Megaloblastic anemia as a differential diagnosis in pancytopenia

Abstract

Introduction: Pancytopenia is considered a reduction of all lineages of blood cells. Megaloblastic anemia is one of its several causes, which is a group of disorders characterized by the presence of different morphological aspects of the maturing cells in the bone marrow associated with ineffective erythropoiesis. Objectives: Description of a clinical case. Case: We present a case of a 39 years old male, ex-drug addict (cocaine and heroin), with severe drinking habits, that was brought to the emergency room for extreme fatigue and palpitations at rest with three months of evolution. He complained about anorexia and frequent epistaxis in the last week too. At physical examination, the patient was awake and oriented; his vital signs were temperature 37 °C, blood pressure 85/44 mm Hg, heart rate 115 bpm, and respiratory rate 24/min, without signs of respiratory distress. The patient was extremely pale and dehydrated, with no rash, absence of petechiae, purpura or hemorrhagic manifestations; no palpable lymphadenopathy; cardiopulmonary auscultation had no significant alterations; painless abdomen with hepatosplenomegaly without palpable masses; and severe generalized edema. From his laboratory tests we highlight a severe pancytopenia: macrocytic anemia (Hb 2.8 g/dL), thrombocytopenia (16,000 platelets/μL) and leukopenia (2650 leukocytes/μL) with decreases in all lineages of leukocytes. Allied to these changes, we found liver cytolysis and a very high LDH (5341). Abdominal CT showed liver cirrhosis with splenomegaly related with portal hypertension. In the study of anemia, a severe deficiency of folic acid was discovered. A peripheral blood smear and bone marrow were done, consistent with megaloblastic anemia. Therefore, we were before a chronic alcoholic liver disease associated with a severe nutritional deficiency. The patient initiated oral supplementation of folate and B12 vitamin, with good response: normalization of all cell lines with three months of treatment. Conclusions: This case reinforces the importance of the exclusion of nutritional deficits in the differential diagnosis of anemia and pancytopenia, even in developed countries.