A 64-year-old male referred for evaluation of macrocytic anemia. On history he consumes 20 alcoholic drinks/day.
- What investigations should you order to investigate his macrocytic anemia?
- Does this patient warrant a bone marrow biopsy at this time?
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Diagnosis: macrocytic anemia/bicytopenia secondary to alcohol use disorder
CBC findings suggestive of diagnosis: (1) Inappropriately normal reticulocyte count
This patient has a significant alcohol use history, but our approach to macrocytic anemia should remain the same. This includes ordering reticulocyte count, Vitamin B12, TSH, and liver enzymes/functional tests to assess our differential diagnoses. It is important to ensure all other causes of macrocytic anemia have been ruled out before diagnosing a patient with alcohol use-related anemia. In this case, the reticulocyte count is inappropriately normal in the setting of anemia, suggesting bone marrow suppression and reduced production. All other testing was normal, thus confirming the diagnosis.
Alcohol has multiple effects on the hematopoietic system, including direct and indirect. Directly, alcohol can cause bone marrow suppression and thus lead to various cytopenias. Indirectly, it can cause nutritional deficiency (such as iron/B12) and chronic liver disease/cirrhosis.
There are no concerning features on the CBC at this time that warrant a bone marrow biopsy. If the patient were to have significant worsening in his cytopenias or presence of immature cells, a biopsy could be considered.
CBC Pearls
• Rule out other causes for macrocytosis before diagnosing as secondary to alcohol
• Alcohol can directly suppress bone marrow and lead to other cytopenias