Megaloblastic anemia

Definition

Anemia is a condition characterized by abnormally low levels of healthy red blood cells or hemoglobin (the component of red blood cells that delivers oxygen to tissues throughout the body).

Description

The tissues of the human body need a regular supply of oxygen to stay healthy. Red blood cells, which contain hemoglobin that allows them to deliver oxygen throughout the body, live for only about 120 days. When they die, the iron they contain is returned to the bone marrow and used to create new red blood cells. Anemia develops when heavy bleeding causes significant iron loss or when something happens to slow down the production of red blood cells or to increase the rate at which they are destroyed.

Types of anemia

Anemia can be mild, moderate, or severe enough to lead to life-threatening complications. More than 400 different types of anemia have been identified. Many of them are rare.

Iron deficiency anemia is the most common form of anemia in the world. In the United States, iron deficiency anemia affects about 240,000 toddlers between one and two years of age and 3.3 million women of childbearing age. This condition is less common in older children and in adults over 50 and rarely occurs in teenage boys and young men.

The onset of iron deficiency anemia is gradual and, at first, there may not be any symptoms. The deficiency begins when the body loses more iron than it derives from food and other sources. Because depleted iron stores cannot meet the red blood cell's needs, fewer red blood cells develop. In this early stage of anemia, the red blood cells look normal, but they are reduced in number. Then the body tries to compensate for the iron deficiency by producing more red blood cells, which are characteristically small in size. Symptoms develop at this stage.

Folic acid deficiency anemia is the most common type of megaloblastic anemia (in which red blood cells are bigger than normal). It is caused by a deficiency of folic acid, a vitamin that the body needs to produce normal cells.

Folic acid anemia is especially common in infants and teenagers. Although this condition usually results from a dietary deficiency, it is sometimes due to inability to absorb enough folic acid from such foods as:

• Cheese
• Eggs
• Fish
• Green vegetables
• Meat
• Milk
• Mushrooms
• Yeast.

Smoking raises the risk of developing this condition by interfering with the absorption of Vitamin C, which the body needs to absorb folic acid. Folic acid anemia can be a complication of pregnancy, when a woman's body needs eight times more folic acid than it does otherwise.

Less common in this country than folic acid anemia, vitamin B₁₂ deficiency anemia is another type of megaloblastic anemia that develops when the body doesn't absorb enough of this nutrient. Necessary for the creation of red blood cells, B₁₂ is found in meat and vegetables.

Large amounts of B₁₂ are stored in the body, so this condition may not become apparent until as much as four years after B₁₂ absorption stops or slows down. The resulting drop in red blood cell production can cause:

• Loss of muscle control
• Loss of sensation in the legs, hands, and feet
• Soreness or burning of the tongue
• Weight loss
• Yellow-blue color blindness.

The most common form of B₁₂ deficiency is pernicious anemia. Since most people who eat meat or eggs get enough B₁₂ in their diets, a deficiency of this vitamin usually means that the body is not absorbing it properly. This can occur among people who have had intestinal surgery or among those who do not produce adequate amounts of intrinsic factor, a chemical secreted by the stomach lining that combines with B₁₂ to help its absorption in the small intestine.

Pernicious anemia usually strikes between the ages of 50-60. Eating disorders or an unbalanced diet increases the risk of developing pernicious anemia. So do:

• Diabetes mellitus
• Gastritis, stomach cancer, or stomach surgery
• Thyroid disease
• Family history of pernicious anemia.

A rare disorder that causes the bone marrow to manufacture abnormally small red blood cells, Vitamin C deficiency anemia results from a severe, long-standing dietary deficiency.

Some people are born with hemolytic anemia. Some acquire this condition, in which infection or antibodies destroy red blood cells more rapidly than bone marrow can replace them.

Hemolytic anemia can enlarge the spleen, accelerating the destruction of red blood cells (hemolysis). Other complications of hemolytic anemia include:

• Pain
• Shock
• Gallstones and other serious health problems.

An inherited form of hemolytic anemia, thalassemia stems from the body's inability to manufacture as much normal hemoglobin as it needs. There are two categories of thalassemia, depending on which of the amino acid chains is affected. (Hemoglobin is composed of four chains of amino acids.) In alpha-thalassemia, there is an imbalance in the production of the alpha chain of amino acids; in beta-thalassemia, there is an imbalance in the beta chain. Alpha-thalassemias most commonly affect blacks (25% have at least one gene); beta-thalassemias most commonly affect people of Mediterranean ancestry and Southeast Asians.

