A 34-year-old woman from rural Maharashtra presents with fatigue, dyspnea on exertion, and glossitis for 3 months. On examination, she has pallor and a smooth, beefy red tongue. Her hemoglobin is 7.2 g/dL with MCV 108 fL and MCH 38 pg. Peripheral blood smear shows hypersegmented neutrophils. What is the most appropriate next step in management?

Question

Accepted Answer

A. Measure serum vitamin B12 and folate levels. ## Clinical Diagnosis The patient presents with macrocytic anemia (MCV 108 fL) with glossitis, dyspnea, and hypersegmented neutrophils on smear — classic features of megaloblastic anemia. The differential includes vitamin B12 deficiency and folate deficiency. ## Next Step in Management **Key Point:** Before initiating specific therapy for megaloblastic anemia, serum B12 and folate levels MUST be measured to identify the underlying etiology. This is the gold standard diagnostic step. **High-Yield:** Measurement of serum cobalamin and folate is the first-line confirmatory test. Normal values: B12 >200 pg/mL, folate >5.4 ng/mL. If B12 is low, proceed to methylmalonic acid and homocysteine to confirm B12 deficiency. ## Why This Approach | Finding | B12 Deficiency | Folate Deficiency | | --- | --- | --- | | Serum B12 | Low (<200 pg/mL) | Normal (>200 pg/mL) | | Serum Folate | Normal or low | Low (<5.4 ng/mL) | | Neurological signs | Present (paresthesia, ataxia) | Absent | | Glossitis | Present | Present | | Source | Pernicious anemia, dietary, post-gastrectomy | Dietary, malabsorption, drugs (MTX, TMP-SMX) | **Clinical Pearl:** Treating B12 deficiency with folate alone can mask neurological manifestations while worsening them — a critical pitfall. Conversely, folate supplementation in undiagnosed B12 deficiency accelerates subacute combined degeneration. **Tip:** The presence of hypersegmented neutrophils and glossitis strongly suggests B12 deficiency (pernicious anemia is common in India due to dietary vegetarianism and malabsorption), but confirmation is mandatory before therapy. [cite:Harrison 21e Ch 104] ![Anemias Overview diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/2609.webp)

Answer

B. Start oral iron supplementation 200 mg ferrous sulfate daily

Answer

C. Initiate parenteral vitamin B12 therapy 1000 mcg weekly

Answer

D. Perform bone marrow biopsy immediately

Explanation

Clinical Diagnosis

Next Step in Management

Why This Approach

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Finding	B12 Deficiency	Folate Deficiency
Serum B12	Low (<200 pg/mL)	Normal (>200 pg/mL)
Serum Folate	Normal or low	Low (<5.4 ng/mL)
Neurological signs	Present (paresthesia, ataxia)	Absent
Glossitis	Present	Present
Source	Pernicious anemia, dietary, post-gastrectomy	Dietary, malabsorption, drugs (MTX, TMP-SMX)