Figure 3.9 Anaerobic breakdown of glucose in red cell metabolism.

third microcytic mechanism occurs in red cells from individuals who have iron overload disorders like hereditary hemochromatosis. These individuals will show a dimorphic blood smear, some microcytes mixed with macrocytes, some red cells exhibiting normal hemoglobin levels, and some showing hypochromia. The final microcytic mechanism is from those individuals who have the anemia of inflammation. Approxi mately 10% of these individuals who have the anemia of inflammation arising from renal failure or thyroid dysfunction also show microcytic red cells in their peripheral smear as iron delivery to the reticuloendothelial system is impaired.

All immature red blood cells are nucleated structures, and nuclear synthesis depends on vitamin B12 and folic acid. If either of these vitamins is unavailable or cannot be absorbed through the gastrointestinal system, a macrocytic cell evolves. More information concerning vitamin B12 and folic acid is available in Chapter 6. Macrocytic red blood cells have a diminished life span, and a megaloblastic anemia develops with an MCV in excess of 110 fL. In the bone marrow, the ery-thropoiesis is ineffective as the red cell precursors are prematurely destroyed before they are released into the peripheral circulation.7 Additionally, an asynchrony develops between the nuclear structure and the cytoplasm, as nuclear development and hemoglobin development become unbalanced. The nuclear age appears to be out of sync with the cytoplasm development. A pancytopenia develops in the CBC and hyperseg-mented neutrophils, and macro-ovalocytes are also part of the megaloblastic picture. In individuals who have borderline increased MCV, large cells may be generated subsequent to alcoholism and liver disease, or the increase in MCV may be as a result of high reticulocyte counts where polychromatophilic macrocytes are seen in the peripheral smear (Fig. 3.10).

Variations in Red Cell Color

Color variations in the red cells are observed as poly-chromasia or hypochromia. Polychromasia occurs subsequent to excessive production of red cell precursors in response to anemic stress. When the bone marrow responds to anemic stress, it releases reticulocytes and,

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