Macrocytosis and Macrocytic Anaemia

Macrocytosis means that the red blood cells are larger than normal. Macrocytic anaemia is when there is also a fall in haemoglobin levels in the blood. Anaemia is usually defined as a haemoglobin level of at least 2 standard deviations below the mean for that age and sex. By this definition, 2.5% of a normal population will be classified as anaemic. The figures are usually taken as below 13 g/dl for men and below 12 g/dl for women. Children have a lower haemoglobin that adults.

As a general rule, macrocytosis occurs when there are problems with the synthesis of the blood cells as in vitamin B12 or folic acid deficiency whilst microcytosis is associated with deficiency of haemoglobin production such as iron deficiency or thalassaemia. New cells, especially reticulocytes, are also slightly larger and so if they occur in excessive numbers, there may be macrocytosis.

The term macrocytosis describes the presence of macrocytes on a blood film, together with a raised mean corpuscular volume (MCV). It is a common finding in the results of a full blood count and may or may not be associated with an anaemia. Macrocytosis may occur as a laboratory artefact, perhaps following incorrect storage of the sample. A spuriously raised MCV may also occur due to cold agglutinins, paraproteins as in myeloma, hyperglycaemia or marked leucocytosis .Macrocytic anaemia describes a macrocytosis associated with a reduced haemoglobin and most commonly occurs as a result of a megaloblastic anaemia.

Macrocytic anaemia can be classified as megaloblastic and non-megaloblastic. Megaloblastic refers to a characteristic abnormality of the erythroblasts in the bone marrow in which the maturation of the nucleus is delayed relative to the cytoplasm. It results from defective DNA synthesis.

• Macrocytosis is common and is found in 1-3.5% of all full blood counts performed.
• The most common cause of all forms of macrocytosis is alcohol abuse which accounts for approximately 35%.
• The most common cause of megaloblastic anaemia is pernicious anaemia. The peak age of diagnosis is 60 years with a female to male ratio of 1.6:1. There is often a family history and it may be associated with other autoimmune disorders.
• Vitamin B12 deficiency or folic acid deficiency together account for most cases of megaloblastic anaemia.
• Vitamin B12 deficiency can be due to disease of the terminal ileum, especially Crohn's disease and other rare causes, but most cases are due to Pernicious Anaemia that is described elsewhere.

The liver has abundant stores of vitamin B12 and so if absorption is impaired, it takes 4 or 5 years for deficiency to develop.

• Vitamin B12 deficiency due to:
  • Autoimmune Addisonian pernicious anaemia (80%).
  • After surgery such as gastrectomy or ileal resection.
  • Bacterial overgrowth or parasitic infestation.
  • HIV infection.
  • Dietary deficiency may occur in strict vegans but even in them, it is rare.
  • Pernicious anaemia tends to be a disease of the elderly, but rarely it can occur in the newborn, usually when there is deficiency in the mother.¹
• Folate deficiency due to:
  • Dietary deficiency
  • Malabsorption
  • Increased demands including haemolysis, leukaemia and rapid cell turnover as may occur in some skin diseases. Macrocytosis but without anaemia will develop in 30% of women in late pregnancy unless they take folic acid supplements.
  • Increased urinary excretion occurs in heart failure, acute hepatitis and dialysis.
  • Drug-induced deficiency includes alcohol, anticonvulsants, methotrexate, sulphasalazine and trimethoprim but they last only if high dose and prolonged course.

• Alcohol abuse is a common cause. There may also be folate deficiency due to a poor diet although beer is a good source of folate.
• Liver disease
• Severe hypothyroidism
• Reticulocytosis
• Other blood disorders including aplastic anaemia, red-cell aplasia, myelodysplastic syndromes, myeloid leukaemia.
• Drugs that affect DNA synthesis such as azathioprine

Macrocytosis per se, does not cause any symptoms or signs but there may be features related to the underlying disease. Mild anaemia is usually asymptomatic but the more severe the anaemia, the more likely are there to be symptoms. Most cases are diagnosed when a blood count is performed as part of an investigation for something other than features of anaemia. People who are older or have coronary heart disease are more likely to suffer symptoms whilst the young can be remarkably anaemic and not complain.

