Essentials Of Diagnosis:
- Macrocytic Anemia
- Macro ovalocytes and hypersegmented neutrophils on peripheral blood smear
- Normal serum vitamin B12 levels
- Reduced folate levels in red blood cells or serum.
Introduction:
Folic acid is present in most fruits and vegetables ( especially citrus fruits and green leafy vegetables) and daily requirements of 50-100 mcg/d are usually met in the diet.
Causes Of Folic Acid Deficiency: By far the most common cause of folic acid deficiency is inadequate dietary intake. Alcoholic or anorexic patients who do not eat fresh fruits and vegetables , and those who over cook their food are candidates for folate deficiency. Reduced folate absorption is rarely seen , since absorption occurs from the entire gastrointestinal tract. However certain drugs may lead to decreased folic acid absorption resulting in folate deficiency.
Folic acid requirements are increased in pregnancy, hemolytic anemias and exfoliative skin diseases and the increased requirements may sometimes not be met by regular diet. The causes are summarized below:
- Dietary deficiency
- Decreased absorption ( in tropical sprue, drugs likes phenytoin , sulfasalazine)
- Increased requirments ( pregnancy, hemplytic anemia)
- Loss (dialysis)
- Inhibition of reduction to active form ( drugs e.g Methotrexate)
Clinical Features: The features and signs and symptoms are similar to those of Vitamin B12 deficiency with megaloblastic anemia and megaloblastic changes in mucosa however there are none of the neurological abnormalities associated with vitamin B12 deficiency.
Laboratory Findings: Megaloblastic anemia is identical to anemia resulting from Vitamin B12 defiecieny however the vitamin B12 levels are normal. A red blood cell folate level less than 150 ng/ml is diagnostic of folate deficiency
Differential Diagnosis: The megaloblastic anemia of folate deficiency should be differentiated from vitamin B12 deficiency by the finding of a normal vitamin B12 level and a reduced red blood cell folate or serum folate level.
Alcoholic patients who often have folate deficiency may also have anemia of liver disease. This latter macrocytic anemia does not cause megaloblastic morphologic changes but rather produces target cells in the peripheral blood.
Hypothyroidism is associated with mild macrocytosis but also with pernicious anemia.
Treatment: Folic acid deficiency is treated with folic acid 1 mg/day orally. The response is a rapid improvement and a feeling of well being. Reticulocytosis is seen in 5-7 daysand total correction of hematologic abnormalities occur within 2 months.
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