Macrocytosis

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Background

Macrocytosis is a term used to describe erythrocytes that are larger than normal, typically reported as mean cell volume (MCV) greater than 100 fL. The amount of hemoglobin increases proportionately with the increase in cell size. Therefore, if the increase in MCV is not related to macrocytic anemia, the mean cell hemoglobin concentration (MCHC) also increases in proportion.

Causes of macrocytosis are many and range from benign to malignant; thus, a complete workup to determine etiology is essential.[1] Macrocytosis may occur at any age, but it is more prevalent in older age groups because the causes of macrocytosis are more prevalent in older persons.[2, 3, 4]

Pathophysiology

The most common cause of macrocytic anemia is megaloblastic anemia, which is the result of impaired DNA synthesis. Although DNA synthesis is impaired, RNA synthesis is unaffected, leading to a buildup of cytoplasmic components in a slowly dividing cell. This results in a larger-than-normal cell. The nuclear chromatin of these cells also has an altered appearance.[5]

Vitamin B-12 and folate coenzymes are required for thymidylate and purine synthesis; thus, their deficiency results in retarded DNA synthesis. In vitamin B-12 deficiency and folic acid deficiency, the defect in DNA synthesis affects other rapidly dividing cells as well, which may be manifested as glossitis, skin changes, and flattening of intestinal villi.

DNA synthesis may also be delayed when certain chemotherapeutic agents are used, including folate antagonists, purine antagonists, pyrimidine antagonists, and even folate antagonist antimicrobials.

Hydroxyurea, an agent now commonly used to decrease the number of vaso-occlusive pain crises in patients with sickle cell disease, interferes with DNA synthesis, causing macrocytosis by which compliance with therapy may be monitored. Patient compliance with zidovudine, an agent used in the treatment of patients with HIV infection, may be monitored in the same way.

Sternfeld et al, in a study using the13 C-methionine breath test to analyze hepatic mitochondrial function in vivo in antiretroviral-treated HIV-infected patients with macrocytosis, found a significantly negative correlation between mean corpuscular erythrocyte volume and the breath test results.[6] They concluded that there is an association between an increase in mean corpuscular erythrocyte volume from treatment with nucleoside reverse transcriptase inhibitors and the hepatic mitochondrial function in vivo.

Nonmegaloblastic macrocytic anemias are those in which no impairment of DNA synthesis occurs. Included in this category are disorders associated with increased membrane surface area, accelerated erythropoiesis, alcoholism, and chronic obstructive pulmonary disease (COPD).

Patients with hepatic disease and obstructive jaundice have macrocytosis that is secondary to increased deposition of cholesterol or phospholipids on the membranes of circulating red blood cells (RBCs). Similarly, in splenectomized patients, RBC membrane lipids that usually are removed during maturation in the spleen are not effectively removed, and the result is a larger-than-normal cell.

In patients with hemolytic anemia or posthemorrhagic anemia, the reticulocyte count increases. The reticulocyte, an immature RBC, is approximately 20% larger than the more mature RBC. When the reticulocyte is released prematurely from the marrow, its volume is averaged with the volume of the more mature RBC, and the resultant MCV is increased.

Macrocytosis, sometimes without associated anemia, is often evident in persons with chronic alcoholism.[7, 8] Although the macrocytosis of alcoholism may be secondary to poor nutrition with a resulting folate or vitamin B-12 deficiency, it is more often due to direct toxicity of the alcohol on the marrow. The macrocytosis of alcoholism usually reverses only after months of abstinence from alcohol.

The macrocytosis associated with COPD is attributed to excess cell water that is secondary to carbon dioxide retention.

A murine study found that disruption of the Gardos channel (the erythrocyte Ca2+ -activated K+ channel [KCa3.1]) caused subtle erythrocyte macrocytosis and led to mild but progressive splenomegaly.[9]

Etiology

Vitamin B-12 deficiency is a cause of macrocytosis. Because DNA synthesis requires cyanocobalamin (vitamin B-12) as a cofactor, a deficiency of the vitamin leads to decreased DNA synthesis in the erythrocyte, thus resulting in macrocytosis. A dietary deficiency of vitamin B-12 is rare and usually only occurs in elderly persons on a "tea-and-toast diet" or in strict vegan vegetarians. However, deficiency can result from the following:

Folate also is needed as a cofactor in the synthesis of DNA. Folate deficiency may be caused by any of the following:

Inherited disorders of DNA synthesis include the following:

Drug-induced macrocytosis is the most common cause in nonalcoholic patients. Usually, no associated anemia is present. The following categories of drugs are known to cause macrocytosis:

Reticulocytosis may be due to posthemorrhagic blood loss or hemolysis. Reticulocytes are immature red cells released in response to decreased hematocrit levels.

