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This impairment of DNA synthesis affects the rapidly dividing cells of the bone marrow earlier than other cells, resulting in the production of large, immature, hemoglobin-poor red blood cells (macrocytosis), as well as effects on white blood cells, including abnormal (hypersegmented) neutrophils and reduced overall cell counts (pancytopenia)

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13 Our patients did not have clinical features suggestive of malabsorption