Megaloblastosis

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Abstract
The Image in Clinical Medicine of the peripheral-blood smear from a patient with vitamin B12 deficiency (Aug. 1 issue)1 beautifully captures many of the features of megaloblastic anemia. The author mentions that the patient's mean corpuscular volume of 103 μm3 was “very low for pure vitamin B12 deficiency of this severity and might have suggested an additional hematologic problem,” but no additional abnormality was found. In fact, many patients with severe megaloblastic anemia have mean corpuscular volumes that are very elevated at first but later decline to the levels seen in this patient, while the red-cell–distribution width increases. Inspection of the peripheral-blood smear in such patients reveals the presence of schistocytes. The small size of the schistocytes lowers the mean corpuscular volume and raises the red-cell–distribution width. Schistocytes may be due to a further decline in the effectiveness of erythropoiesis in the bone marrow. The field shown in the image does not reveal schistocytes; however, they may be present in other fields.

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