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Alcohol withdrawal
3%
5/156
Folate deficiency
25%
39/156
Iron deficiency
4%
6/156
Thiamine deficiency
27%
42/156
Vitamin B12 deficiency
40%
63/156
Select Answer to see Preferred Response
This patient has a megaloblastic anemia given his low hemoglobin and elevated MCV in the setting of hypersegmented neutrophils on peripheral smear. The most likely cause of these findings is folate deficiency. The most common causes of folate deficiency are poor nutrition, alcohol abuse, and certain medications (such as trimethoprim, pyrimethamine, methotrexate, and phenytoin). Folate deficiency can develop within 4-5 months, whereas vitamin B12 stores take years to deplete. In addition, while serum homocysteine levels are elevated in both folate and vitamin B12 deficiencies, serum methylmalonic acid levels are normal in folate deficiency and elevated in vitamin B12 deficiency which is another differentiating factor. Hypersegmented neutrophils can be seen on peripheral smear from both folate and vitamin B12 deficiency. Figure A demonstrates the macrocytic/megaloblastic anemia (arrows showing enlarged RBCs) with hypersegmented neutrophils (red circle) seen in both folate and vitamin B12 deficiency. Incorrect Answers: Answer 1: Alcohol withdrawal would not cause hematologic changes seen on peripheral smear. In terms of the patient’s clinical picture, his presentation suggests a diagnosis of Wernicke encephalopathy rather than alcohol withdrawal given his nystagmus and ataxia. Alcohol withdrawal would present with tremulousness, tachycardia, diaphoresis, and hypertension. Answer 3: Iron deficiency causes a microcytic, hypochromic anemia and can be seen in alcoholics and pregnant patients. Answer 4: Thiamine deficiency can cause Wernicke encephalopathy but does not cause hypersegmented neutrophils on peripheral smear. Wernicke encephalopathy is characterized by the classic triad of encephalopathy, oculomotor dysfunction (nystagmus being the most common), and gait ataxia. Answer 5: Vitamin B12 deficiency causes the same macrocytic/megaloblastic anemia as folate deficiency; however, vitamin B12 deficiency takes years to develop, whereas folate deficiency usually takes 4-5 months. Because this patient only started drinking heavily a few months ago, folate deficiency is more likely. Bullet Summary: Folate deficiency can cause megaloblastic anemia and hypersegmented neutrophils.
3.1
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