Megaloblastic anemia due to folate deficiency - Chronic
Definition
A megaloblastic anemia caused by a deficiency in folate that affects erythropoiesis
Medical History
* Folate deficiency anemia due to dietary causes
* Pregnancy, Third Trimester
* Hemolytic anemia [Hemolytic anemia - Chronic]
* Alcohol Abuse
* Anticonvulsant use
* Sulfasalazine use
* Methotrexate use
* Trimethoprim/Sulfamethoxazole use
* Renal dialysis
Findings
* Dyspnea - Chronic
* Sinus tachycardia
* Diarrhea
* Fatigue
* Glossitis
* Irritability
* Jaundice
* Loss of appetite
* Neuropathy
* Pallor
* Weight loss
Tests
All patients with suspected folate deficiency anemia should have a CBC with WBC differential to aid in diagnosis.
* Complete blood count with white cell differential, manual
Anemia
* Peripheral blood smear examination, light microscopy: Blood smear examination is indicated in the initial evaluation of suspected or unexplained anemia .
Erythrocyte mean corpuscular volume will be above 100 in patients with megaloblastic anemia due to folate deficiency.
* Erythrocyte mean corpuscular volume determination
RBC folate levels are more sensitive in determining a patient's folate stores than is a serum folate measurement in patients with folate deficiency megaloblastic anemia. RBC folate levels below 200 ng/mL are diagnostic of megaloblastic anemia due to folate deficiency. Serum folate is usually be correspondingly low (under 2).
* Folic acid measurement, RBC
Screening for iron deficiency anemia
* Measurement of total hemoglobin concentration: Two Hgb values below the accepted threshold are presumptive for iron-deficiency anemia. The diagnosis can be confirmed if hgb values rise to 1 g/dL or greater after 4 weeks of iron supplementation therapy .
Serum folate levels may be checked but are less specific and sensitive for folate deficiency than is a RBC folate level.
* Folic acid measurement, serum
Suspected anemia
* Hematocrit determination: Very mild anemias are associated with few or no clinical signs or symptoms; therefore, a mild anemia usually is first detected from a screening measurement of Hgb or HCT.
Suspected or known anemia
* Reticulocyte count: The reticulocyte count is essential for differentiating between anemias arising from nonfunctional versus functional bone marrow .
Suspected vitamin B12 (cobalamin) deficiency secondary to pernicous anemia
* Serum vitamin B12 measurement: Serum cobalamin levels below 74 pmol/L indicate a probable cobalamin deficiency .
Differential Diagnosis
* ETHANOL
* Disease of liver
* Hypothyroidism - Chronic
* Megaloblastic anemia due to chronic hemolytic anemia
* Megaloblastic anemia due to dietary causes
* Celiac disease - Chronic
* Anemia of pregnancy
* METHOTREXATE AND RELATED AGENTS
* AIDS ANTIVIRAL NUCLEOSIDES
* AIDS ANTIVIRAL PROTEASE INHIBITORS
* Megaloblastic anemia due to increased requirements
* Megaloblastic anemia due to disease of small intestine
* Megaloblastic anemia due to vitamin B12 deficiency - Chronic
* Multiple myeloma - Chronic
Treatment
Drug Therapy
Anemia of pregnancy
FOLIC ACID
All pregnant women: 400 mcg orally once daily; initiate therapy before conception
Anemic pregnant women on anti-epileptic drugs, proguanil, maloprim, or with a previous baby with a neural tube defect
FOLIC ACID
Pregnant women on anti-epileptic drugs, proguanil, maloprim, or with a previous baby with a neural tube defect: 5 mg orally once daily
Folate deficiency megaloblastic anemia
FOLIC ACID
Adults: 1 to 5 mg orally daily for 4 months minimum
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