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I agree with your diagnosis of megaloblastic anemia. The MCHC is not
 
given, which would be helpful to document hypochromia; I don't
 
appreciate hypochromia on the slides. I wish I could see the Cabot
 
rings, if present, but I can't make them out. Was the WBC count
 
corrected for nucleated RBCs? If not, then neutropenia may be present.
 
Have serum folate and vitamin B12 levels been checked? Is the patient an
 
alcoholic? These are side issues, but it would be nice to know the
 
answers, if available.
 

In my view neither age nor this amount of nucleated cells and precursors are seen in a "normal" megaloblastic anemia. In my differential diagnosis are megaloblastic features in extramedullary hematopoiesis .BM biopsy should be performed .

Are there any signs of haemolysis? Spleen size? If the patient had a longstanding haemolysis he could have developed secondary grave folic acid deficiency. However that does not explain easily the presenc if immature granulopoesis. I agree that bone marrow biopsy should be performed.

Thnaks everyone for youe comment. MCHC-37.5%, True leukocyte count: 58100/cumm.

I have seen morphologically the similar case of megaloblastic anemia, complicated with secondary hemolytic crisis (AIHA or other reasons). Patient died. Also I have seen severe megaloblastic anemia in young patient due to massive parsitosis with tapeworm.

I think this is severe megaloblastic anaemia, with megaloblasts, giant staff (stab) cells and hypersegmented neutrophils in the blood film. The degree of macrocytosis is small for this level of anaemia, but this tends to occur when there is red cell fragmentation in megaloblastic anaemia.  
If serum B12/folate assays are not available, the practical approach would be to treat with B12 injections and folic acid by mouth (never folic acid alone) and do reticulocyte counts at 7-10 days. If there is no reticulocytosis, the diagnosis would be questioned, and the most difficult differential is erythroleukaemia, but I see no evidence for this. The reticulocytosis will be suboptimal if the patient is transfused.

I think there is a more or less universally accepted laboratory work-up for severe anaemias. It includes, besides mentioned parameters, - bilirubin, reticulocytes, ferritin/iron, erythropoetin, B12/folate (not possible in this case?). All of them, and the already mentioned MCHC, should be available for evaluation in order not to miss something relevant, like anaemia of combined origin, for example.  
 
In case of B12 deficiency with HGB of 4, there should be clinical manifestations and a rather long anamnesis.  
 
Personally, I would warmly second Dr Metz's suggestion to give B12 and folate ex juvantibus and check reticulocytes in 7 days. The whole thing will ask for a week only, dramatic clinical improvement is usually seen in a couple of days. It could be really faster than immunos or moleculars :).  
 
Still, for me such prominent increase in peripheral normoblasts is very unusual. And they are not as atypical as B12 normoblasts usually are. There is monocytosis. Typical polysegmentation is not very prominent.  
 
About bone marrow examination - it should be done before B12 administration, otherwise the whole picture will be smeared. If I remember correctly, indications for bone marrow investigation in case of megaloblastic anaemia are:  
- 2 or more cell lines affected  
- Indeterminate iron status  
- Leukoerythroblastic peripheral smear  
- Monoclonal gammopathy,  
quite sufficient for this case  

Sorry, true total WBC count is 5810/cumm( not 58100/cumm)