Long-term alcohol intake directly affects bone marrow. This effect is not related to the presence of liver disease or vitamin deficiency and resolves only after months of abstinence from alcohol.

Refractory anemias of the following types may cause macrocytosis:

Macrocytosis in patients with COPD is attributed to excess cell water secondary to carbon dioxide retention.

Benign familial macrocytosis is an inherited syndrome in which patients have mild asymptomatic macrocytosis.[11]

Macrocytosis of liver disease is secondary to increased cholesterol and phospholipids deposited on membranes of circulating erythrocytes. This deposition effectively increases the surface area of the erythrocyte.

Hypothyroidism is a manifestation of hormone deficiency. More commonly, hypothyroid patients exhibit a normocytic anemia. Artifactually elevated MCVs must be considered in certain patients. These are observed less frequently with newer counting machines. Hyperglycemia and cold agglutinins may cause artificially elevated MCVs.[12]

History

The symptoms of macrocytosis are attributable either to the anemia itself or to the underlying condition causing the anemia. They may include the following:

A history of alcohol abuse may be an important clue to the cause of the increased mean cell volume (MCV); long-term use of alcohol may have a direct toxic effect on the bone marrow, causing macrocytosis.[15] A thorough examination of the patient’s medication regimen is also crucial in the workup of macrocytosis; a variety of medications may have an effect on the MCV. Recent acute blood loss may signal that reticulocytosis is causing the MCV increase.

Physical Examination

The following physical findings may be noted:

Laboratory Studies

A complete blood count (CBC) with platelet count is indicated. The hemoglobin concentration and hematocrit may help guide diagnosis and determine the presence and severity of anemia. White blood cell (WBC) and platelet counts may be decreased in primary marrow disturbances. Mean cell volume (MCV) is a calculated average red blood cell (RBC) volume. An MCV greater than 100 fL is macrocytosis by definition. Because evaluation of RBC size is key to the diagnosis of an anemia, the MCV is considered to be the most important of the RBC indices.

Peripheral blood smear morphology may be helpful. Round macrocytes suggest liver or marrow infiltrative disease, whereas oval macrocytes tend to suggest a megaloblastic disorder. This study provides clues to the etiology of macrocytosis. Hypersegmented neutrophils and macro-ovalocytes strongly suggest megaloblastic anemia. Nucleated RBCs, teardrop cells, decreased or large platelets, and immature WBCs are often present in myelophthisic disease and leukemias.

The reticulocyte count helps determine whether hemolysis is present; it can also indicate malfunctioning bone marrow. Marked reticulocytosis (>4%) is to be expected in hemolytic anemias. A reticulocyte count lower than 1% indicates inadequate marrow production. The reticulocyte count must be corrected for the degree of anemia present.

If the reticulocyte count is elevated, a Coombs test should be performed to aid in identifying the cause of hemolysis. A positive direct Coombs test finding is to be expected in autoimmune hemolytic anemias, hemolytic transfusion reactions, and some drug-induced anemias (eg, those caused by penicillin, methyldopa, some cephalosporins, or sulfonamides).

Lactate dehydrogenase (LDH) levels are elevated in both intravascular and extravascular hemolysis, including the ineffective erythropoiesis that occurs in megaloblastic anemias.

Because the haptoglobin binds free hemoglobin, a low or absent haptoglobin level indicates intravascular hemolysis.

If macro-ovalocytes and hypersegmented neutrophils are noted on peripheral smear, the vitamin B-12 level may be low. If folate deficiency is the cause of the macrocytosis, the RBC folate level likely will be decreased. As in vitamin B-12 deficiency, peripheral smear may reveal hypersegmented neutrophils and macro-ovalocytes.

Serum total homocysteine levels are almost always elevated in patients with folate deficiency because folate is required in the remethylation step that converts homocysteine to methionine.[16] Serum methylmalonic acid and homocysteine levels are increased early in vitamin B-12 deficiency, even before hematologic manifestations or decreases in B-12 levels are noted.[17]

Serum unconjugated bilirubin is expected to be elevated in hemolysis.

If vitamin B-12 deficiency is the cause of the macrocytosis, the serum vitamin B-12 level likely will be decreased. A Schilling test was previously considered the criterion standard for further investigation of a low vitamin B-12 level. However, many institutions no longer offer the Schilling test. Alternative tests to the Schilling test are antibodies to parietal cells and intrinsic factor antibodies.

A serum folate level may be obtained,[18] although an RBC folate level is more reliable because it reflects the level over the lifespan of the RBC.

