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Drug Induced Macrocytic Megaloblastic Anemia DTP Group CResearch: Sunil BacharaniandaGroup Leader: Siobhan TaylorNarration: Ervin MagicScribe: Tara Duesbury June 16, 2014

1Hematology Case 3OverviewHistoryPhysical ExaminationLab Investigations: results and interpretationAssessment: DDx and most likely DxManagementPrognosis and Patient education

2History37 year old male.seizure disorder since age 2.At routine neurology check, complained of feeling fatigued, shortness of breath on exertion, and lightheadedness over the past month or so.

3Additional Relevant History QuestionsAny weakness, paresthesias of fingers and toes, loss of coordination of legs, tremors, irritability, somnolence?Any weight loss, decreased appetite, abdominal pain, night sweats, chronic cough?Any gastritis, hemoptysis, hematemesis, melena, bleeding disorder?Is he on a restricted or vegan diet? Does he have a malabsorption disorder (ie. Short bowel syndrome, Crohns disease, Tropical sprue)?Does he consume excessive alcohol? Past medical history of: liver disease, thyroid disease, tuberculosis, malignancy or exfoliative dermatitis?Which medications is he taking for seizures (ie. Phenytoin/Primidone/Phenobarb)? Any recent change in dosage?Is he on medications such as Antineoplastic agents, Zidovidine, Methotrexate, Sulpha drugs, Proton pump inhibitors, Metformin, Colchicine, Neomycin or Para-aminosalicylic acid?

4Physical ExamSkin pallor noted. Otherwise, physical exam was unremarkable.

5Laboratory InvestigationsRBC 1.24 x 1012/L Hgb 58 g/L Hct 0.162 MCV 131 fL MCHC 348 g/L RDW 0.184 WBC 6.1 x 109/L Neutrophils 73 % Lymphocytes 21% Monocytes 1% Eosinophils 4% Basophils 1% Platelets 219 x 109/LBlood Smear AnalysisRed blood cellsNormochromic2+ macrocytosis2+ anisocytosismany oval macrocytesOccasional teardrop cells and fragments

WBC morphologyMultiple neutrophils with nuclear hypersegmentation

Platelets normal

Laboratory InvestigationsBone marrow biopsy:Numerous Howell Jolly bodies. Increased number of erythroids with megaloblastic maturation. Neutrophils show premature nuclear segmentation. Giant metamyelocytes and band forms.

Chemistry:Serum folate