindle arearginine rich and acidophilic)
 Basophilic stippling
 Nucleated red cells 1-10/100WBC(released from liver
spleen extramedullary hematopoiesis).

35. Bone marrow findings
 Hypercellular
 Erythroid hyperplasia
 Reversal of M:E to even 1:8
 Hallmark::NC maturation dissociation(megaloblast
,have open sieve like chromatin with 1-4 nucleoli)
 Initial change is MEGALOBLASTOSIS
 EM>IM>LM

36.  Intramedullary death of defective erythroid precursor
 Howell jolly body and stippling of cytoplasm in some
megaloblast
 Nucleus of megaloblast –nuclear budding,irregular
nuclei,dumb bell shaped nuclei and nuclear fragments.
 Both abnormal and normal mitosis observed
 Giant metamyelocytes and Band form(ineffective
myelopoiesis)
 Megakaryopoiesis less disturbed-open chromatin pattern
and complex nuclear lobular hypersegmentation
 Se Fe invariably elevated marrow Fe stores increased

39. Serum B12 and folate levels
Diagnostic of deficiency
B12 level < 200 pg/mL
folate level < 2 ng/mL
B12 levels between 200 to 300 pg/mL are nondiagnostic,
and in this case,
both a methylmalonic acid (MMA) and homocysteine (HCY)
level should be checked.
Serum levels of MMA and HCY are both elevated
in B12 deficiency,
while only HCY is elevated in folate deficiency.

40. Multiple deficiency
anemia(B12,FA,Fe)
 MCV –normal to slightly low
 Causes DIMORPHIC ANEMIA
 Macrocytes and microcytic hypochromic red cell is found.
 Giant metamyelocye in marrow and hypersegmented
neutrophils on PBS show vitB12/FA defncy
 Lack of Fe in marrow-fe defncy
 Due to multiple nutritional defncy—need for perl stain
 Jejunal biopsy to rule out coeliac ds and tropical
sprue(subtotal villous atrophy with absence of villi and
hypertrophy of mucosal crypts).

42. Pernicious Anemia
 Chronic disease
 Age>60 yrs
 Sex F:M::1.5:1
 Defncy of IF
Atrophic gastritis-parietal cell atrophy(by cellular and humoral
immune reaction-impaired secretion of HCL,pepsin and intrinsic
factor –impaired absorption of vit b12>megaloblastic anemia.
 c/f::weakness ,sore throat,paresthesia(classic triad)diarrhoea is
frequent complaint.glove and stocking paresthesia.ataxic and
uncordinated gait,exaggerated reflexes

43. Diagnosis
 Macrocytic anemia with
Megaloblastic
erythropoiesis as in vit b12
and FA defncy
 Atrophy of gastric glands in
fundus and body of stomach
affecting both chief cells and
parietal cells with infiltration
by lymphocyte in mucosa
 Later intestinalization of
stomach occur.

44. Differential diagnosis of MA
1. Macrocytosis with
normoblastic
bonemarrow reaction
2.Hypersegmented
neutrophils
 Liver disease
 Aplastic anemia
 Pure red cell aplasia
 Hypothoroidism
 Excessive alcohol intake
 Reticulocytosis in hemolytic
anemia
 following hydroxyurea therapy in
CML
 anticonvulsants
 CML
 Myelofibrosis
 t/t with 5FU/hydroxyurea
 Cases of ITP on steroid therapy

45.  On appropriate vitamin therapy
in 12-48 hrs megaloblastic marrow changes to
normoblastic(giant metamyelocyte persist for few
days).
Reticulocyte count begin to rise on 2nd day peak on
6th day
Erythropoeisis becomes effective.