Characterized by production of red blood cells that are unusually small and fragile, thalassemia only affects people who inherit the gene for it from each parent (autosomal recessive inheritance).

Warm antibody hemolytic anemia is the most common type of this disorder. This condition occurs when the body produces autoantibodies that coat red blood cells. The coated cells are destroyed by the spleen, liver, or bone marrow.

Warm antibody hemolytic anemia is more common in women than in men. About one-third of patients who have warm antibody hemolytic anemia also have lymphoma, leukemia, lupus, or connective tissue disease.

In cold antibody hemolytic anemia, the body attacks red blood cells at or below normal body temperature. The acute form of this condition frequently develops in people who have had pneumonia, mononeucleosis, or other acute infections. It tends to be mild and short-lived, and disappears without treatment.

Chronic cold antibody hemolytic anemia is most common in women and most often affects those who are over 40 and who have arthritis. This condition usually lasts for a lifetime, generally causing few symptoms. However, exposure to cold temperatures can accelerate red blood cell destruction, causing fatigue, joint aches, and discoloration of the arms and hands.

Sickle cell anemia is a chronic, incurable condition that causes the body to produce defective hemoglobin, which forces red blood cells to assume an abnormal crescent shape. Unlike normal oval cells, fragile sickle cells can't hold enough hemoglobin to nourish body tissues. The deformed shape makes it hard for sickle cells to pass through narrow blood vessels. When capillaries become obstructed, a life-threatening condition called sickle cell crisis is likely to occur.

Sickle cell anemia is hereditary. It almost always affects blacks and people of Mediterranean descent. A child who inherits the sickle cell gene from each parent will have the disease. A child who inherits the sickle cell gene from only one parent carries the sickle cell trait, but does not have the disease.

Sometimes curable by bone marrow transplant, but potentially fatal, aplastic anemia is characterized by decreased production of red and white blood cells and platelets (disc-shaped cells that allow the blood to clot). This disorder may be inherited or acquired as a result of:

• Recent severe illness
• Long-term exposure to industrial chemicals
• Use of anticancer drugs and certain other medications.

Cancer, chronic infection or inflammation, and kidney and liver disease often cause mild or moderate anemia. Chronic liver failure generally produces the most severe symptoms.

Causes & symptoms

Anemia is caused by bleeding, decreased red blood cell production, or increased red blood cell destruction. Poor diet can contribute to vitamin deficiency and iron deficiency anemias in which fewer red blood cells are produced. Hereditary disorders and certain diseases can cause increased blood cell destruction. However, excessive bleeding is the most common cause of anemia, and the speed with which blood loss occurs has a significant effect on the severity of symptoms. Chronic blood loss is usually a consequence of:

• Cancer
• Gastrointestinal tumors
• Diverticulosis
• Polyposis
• Heavy menstrual flow
• Hemorrhoids
• Nosebleeds
• Stomach ulcers
• Long-standing alcohol abuse.

Acute blood loss is usually the result of:

• Childbirth
• Injury
• A ruptured blood vessel
• Surgery.

When a lot of blood is lost within a short time, blood pressure and the amount of oxygen in the body drop suddenly. Heart failure and death can follow.

Loss of even one-third of the body's blood volume in the space of several hours can be fatal. More gradual blood loss is less serious, because the body has time to create new red blood cells to replace those that have been lost.

Symptoms

Weakness, fatigue, and a run-down feeling may be signs of mild anemia. Skin that is pasty or sallow, or lack of color in the creases of the palm, gums, nail beds, or lining of the eyelids are other signs of anemia. Someone who is weak, tires easily, is often out of breath, and feels faint or dizzy may be severely anemic.

Other symptoms of anemia are:

• Angina pectoris (chest pain, often accompanied by a choking sensation that provokes severe anxiety)
• Cravings for ice, paint, or dirt
• Headache
• Inability to concentrate, memory loss
• Inflammation of the mouth (stomatitis) or tongue (glossitis)
• Insomnia
• Irregular heartbeat
• Loss of appetite
• Nails that are dry, brittle, or ridged
• Rapid breathing
• Sores in the mouth, throat, or rectum
• Sweating
• Swelling of the hands and feet
• Thirst
• Tinnitus (ringing in the ears)
• Unexplained bleeding or bruising .

In pernicious anemia, the tongue feels unusually slick. A patient with pernicious anemia may have:

• Problems with movement or balance
• Tingling in the hands and feet
• Confusion, depression, and memory loss.

