Ineffective haemopoiesis

There is an accumulation of unconjugated bilirubin in plasma due to the death of nucleated red cells in the marrow (ineffective erythropoiesis). Other evidence for this includes raised urine urobilinogen, reduced haptoglobins and positive urine haemo-siderin, raised serum lactate dehydrogenase to values of between 1000 and 10 000 IU/dL and raised serum iron, non-transferrin-bound iron and ferritin levels. Carbon monoxide production is also increased. The serum lysozyme may also be raised, suggesting ineffective granulopoiesis.

In rare patients, ineffective haemopoiesis is associated with features of disseminated intravascular coagulation, with raised serum fibrin degradation products. Thrombocytopenia, when it occurs, is usually caused by ineffective megakaryopoiesis. A weakly positive direct antiglobulin test due to complement can lead to a false diagnosis of autoimmune haemolytic anaemia.

Haemolysis Assay

Figure 5.4 (a) The peripheral blood in severe megaloblastic anaemia. (b) The bone marrow in severe megaloblastic anaemia.

Figure 5.4 (a) The peripheral blood in severe megaloblastic anaemia. (b) The bone marrow in severe megaloblastic anaemia.

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