Folate-deficiency anemia frequently appears in women of childbearing age, in those who are pregnant or lactating, in alcohol abusers and malnourished individuals, thus proving the necessity of folate oral supplementation. Prevention must be carefully conducted, since the elderly may have difficulties tolerating folate intake.
Folate-deficiency anemia causes symptoms that are common for all types of anemia, like fatigue, irritability, headaches, diminished concentration ability, dyspnea, and palpitations, but also has certain supplementary features. When faced with a patient suffering from this condition, the physician must spend time on history inquiry in order to determine if the individual has risk factors like the use of certain drugs (e.g. methotrexate, sulfonamides, or phenytoin) or suffers from other diseases, such as malabsorption syndromes and chronic hemolytic anemia. Patients address their physician for tongue pain and ulcerations or angular stomatitis, vomiting, anorexia, weight loss, abdominal pain and diarrhea that usually occur after food intake. Hair pigmentation may also change. Neurologic symptoms include depression, impaired abstraction performance , a diminished cognitive status that may progress to dementia . Keeping in mind that some studies have shown that folate deficiency may be associated with cervical, esophageal, and colon cancer, as well as ulcerative colitis , the physician must inquire about symptoms related to these illnesses, too. Heart disease signs must also be searched for, knowing that low folate intake increases the risk of coronary artery disease  . Pregnant women must be closely monitored regarding folate-deficiency anemia signs because folate deficiency is known to cause neural tube birth defects, preterm delivery, growth retardation, and low birth weight .
Oral cavity examination frequently reveals a red, swollen, and shiny tongue. Some patients are subfebrile although infection is excluded and present with patchy hyperpigmented areas of the skin and mucous membranes. Their typical location includes dorsal aspects of the toes and fingers, as well as creases of soles and palms.
Blood workup should include a complete blood count, demonstrating the presence of megaloblastic anemia. The mean corpuscular volume is typically increased (above 96 fL ). A blood smear will show macrocytes, hypersegmented polymorphs, leukopenia, and thrombocytopenia if the deficiency is severe enough. In extreme cases, pancytopenia can be observed. The next step is to demonstrate folate deficiency and that is achieved by measuring folate levels. Cobalamin serum levels should also be measured in order to exclude cobalamin deficiency. Blood homocysteine will be found increased, above the reference range of 5-16 mmol/L, but it can be influenced by other factors, like kidney disease . Folate levels can also be measured in the red blood cells by radioisotope dilution, but this value is considered to be less reliable because it offers information about the folate status over the lifetime of the erythrocytes, whereas short term folate status is reflected by its serum level . A bone marrow biopsy will demonstrate megaloblastic cell maturation. Liver function tests and thyroid function tests are useful in cases where undeclared alcohol abuse or hypothyroidism are suspected, respectively. Malabsorptive disorders, if suspected, should be thoroughly searched for.