Pernicious anemia can damage the spinal cord. A doctor should be notified whenever symptoms of this condition occur.

A doctor should also be notified if a patient who has been taking iron supplements develops:

• Diarrhea
• Cramps
• Vomiting.

Diagnosis

Personal and family health history may suggest the presence of certain types of anemia. Laboratory tests that measure the percentage of red blood cells or the amount of hemoglobin in the blood are used to confirm diagnosis and determine which type of anemia is responsible for a patient's symptoms. X rays and examinations of bone marrow may be used to identify the source of bleeding.

Treatment

Anemia due to nutritional deficiencies can usually be treated at home with iron supplements or self administered injections of vitamin B₁₂. People with folic acid anemia should take oral folic acid replacements. Vitamin C deficiency anemia can be cured by taking one vitamin C tablet a day.

Surgery may be necessary to treat anemia caused by excessive loss of blood. Transfusions of red blood cells may be used to accelerate production of red blood cells.

Medication or surgery may also be necessary to control heavy menstrual flow, repair a bleeding ulcer, or remove polyps (growths or nodules) from the bowels.

Patients with thalassemia usually do not require treatment. However people with a severe form may require periodic hospitalization for blood transfusions and/or bone marrow transplantation.

Treatment for sickle cell anemia involves regular eye examinations, immunizations for pneumonia and infectious diseases, and prompt treatment for sickle cell crises and infections of any kind. Psychotherapy or counseling may help patients deal with the emotional impact of this condition.

A life-long regimen of B₁₂ shots is necessary to control symptoms of pernicious anemia. The patient may be advised to limit physical activity until treatment restores strength and balance.

People who have aplastic anemia are especially susceptible to infection. Treatment for aplastic anemia may involve blood transfusions and bone marrow transplant to replace malfunctioning cells with healthy ones.

There is no specific treatment for anemia associated with chronic disease, but treating the underlying illness may alleviate this condition. This type of anemia rarely becomes severe. If it does, transfusions or hormone treatments to stimulate red blood cell production may be prescribed.

There is no specific treatment for cold-antibody hemolytic anemia. About one-third of patients with warm-antibody hemolytic anemia respond well to large doses of intravenous and oral corticosteroids, which are gradually discontinued as the patient's condition improves. Patients with this condition who don't respond to medical therapy must have the spleen surgically removed. This operation controls anemia in about half of the patients on whom it's performed. Immune-system suppressants are prescribed for patients whose surgery is not successful.

Self-care

Anyone who has anemia caused by poor nutrition should modify his or her diet to include more vitamins, minerals, and iron. Vitamin C can stimulate iron absorption. The following foods are also good sources of iron:

• Almonds
• Broccoli
• Dried beans
• Dried fruits
• Enriched breads and cereals
• Lean red meat
• Liver
• Potatoes
• Poultry
• Rice
• Shellfish
• Tomatoes.

Because light and heat destroy folic acid, fruits and vegetables should be eaten raw or cooked as little as possible.

Alternative treatment

As is the case in standard medical treatment, the cause of the specific anemia will determine the alternative treatment recommended. If the cause is a deficiency, for example iron deficiency, folic acid deficiency, B₁₂ deficiency, or vitamin C deficiency, supplementation is the treatment. For extensive blood loss, the cause should be identified and corrected. Other types of anemias should be addressed on a deep healing level with crisis intervention when necessary.

Many alternative therapies for iron-deficiency anemia focus on adding iron-rich foods to the diet or on techniques to improve circulation and digestion. Iron supplementation, especially with iron citrate (less likely to cause constipation), is used by alternative practitioners. This can be given in combination with herbs that are rich in iron. Some examples of iron-rich herbs are dandelion (Taraxacum officinale), parsley (Petroselinum crispum), and nettle (Urtica dioica). The homeopathic remedy ferrum phosphoricum can also be helpful.

An iron-rich herbal tonic can also me made using the following recipe:

• Soak 1/2 oz of yellow dock root and 1/2 oz dandelion root in 1 qt of boiled water for 4-8 hours
• Strain and simmer until the amount of liquid is reduced to 1 cup
• Remove from heat and add 1/2 cup black strap molasses, mixing well
• Store in refrigerator; take 1 tsp-2 Tbsp daily.

Other herbal remedies used to treat iron-deficiency anemia aim to improve the digestion. Gentian (Gentiana lutea) is widely used in Europe to treat anemia and other nutritionally based disorders. The bitter qualities of gentian help stimulate the digestive system, making iron and other nutrients more available for absorption. This bitter herb can be brewed into tea or purchased as an alcoholic extract (tincture).

