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Autor*: Monika Antošová, A. Buliková, J. Kissová
Description:
56-years old man hospitalised in medical department due to bicytopenia with severe macrocytic anemia (Hb 67,8 g/l, MCV 118 fl, platelets 91,2 G/l). Peripheral blood smear and also bone marrow examination shows features of megaloblastic haematopoiesis. Serum B12 level is 30 pg/ml. Gastrofibroscopia exhibits atrophic gastritis. Final diagnose is pernicious anemia.
Zařazení*:
Red blood cell disorders
Přílohy*:
Description: There are macrocytes and also characteristic oval macrocytes in peripheral blood smear. There is also some degree of anisocytosis and poikilocytosis in this rather severe case, including the presence of tear-drop poikilocytes, fragments. 
Description: Cabot ring can be find in severe case of megaloblastic erythropoiesis. 
Description: The presence of hypersegmented neutrophils is highly suggestive of megaloblastic haematopoiesis in peripheral blood smear although not patognomic. It persists for a week or more after commencement of of vitamin B12 or folic acid therapy. 
Description: Erythropoiesis is hyperplastic and is characterized by the presence of megaloblasts. They are large erythroid cells with a chromatin pattern more immature than is appropriate for the degree of maturation of the cytoplasm. The most typical cell is at the 8 o'clock. 
Description: Hyperplastic erythropoiesis with numerous megaloblasts of various degree of maturity. 
Description: There is the giant metamyelocyte at 6 o'clock at a typical change in granulocytic lineage. It is approximately twice times the size of a normal metamyelocyte with abnormal shape of nuclei. There is a hypersegmented neutrophil at right. 
Description: Giant metamyelocytes and bands in neutrophil series are usually present. Detection of these cells is diagnostically important in cases, when megaloblastic features of erythropoiesis are masked by co-existing iron deficiency. Granulopoiesis use to be also hyperplastic in bone marrow, although less so than erythropoiesis. 
Description: Some early and late (at right) megaloblasts, one promegaloblast at middle left. Both types of megaloblasts have abundant cytoplasm and rather immature nuclear chromatin. 
Description: Mature megakaryocyt with more finely stippled chromatin then normal megakaryocytes. 
Description: Hypersegmented moderately mature megakaryocyte. 
Description: Megaloblastic erythropoiesis is ineffective, early erythroid cells are over-represented in comparison with mature cells. Macrophages are increased and contain defective red cell precursors and cellular debris. 
Description: Mitoses are more frequent in bone marrow (mitosis of granulocytic lineage at left, erythroid mitosis at right). Cell in metaphase shows that chromosomes are unusually long. 
Description: More (at right) or less (at left) mature megaloblasts with abundant cytoplasm. The more mature one contains numerous Howell Jolly bodies. Erythrocyte at the middle left shows basophilic stippling - this picture can be find also in peripheral blood smears. 
Description: Multilobular erythroblast can also occur, but this feature is less strongly associated with megaloblastic erythropoiesis unless co-existing myelodysplastic syndrome. 
Description: The mitotic rate is increased. This picture shows intercellular bridge between two megaloblasts. 
Description: An iron stain shows numerous sideroblast (in the middle) and siderocytes. 
Description: Siderotic granules in Pearl's stain in sideroblast are abnormally prominent, sometimes occasional ring sideroblast can also occur (not shown). 
Description: Storage iron is usually increased in case of megaloblastic erythropoiesis. Haemophagocytosis is also shown here. 
Description: Macrophage contains erythroid precursors. It is also fully filed with iron.