A study designed to identify the underlying causes of macrocytosis by analyzing hematological features concluded that complete medical histories, analysis of red cell parameters, and peripheral blood smears were simple and inexpensive tools that can be helpful in settings with limited resources.[19]

Bone Marrow Biopsy and Aspiration

Bone marrow biopsy and aspiration are performed to determine whether the marrow is functioning adequately and also may reveal replacement of marrow with tumor, granuloma, or fibrosis. The bone marrow should be obtained before any vitamin B-12 or folate therapy or blood transfusion because megaloblastic changes may reverse rapidly.

The bone marrow in megaloblastic anemias is usually hypercellular, with all cell lines proliferating. Marked erythroid hyperplasia may occur to the point at which the myeloid-erythroid ratio is reversed. Nuclear-chromatin dissociation with a young-appearing nucleus and abundant mature-appearing cytoplasm may occur. Granulocytic hyperplasia with giant metamyelocytes and bands is often noted.

Histologic Findings

On peripheral blood smear, large RBCs are evident. Depending on the etiology of the macrocytosis, peripheral smear may reveal nucleated RBCs, target cells, RBC fragments, hypersegmentation of neutrophils, immature WBCs, large platelets, or pancytopenia.

Depending on the etiology of the macrocytosis, the marrow may reveal hypercellularity, megaloblastic changes, fibrosis, infiltration by tumor or granulomatous disease, leukemic changes, or erythroid hyperplasia.

Approach Considerations

Evaluation usually can be performed on an outpatient basis. Medical treatment depends on the etiology of the macrocytosis, the presence and severity of anemia, and the symptoms and physical findings. Hematologic and oncologic consultation should be obtained as necessary. After the appropriate laboratory studies are obtained, the symptomatic anemic patient may undergo transfusion with packed red blood cells (RBCs).

If a drug is thought to be the cause of the macrocytic anemia, especially if hemolysis is occurring, discontinue administration of the offending drug. If the patient is suspected of abusing alcohol, counsel abstention.

Patients deficient in vitamin B-12 or folate should receive replacement therapy.[20] Folate 1 mg/day may be prescribed in patients with folate deficiency. Intramuscular vitamin B-12 injections (100-1000 g/mo), continued indefinitely, may be prescribed.

Treat malignancies, granulomatous diseases, and chronic obstructive pulmonary disease (COPD) according to the standards appropriate for each. Hospitalization may be required to treat some causes of macrocytosis, especially acute leukemias. Outpatient follow-up depends on the cause of the macrocytosis.

Diet

If folate or vitamin B-12 deficiency is the cause of the macrocytosis, modify the diet to include foods rich in these vitamins. Red meat is a good source of vitamin B-12, and green leafy vegetables are excellent sources of folate. Do not provide folate supplementation without vitamin B-12 replacement therapy in any patient with vitamin B-12 deficiency or with suspected vitamin B-12 deficiency; doing so may precipitate subacute combined degeneration of the spinal cord.

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Folic acid (Folacin-800)

Clinical Context:  Folic acid is an important cofactor for enzymes used in the production of red blood cells (RBCs).

Vitamin B-12 (CaloMist, Nascobal, Ener-B)

Clinical Context:  Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans. Vitamin B-12 is synthesized by microbes but not by humans or plants. Vitamin B-12 deficiency may result from intrinsic factor deficiency (pernicious anemia), partial or total gastrectomy, or diseases of the distal ileum.

Multivitamins (M.V.I.-12, Infuvite)

Clinical Context:  Multivitamins are used as dietary supplements.

Class Summary

In macrocytosis associated with vitamin deficiencies, the deficient vitamin is replaced to meet necessary dietary requirements. Used in metabolic pathways, DNA and protein synthesis.

Author

Joseph E Maakaron, MD, Research Fellow, Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

Coauthor(s)

Ali T Taher, MD, PhD, FRCP, Professor of Medicine, Associate Chair of Research, Department of Internal Medicine, Division of Hematology/Oncology, Director of Research, NK Basile Cancer Center, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Disclosure: Nothing to disclose.

Additional Contributors

Russell Burgess, MD (Retired) Chief, Division of Hematology/Oncology, Eastern Carolina Internal Medicine, PA

Russell Burgess, MD is a member of the following medical societies: American College of Physicians and American Medical Association

Disclosure: Nothing to disclose.

Ronald A Sacher, MB, BCh, MD, FRCPC Professor, Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MB, BCh, MD, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, and Royal College of Physicians and Surgeons of Canada

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Talecris Honoraria Board membership

Paul Schick, MD Emeritus Professor, Department of Internal Medicine, Thomas Jefferson University Medical College; Research Professor, Department of Internal Medicine, Drexel University College of Medicine; Adjunct Professor of Medicine, Lankenau Hospital, Wynnewood, PA

Paul Schick, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Hematology, International Society on Thrombosis and Haemostasis, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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