Other herbs recommended to promote digestion include:

• Anise (Pimpinella anisum)
• Caraway (Carum carvi)
• Cumin (Cuminum cyminum)
• Linden (Tilia spp.)
• Licorice (Glycyrrhiza glabra).

Traditional Chinese treatments for anemia include:

• Acupuncture to stimulate a weakened spleen
• Asian ginseng (Panax ginseng) to restore energy
• Dong quai (Angelica sinensis) to control heavy menstrual bleeding
• A mixture of dong quai and Chinese foxglove(Rehmannia glutinosa) to clear a sallow complexion.

Prognosis

Folic-acid and iron-deficiency anemias

It usually takes three to six weeks to correct folic acid or iron deficiency anemia. Patients should continue taking supplements for another six months to replenish iron reserves and should have periodic blood tests to make sure the bleeding has stopped and the anemia has not recurred.

Pernicious anemia

Although pernicious anemia is considered incurable, regular B₁₂ shots will alleviate symptoms and reverse complications. Some symptoms will disappear almost as soon as treatment begins.

Aplastic anemia

Aplastic anemia can sometimes be cured by bone marrow transplantation. If the condition is due to immunosuppressive drugs, symptoms may disappear after the drugs are discontinued.

Sickle cell anemia

Although sickle cell anemia cannot be cured, effective treatments enable patients with this disease to enjoy longer, more productive lives.

Thalassemia

People with mild thalassemia (alpha thalassemia trait or beta thalassemia minor) lead normal lives and do not require treatment. Those with severe thalassemia may require bone marrow transplantation. Genetic therapy is is being investigated and may soon be available.

Hemolytic anemia

Acquired hemolytic anemia can generally be cured when the cause is removed.

Prevention

Inherited anemias cannot be prevented. Genetic counseling can help parents cope with questions and concerns about transmitting disease-causing genes to their children.

Avoiding excessive use of alcohol, eating a balanced diet that contains plenty of iron-rich foods, and taking a daily multivitamin can help prevent anemia.

Methods of preventing specific types of anemia include:

• Avoiding lengthy exposure to industrial chemicals and drugs known to cause aplastic anemia
• Not taking medication that has triggered hemolytic anemia and not eating foods that have caused hemolysis (breakdown of red blood cells)
• Receiving regular B₁₂ shots to prevent pernicious anemia resulting from gastritis or stomach surgery.

Key Terms

Aplastic

Exhibiting incomplete or faulty development.

Diabetes mellitus

A disorder of carbohydrate metabolism brought on by a combination of hereditary and enviornmental factors.

Hemoglobin

An iron-containing pigment of red blood cells composed of four amino acid chains (alpha, beta, gamma, delta) that delivers oxygen from the lungs to the tissues of the body.

Megaloblast

A large erythroblast (a red marrow cell that synthesizes hemoglobin).

Further Reading

For Your Information

Books

• Berkow, Robert, editor-in-chief. The Merck Manual of Medical Information: Home Edition. Whitehouse Station, NJ: Merck & Co., Inc., 1997.
• The Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative & Conventional Treatments. Alexandria, VA: Time Life, Inc., 1996.
• Tierney, Lawrence M., Jr., Current Medical Diagnosis & Treatment, 1998. Stamford, CT: Appleton & Lange, 1998.

  Other

• Aplastic anemia. http://www.thriveonline.com/health/Library/illsymp/illness15.html (2 June 1998).
• Folic acid deficiency anemia. http://www.thriveonline.com/health/Library/pedillsymp/pedillsymp19.html (2 June 1998).
• Hemolytic anemia. http://www.thriveonline.com/health/Library/illsymp/illness18.html (2 June 1998).
• Iron deficiency anemia. http://www.thriveonline.com/health/Library/pedillsymp/pedillsymp21.html (2 June 1998).
• Pernicious anemia. http://www.thriveonline.com/health/Library/illsymp/illness.20.html (3 June 1998).
• Prevalence of iron deficiency in the United States. http://www.thriveonline.com/health/Library/CAD/abstract26494.html (2 June 1998).
• Sickle cell anemia & sickle cell trait. http://www.thriveonline.com/health/Library/illsymp/illness476.html (2 June 1998).
• Thalassemia. http://www.thriveonline.com/health/Library/pedillsymp/pedillsymp416.html (2 June 1998).

Gale Encyclopedia of Medicine. Gale Research, 1999.