[Differential diagnosis of a macrocytic, hyperchromic anemia following alcohol abuse and simultaneous therapy with triamterene and cotrimoxazole].
METHODS
A 50-year-old woman was admitted to our emergency room because of progressive weakness. She collapsed the night before admission. Skin and mucosa were pale, she denied major infections or bleedings. An alcohol abuse was known for many years. Because of edema she received a therapy with triamteren, an infection of the urinary tract was treated with cotrimoxacol.


METHODS
In addition to thrombocytopenia (50 Gpt/l) and leukocytopenia (1,51 10 (9)/l) we diagnosed a hyperchromic and macrocytic anemia (Hb 3,6 mmol/l [5,8 g/dl], Hk 0,17, MCH 2.52 fmol, 116,8 fl). Folic acid was decreased to 0.677 ng/ml, whereas levels of cobalamin, ferritin and iron were normal. Examination of bone marrow showed a hypercellular marrow with typical megaloblastic features of erythropoiesis and granulopoiesis. A systemic hematological disorder could be ruled out. The folic acid deficiency in our patient was the result of a long time alcohol abuse and a simultaneous therapy with mild folate antagonists (triamteren and cotrimoxacol).


METHODS
The patient received folic acid (5 mg/d orally). Within one week the peripheral blood counts increased to normal, the follow up bone marrow examination showed a hyperplastic marrow with normal hematopoietic maturation.


CONCLUSIONS
Folic acid deficiency can be aggravated because of simultaneous therapy with mild folate antagonists. In addition to megaloblastic anemia this can lead to thrombocytopenia and/or leukocytopenia. Therefore in patients with pancytopenia a deficiency of folic acid should be ruled out.
Kahl
C
C
Abteilung Hämatologie und Onkologie, Klinik und Poliklinik für Innere Medizin, Universität Rostock. christoph.kahl@med.uni-rostock.de
Freund
M
M
D000437:Alcoholism / Q000150:complications*; D000748:Anemia, Macrocytic / Q000175:diagnosis* / Q000209:etiology; D000892:Anti-Infective Agents, Urinary / Q000009:adverse effects / Q000627:therapeutic use; D003937:Diagnosis, Differential; D004232:Diuretics / Q000009:adverse effects / Q000627:therapeutic use; D004487:Edema / Q000188:drug therapy; D005260:Female; D005492:Folic Acid / Q000097:blood / Q000627:therapeutic use; D005493:Folic Acid Antagonists / Q000009:adverse effects* / Q000627:therapeutic use; D005494:Folic Acid Deficiency / Q000139:chemically induced / Q000150:complications* / Q000209:etiology; D006801:Humans; D008875:Middle Aged; D010198:Pancytopenia / Q000209:etiology; D014223:Triamterene / Q000009:adverse effects* / Q000627:therapeutic use; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000009:adverse effects* / Q000627:therapeutic use; D014552:Urinary Tract Infections / Q000188:drug therapy
D000892:Anti-Infective Agents, Urinary; D004232:Diuretics; D005493:Folic Acid Antagonists; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D005492:Folic Acid; D014223:Triamterene