A patient with chronic alcohol use has macrocytic anemia. Which finding is most characteristic on peripheral smear?

• A. Macro-ovalocytes with hypersegmented neutrophils
• B. Target cells
• C. Spherocytes
• D. Elliptocytes

Answer: (A)

Macrocytic anemia with large, oversized red cells and abnormal neutrophil nuclei points to impaired DNA synthesis, i.e., megaloblastic changes from folate or B12 deficiency. In chronic alcohol use, poor nutrition can lead to folate deficiency, and alcohol itself can promote macrocytosis. On the peripheral smear you’d expect macro-ovalocytes—abnormally large red cells because nuclear maturation lags behind cytoplasmic growth—and hypersegmented neutrophils (neutrophils with more than the normal number of lobes). This combination is the hallmark of megaloblastic processes and is most characteristic here.

Other patterns like target cells, spherocytes, or elliptocytes reflect different conditions (liver disease or thalassemia, autoimmune hemolysis/hereditary spherocytosis, or elliptocytosis/membrane disorders, respectively) and aren’t the classic feature set linked to megaloblastic macrocytosis.