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A student with macrocytic anaemia

BMJ 2014; 348 doi: (Published 15 May 2014) Cite this as: BMJ 2014;348:g3099

This article has a correction. Please see:

  1. W Thomas, specialist trainee year 4, haematology,
  2. F d’Orey, medical student,
  3. G Turner, consultant haematologist
  1. 1Haematology Department, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
  1. Correspondence to: W Thomas whcthomas{at}

A 22 year old university student presented to hospital with syncope shortly before submitting her final dissertation. She had a two month history of tiredness and breathlessness on minimal exertion. She denied menorrhagia. Her medical history and family history were unremarkable. She had a non-vegetarian diet, mainly based on carbohydrates, and she drank alcohol only occasionally.

On examination she was pale, with a pulse of 112 beats/min, no orthostatic hypotension, and mild sclera icterus. She had a normal body weight. Neurological examination was normal.

Blood tests showed white cell count 4.2×109/L (normal range 4-10), haemoglobin 49 g/L (120-150), mean cell volume 115 fL (83-101), platelets 161×109/L (150-400), lactate dehydrogenase 7951 U/L (125-243; 1 U/L= 0.02 µkat/L). Thyroid, renal, and liver function tests were normal apart from a bilirubin of 30 µmol/L (0-20; 1 µmol/L=0.06 mg/dL). Blood was also taken for a blood film (fig 1).


  • 1. What features are seen on the blood film?

  • 2. What is the diagnosis?

  • 3. How should this condition be treated and monitored?

  • 4. What are the underlying causes of this condition?

  • 5. What are the differential diagnoses of macrocytic anaemia?


1. What features are seen on the blood film?

Short answer

A hypersegmented neutrophil with a red cell fragment, red cell anisopoikilocytosis, and a megaloblastic nucleated red blood cell.

Long answer

The blood film shows a hypersegmented neutrophil with a red cell fragment to the right of the neutrophil, red cell anisopoikilocytosis, and a megaloblast (fig 2). Neutrophils normally have two to five lobes, but the one in the image has eight lobes and is termed hypersegmented. A red cell fragment is a pointed, distorted, often triangular red cell. Anisocytosis refers to a change in size and poikilocytosis refers to a change in shape …

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