A female who is 36-year-old, experienced a recent weight loss. Her tongue was red and fissured. She also complained of chronic fatigue and shortness of breath upon exertion. Physical examination suggested signs of jaundice and increased numbness and a tingling sensation of fingers and toes. She was hospitalized with the general diagnosis of moderate anemia, jaundice, and neurological symptoms. Her admitting CBC demonstrated the following laboratory results: RBC: 2.5 X 10¹2/L WBC: 4.5 X 10⁹/L Hb: 10.0 g/dL Hct: 31% MCV: 124.0 fL MCH: 40.5 pg/dL MCHC: 32.7 gm/dL RDW: 21.2 PLT: 155 X10⁹/L WBC Differential Lymphs: % 36.0 Monos: % 3.8 Neutrophils: % 59.4 Eosinophils: % 1.0 Basophils: % 0.0 NRBCs/100WBCS: 5 The blood film shows anisocytosis and Poikilocytosis in which moderate hyper-segmented neutrophils and abnormal erythrocyte morphology was reported: Macrocytes, Ovalocytes with presence of basophilic stippling and occasional Howell-Jolly bodies. Also, 50 pg/mL (Low) Folate 10.3 ng/mL (Normal) Total Bilirubin 2.5 mg/dL (High) Direct Bilirubin 0.8 mg/dL (Normal) AST 35 U/mL (Normal) ALT 30 U/mL (Normal) Examination of her bone marrow aspirate revealed an erythroblastic hyperplasia with megaloblastic erythroblasts. A Schilling test and antibody testing were done, with the following results: Part I, before intrinsic factor, 1% Part II, after intrinsic factor, 8% Intrinsic-factor-blocking Positive to a titer of 1:6400 antibodies What is the morphologic classification of the patient's anemia? Based on the information obtained so far, what is the most likely defect? What is the importance to perform of the AST and ALT tests? What do you think about their results are they within the normal range? 4. What further testing can be done to obtain a definitive diagnosis? 1. 2. 3.

A female who is 36-year-old, experienced a recent weight loss. Her tongue was red and fissured. She also complained of chronic fatigue and shortness of breath upon exertion. Physical examination suggested signs of jaundice and increased numbness and a tingling sensation of fingers and toes. She was hospitalized with the general diagnosis of moderate anemia, jaundice, and neurological symptoms. Her admitting CBC demonstrated the following laboratory results: RBC: 2.5 X 10¹2/L WBC: 4.5 X 10⁹/L Hb: 10.0 g/dL Hct: 31% MCV: 124.0 fL MCH: 40.5 pg/dL MCHC: 32.7 gm/dL RDW: 21.2 PLT: 155 X10⁹/L WBC Differential Lymphs: % 36.0 Monos: % 3.8 Neutrophils: % 59.4 Eosinophils: % 1.0 Basophils: % 0.0 NRBCs/100WBCS: 5 The blood film shows anisocytosis and Poikilocytosis in which moderate hyper-segmented neutrophils and abnormal erythrocyte morphology was reported: Macrocytes, Ovalocytes with presence of basophilic stippling and occasional Howell-Jolly bodies. Also, 50 pg/mL (Low) Folate 10.3 ng/mL (Normal) Total Bilirubin 2.5 mg/dL (High) Direct Bilirubin 0.8 mg/dL (Normal) AST 35 U/mL (Normal) ALT 30 U/mL (Normal) Examination of her bone marrow aspirate revealed an erythroblastic hyperplasia with megaloblastic erythroblasts. A Schilling test and antibody testing were done, with the following results: Part I, before intrinsic factor, 1% Part II, after intrinsic factor, 8% Intrinsic-factor-blocking Positive to a titer of 1:6400 antibodies What is the morphologic classification of the patient's anemia? Based on the information obtained so far, what is the most likely defect? What is the importance to perform of the AST and ALT tests? What do you think about their results are they within the normal range? 4. What further testing can be done to obtain a definitive diagnosis? 1. 2. 3.