Macrocytosis

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Macrocytosis

• Clinical Cases

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Case 1 Ms JM Age 46 yr "I have not seen this
lady for 9 years. She recently appeared in my
office looking rather pale". Blood Count WBC x
109/L 1.9 4-11 Hb g/L 56 120-160 MCV
fl 146 79-98 Platelets x 109/L 102 150-450 R
etics x 109/L 10 25-100
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Neuts x 109/L 1.4 2-7.5 Lymphs x
109/L 0.5 1.5-4 Monos x 109/L - 0.2-0.8 Eos
x 109/L - 0-0.7 Basos x 109/L - 0-0.1 Blas
ts x 109/L - 0 Promyelocytes x
109/L - 0 Myelocytes x 109/L - 0 Metamyelocyt
es x 109/L - 0 Nucleated RBC x
109/L - 0 Film Comment hypersegmented
neutrophils, oval macrocytes
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Ms JM - history

• Vitamin B12/folate
• Diet
• malabsorption/gastrectomy
• pernicious anemia/family history
• excess requirements
• Other
• alcohol
• drugs
• thyroid
• liver

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Ms JM - exam

• Jaundiced and pale, red beefy tongue
• Cardiovascular assessment
• Absent ankle jerks, absent vibration sensation at
  ankles, positive Romberg's test

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Ms JM - investigations
1. Serum vitamin B12 lt74 pmol/L (165-740) 2.
Serum folate 17.7 nmol/L (7-45) 3. LDH 3060
U/L (94-172) 4. Bilirubin 43 umol/L (lt17)
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Ms JM - Schilling Test
Schilling Test part I 1.4 (10-25)
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Ms JM - Schilling Test
Schilling Test part I 1.4 (10-25) Schilling
Test part II 11.8 (10-25)
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Case Number 2

• Ms FM
• age 53

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Ms FM - age 53

• Fatigue
• Past history of hypertension, depression,
  hysterectomy
• Premarin, hydrochlorthiazide, potassium
• Physical examination negative

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Ms FM - blood count
Blood Count (CBC) (F) WBC x 109/L 2.8 4-11 Hb
g/L 109 120-160 MCV fl 102 79-98 Platelets
x 109/L 219 150-450 Retics x 109/L
36 25-100
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Neuts x 109/L 1.4 2-7.5 Lymphs x
109/L 1.3 1.5-4 Monos x 109/L 0.1 0.2-0.8 Eo
s x 109/L - 0-0.7 Basos x 109/L - 0-0.1 Bl
asts x 109/L - 0 Promyelocytes x
109/L - 0 Myelocytes x 109/L - 0 Metamyelocyt
es x 109/L - 0 Nucleated RBC x
109/L - 0 Film Comment rouleaux
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Ms FM - investigations
1. Serum vitamin B12 250 pmol/L (165-740) 2.
Serum folate 17.7 nmol/L (7-45)
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Case number three

• Ms KF
• age 32

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Ms KF - history

• Routine CBC abnormal
• No prior history except recent tooth abscess
• No medications
• Feeling generally healthy

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Ms KF - blood count
Blood Count (CBC) (F) WBC x 109/L 4.4 4-11 Hb
g/L 109 120-160 MCV fl 108 79-98 Platelets
x 109/L 72 150-450 Retics x 109/L 20 25-100
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Neuts x 109/L 1.0 2-7.5 Lymphs x
109/L 3.0 1.5-4 Monos x 109/L 0.4 0.2-0.8 Eo
s x 109/L - 0-0.7 Basos x 109/L - 0-0.1 Bl
asts x 109/L - 0 Promyelocytes x
109/L - 0 Myelocytes x 109/L - 0 Metamyelocyt
es x 109/L - 0 Nucleated RBC x
109/L - 0 Film Comment hypogranular
neutrophils. Dysplastic NERCs.
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Ms KF - investigations
1. Serum vitamin B12 320 pmol/L (165-740) 2.
Serum folate 17.7 nmol/L (7-45)
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Case 4
Male 48 years, referred after abnormal CBC result
from FP
WBC x 109/L 2.9 4-11 Hb g/L 99 140-180 MCV
fl 104 80-100 Platelets x 109/L 55 150-450
Retics x 109/L 40 25-100
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Case 4
Neuts x 109/L 1.0 2-7.5 Lymphs x
109/L 1.7 1.5-4 Monos x 109/L 0.2 0.2-0.8 Eo
s x 109/L - 0-0.7 Basos x 109/L - 0-0.1 Fi
lm Comment target cells
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Case 4 history Diet OK Ethanol 3 per
day Family History Father died of
cirrhosis Thyroid Mother on thyroxine Medication
s None Jaundice Partner has noticed yellow
eyes Abdominal swelling Last few
weeks Peripheral edema Last few weeks
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