1. Macrocytic cell , this are cells that are larger than normal cell.

The common cause if this is B12

deficiency

2. Megaloblastic anemia due to the B12 deficiencies. The patient was admitted with moderate anemia.
Erythrocyte show marked anisocytosis and poikilocytosis with many ival macrocyte and severe cases,
basophilic stippling and howell jolly bidies. On differential diagnosis neurological symptoms typically
accompany B12 than folate deficiency.

3. What is the significance of the ALT/AST results?

Answer: There is no liver disease. Since the liver enzymes are normal, liver disease is rules out as a
source of jaundice or the macrocytic anemia.

Rationale: The blood test for aspartate aminotransferase (AST) is usually used to detect liver damage. It
is often ordered in conjunction with another liver enzyme, alanine aminotransferase (ALT), or as part of
a liver panel or comprehensive metabolic panel (CMP) to screen for and/or help diagnose liver disorders.
AST and ALT are considered to be two of the most important tests to detect liver injury, although ALT is
more specific for the liver than is AST and is more commonly increased than is AST.

6. What would you predict the patient’s reticulocyte count be ?

Answer: Low Reticulocyte count

Rationale:

The reticulocyte is low since this megaloblastic anemia is a defective DNA synthesis which
caused by a decrease RBC production or abnormal nuclear maturation even though the bone marrow is
generally hypercellular, as a result of ineffective erythropoiesis and intramarrow erythrocyte destruction.
Otherwise, vitamin B12 deficiency affects all hematopoietic cell lines.

Review of Related Literature

Vitamin B12 (B12) also known as cobalamin, is classified as a water-soluble vitamin, and is distinctive
among all vitamins due to its large size, complexity, and that it contains the metal ion cobalt. It is
necessary for appropriate nervous system function and for the metabolism of carbohydrate, protein, and
fat. Vitamin B12 deficiency is characterized by megaloblastic anemia, fatigue, weakness, constipation, loss of appetite,
and weight loss. Neurological changes, such as numbness and tingling in the hands and feet, can also occur. Additional
symptoms of vitamin B12 deficiency include difficulty maintaining balance, depression, confusion, dementia, poor
memory, and soreness of the mouth or tongue. The neurological symptoms of vitamin B12 deficiency can occur without
anemia, so early diagnosis and intervention is important to avoid irreversible damage. During infancy, signs of a vitamin
B12 deficiency include failure to thrive, movement disorders, developmental delays, and megaloblastic anemia. Many of
these symptoms are general and can result from a variety of medical conditions other than vitamin B12 deficiency. The
main dietary sources of B12 are animal products including meat, fish, eggs, and dairy products. Other
sources include B12-containing, fortified plant products such as cereals, plant-based milks, soy products,
and B12-fortified yeast extract

CLINICAL SIGNIFICANCE
Deficiency is usually caused by the malabsorption of vitamin B12 although dietary inadequacy is
common in the elderly, vegans or ovo-lacto vegetarians with poor diets. Causes can also relate to
inadequate Intrinsic Factor production, atrophic gastritis, interference with the ileal uptake of vitamin B12
due to disease, resection or interference by bacterial overgrowth, drug-nutrient interactions as well as
some less common genetic defects. Pernicious anemia is the end stage of an auto-immune gastritis and
results in the loss of synthesis of Intrinsic Factor or a deficiency of Intrinsic Factor, antibodies to intrinsic
factor, or antibodies to parietal cells. It is a loss of Intrinsic Factor that causes vitamin B12 deficiency and
if untreated, megaloblastic anaemia and neurological complications develop. Pernicious anaemia is
treated with vitamin B12 injections, or large doses of oral vitamin B12. Vitamin B12 deficiency will also
develop after gastric antrum resection or gastrectomy as this is the site of secretion of Intrinsic Factor and
acid.