Symptoms may include:

• Shortness of breath on exertion
• Fatigue
• Palpitations
• Exacerbation of angina
• Complaining of looking pale

Overt high output cardiac failure can occur. Physical signs also depend upon the degree of anaemia and may include:

• Pallor. Look at the nail beds and tongue.
• A bounding pulse
• Systolic pulmonary flow murmur

The term pernicious anaemia emphasises how slow and gradual is the onset. There are three classic diseases in which the doctor who has known the patient well over the years is at a disadvantage whilst the new doctor may instantly recognise a "barn door" diagnosis. They are pernicious anaemia, myxoedema and acromegaly.

Megaloblastic anaemia is not a final diagnosis and a cause for the condition must be sought.

• The first investigation is a full blood count with examination of a blood film.
• This may need to be followed by bone marrow examination to differentiate between megaloblastic and non-megaloblastic anaemia. Usually bone marrow examination is not necessary unless an underlying haematological disease such as leukaemia is suspected.
• A raised reticulocyte count may indicate rapid turnover of erythrocytes.
• Serum folate levels are readily available but most laboratories offer red cell folate that is more specific.
• Serum vitamin B12 level
• Abnormal LFTs may suggest alcohol abuse or other diseases.
• As a matter of routine, perform urinalysis and get U&E and creatinine. This is because of the association with diabetes and homocystinuria. Homocystinuria can cause haematuria, proteinuria, mild uraemia.
• Perform other tests as may be required from clinical suspicion.

• Pernicious anaemia is commonly found in association with other autoimmune diseases such as diabetes and hypothyroidism, and patients diagnosed as having pernicious anaemia should be screened for these routinely both at diagnosis and at annual review.
• Vitamin B12 deficiency can also be associated with neurological features but they will not be considered here.
• There is a three-fold increase in the risk of gastric carcinoma, raising it to 4%.
• Folate deficiency in early pregnancy may be associated with neural tube defects.
• Defects in vitamin B12 metabolism can be associated with homocystinuria.

Management involves two components:

• Correcting the deficiency that has caused the macrocytosis, with or without anaemia.
• Treating the underlying condition that led to the deficiency.

Vitamin B12 is ubiquitous in food and so deficiency is usually due to malabsorption. Hence there seems little point in giving it by mouth. However, there is some evidence that the oral form may be as effective as parenteral administration if given in twice the dose.² Cyanocobalamin is available in tablet form but hydroxocobalamin is usually given by parenteral injection in the form of 1 mg in 1 mL. In severe anaemia it may need to be given every week at first but before long this is changed to once every 3 months and continued for life.

Some patients seem to develop a psychological dependence upon the injection and demand that they need it more often. There is no haematological basis for this. In the past there has been a tendency to give cyanocobalamin injections to people with little or no objective evidence of vitamin B12 deficiency but possibly with psychological problems. They seem to be especially susceptible to a "need" to continue the injections.^3,4 A little pink injection appears to have great placebo power.

In severe cases of vitamin B12 deficiency, there have been reports of sudden death in the early stages of treatment.⁵ It is thought that this may be related to rapid synthesis of cells requiring much potassium and leading to hypokalaemia but this appears to be speculation rather than evidence based. In such cases potassium supplementation may be advised.

Folic acid is produced in 5 mg tablets. The oral form is usually sufficient although in severe malabsorption it may be necessary to give it parenterally. The usual dose is 5 mg daily for 4 months after which a tablet is given between 1 and 7 days a week, depending upon the nature of the malabsorption.

If there is both folate and vitamin B12 deficiency, it is essential to start treating the B12 deficiency before starting folate or the latter may aggravate the B12 deficiency and precipitate subacute combined degeneration of the cord.

As well as treating the deficiency, attention must be paid to the underlying condition. With pernicious anaemia this usually involves just injections every 3 months, an annual FBC and a great readiness to investigate any suspicion of gastric malignancy.

Alcoholism diagnosis and management in primary care can be very difficult, not least because of the problem of denial.

When to refer

It is important to consider when specialist help should be sought.⁶