Vancouver IM LMR

In today’s noon report we reviewed a case of an 80 year old man who presented with macrocytic anemia with megaloblastic features. He was eventually diagnosed with myelodysplastic syndrome on bone marrow biopsy.

Here are the didactic slides from this report.

Key takeaways:

• Etiologies of macrocytic anemia:
  • Reticulocytosis
  • Megaloblastic anemia (usually B12/ folate deficiency)
  • Others: alcohol use, liver disease, thyroid disease, HIV, primary hematologic disorders (multiple myeloma, MDS, aplastic anemia)
• Megaloblastic anemia:
  • B12 deficiency: think about veganism, GI surgeries (gastrectomy, ileal resection), IBD, Celiac disease, pernicious anemia
  • Folate deficiency: very rare since grains (bread, pasta, rice, cereal etc) in most countries are fortified with folate
  • If B12 or folate levels in serum are borderline low, can test for metabolites
    • Homocysteine will be elevated in both B12 and folate deficiency
    • Methylmalonic acid (MMA) will be elevated in only B12 deficiency
• Myelodysplastic syndrome:
  • A type of chronic myeloid disorder (not the same as but overlaps with MPNs)
  • MDS is a heterogenous group of clonal disorders of the hematopoietic stem cell characterized by dysplasia and ineffective hematopoiesis (cytopenias)
  • Incidence increases with age (probably a more common cause of macrocytic anemia in elderly than you would think)!
  • Diagnosis requires peripheral blood smear, bone marrow aspirate and biopsy, and cytogenetic/ molecular testing
  • Treatment is varied depending on disease features and patient fitness level (ranges from supportive care to induction chemotherapy and stem cell transplant)