What could cause a normal hematocrit with borderline macrocytosis (MCV 98 fL) and increased red‑cell distribution width (RDW 16.6 %) and how should it be evaluated?

Evaluation of Normal Hematocrit with Borderline Macrocytosis and Elevated RDW

Most Likely Diagnostic Considerations

The combination of normal hematocrit (46.8%), borderline-high MCV (98 fL), and elevated RDW (16.6%) most commonly indicates early nutritional deficiency—particularly iron, vitamin B12, or folate deficiency—or a mixed deficiency state where two processes are offsetting each other. 1, 2

The elevated RDW is the key finding here, signaling increased variation in red cell size (anisocytosis), which occurs when the bone marrow is producing cells of different sizes due to evolving deficiency or mixed pathology. 1, 3

Why This Pattern Occurs

Early or Mixed Nutritional Deficiency

• Iron deficiency combined with folate or B12 deficiency creates a "dimorphic" blood picture where microcytic cells (from iron deficiency) coexist with macrocytic cells (from megaloblastic deficiency), resulting in a normal or borderline-high MCV but markedly elevated RDW. 1, 2, 3

• Early vitamin B12 or folate deficiency may present with borderline macrocytosis (MCV 95-100 fL) and elevated RDW before frank macrocytic anemia develops; up to 20% of B12-deficient patients present with isolated macrocytosis without anemia. 2

• RDW is more sensitive than MCV for detecting early nutritional deficiencies, with sensitivities of 62.5% for folate, 72% for iron, and 75% for B12 deficiency in at-risk populations. 3

Alcohol Use

• Chronic alcohol consumption is the single most common cause of macrocytosis in adults, accounting for 36.5% of cases in systematic evaluations, and typically produces MCV 100-110 fL with elevated RDW due to direct toxic effects on erythropoiesis and associated folate deficiency. 2

Medication Effects

• Drug-induced macrocytosis (hydroxyurea, methotrexate, antiretrovirals, anticonvulsants, chemotherapy agents) accounts for 12.9% of macrocytosis cases and often presents with elevated RDW as the bone marrow transitions from producing normal-sized to enlarged red cells. 2, 4

• Hydroxyurea specifically causes self-limiting macrocytosis that resembles pernicious anemia morphologically but is not related to vitamin B12 or folic acid deficiency; prophylactic folic acid administration is recommended during hydroxyurea therapy. 4

Hemolysis or Reticulocytosis

• Compensatory reticulocytosis from any cause (hemolysis, recent blood loss, recovery from anemia) shifts larger, immature reticulocytes into circulation, raising both MCV and RDW; reticulocytes are 20% larger than mature red cells and contain more hemoglobin. 1, 5

• In autoimmune hemolytic anemia, reticulocytes often contain inappropriately high hemoglobin content (elevated RET-He) and become larger than normal reticulocytes, contributing to macrocytosis with elevated RDW. 5

Essential Diagnostic Workup

First-Line Laboratory Tests

• Complete blood count with red cell indices (hemoglobin, MCV, MCH, MCHC, RDW) using an automated analyzer to confirm the pattern and evaluate for anemia. 1, 6

• Reticulocyte count to assess bone marrow response; an elevated corrected reticulocyte count suggests hemolysis or recent blood loss, while a normal or low count points toward nutritional deficiency or marrow dysfunction. 1, 6

• Serum ferritin and transferrin saturation to evaluate iron status; iron deficiency is present in 25-37.5% of patients with unexplained hematologic abnormalities and can coexist with macrocytosis. 1, 6

• Vitamin B12 and folate levels to screen for megaloblastic deficiency; B12 deficiency accounts for 24.1% of macrocytosis cases in systematic studies. 2

• Peripheral blood smear review to identify hypersegmented neutrophils (present in 86% of megaloblastic cases), macro-ovalocytes (72% of megaloblastic cases), or other morphologic abnormalities. 2, 6

Additional Testing Based on Initial Results

• Thyroid function tests (TSH, free T4) because hypothyroidism is a recognized cause of macrocytosis. 2

• Liver function tests (AST, ALT, bilirubin, alkaline phosphatase) to screen for liver disease, which accounts for a subset of macrocytosis cases and may indicate alcohol-related pathology. 2, 6

• Lactate dehydrogenase (LDH), haptoglobin, and indirect bilirubin if reticulocytosis is present to evaluate for hemolysis. 1, 4

• Medication review for drugs known to cause macrocytosis (hydroxyurea, methotrexate, antiretrovirals, anticonvulsants, chemotherapy). 2, 4

Clinical Significance and Management Approach

When to Pursue Aggressive Workup

• Macrocytosis requires evaluation even in the absence of anemia because it may be the first clue to an underlying pathology such as early B12 deficiency, occult hemolysis, or myelodysplastic syndrome. 2

• Elevated RDW with normal or borderline MCV is not benign; it signals evolving or mixed pathology and warrants complete nutritional assessment and peripheral smear review. 1, 3

Common Pitfalls to Avoid

• Do not assume normal hematocrit excludes significant pathology; isolated macrocytosis with elevated RDW can represent early B12 deficiency (20.9% of B12-deficient patients present without anemia), mixed deficiency states, or compensated hemolysis. 2, 5

• Do not rely on MCV alone to detect nutritional deficiencies; in mixed iron and folate/B12 deficiency, microcytic and macrocytic populations cancel each other out, producing a falsely normal MCV while RDW remains elevated. 1, 3

• Do not overlook alcohol use; a detailed alcohol history is essential because alcoholism is the most common cause of macrocytosis (36.5% of cases) and is often underreported by patients. 2

• Do not miss medication-induced macrocytosis; hydroxyurea and other drugs cause self-limiting macrocytosis that mimics megaloblastic anemia but does not respond to B12 or folate supplementation. 4, 2

Specific Management Based on Etiology

If Iron Deficiency Is Confirmed

• Initiate oral iron supplementation and investigate potential sources of blood loss (gastrointestinal bleeding, menorrhagia); perform stool guaiac testing to screen for occult GI bleeding. 1

If B12 or Folate Deficiency Is Confirmed

• Initiate appropriate vitamin replacement therapy; for B12 deficiency, intramuscular or high-dose oral B12 is required, while folate deficiency responds to oral folic acid supplementation. 2

If Alcohol-Related Macrocytosis Is Identified

• Counsel on alcohol cessation and provide folate supplementation; alcohol-related macrocytosis typically resolves with abstinence and nutritional repletion. 2

If Drug-Induced Macrocytosis Is Suspected

• Review necessity of causative medication and consider alternatives if feasible; for hydroxyurea, prophylactic folic acid is recommended to mitigate macrocytosis. 4

If Hemolysis Is Detected

• Perform direct and indirect antiglobulin (Coombs) tests to evaluate for autoimmune hemolytic anemia; if confirmed, discontinue any potentially causative drugs and consider hematology referral. 4

Follow-Up Strategy

• Repeat CBC with indices after 4-6 weeks of targeted therapy (iron, B12, folate supplementation or alcohol cessation) to assess response; MCV and RDW should normalize if the correct deficiency has been identified and treated. 2, 3

• If initial workup is unrevealing, consider bone marrow evaluation to exclude myelodysplastic syndrome, particularly in older adults or those with additional cytopenias. 2

• Monitor for progression; if macrocytosis or RDW worsens despite treatment, escalate evaluation to include hematology consultation and consideration of primary marrow disorders. 2, 6