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The nucleated RBC in the center contains basophilic stippling of the cytoplasm.
Basophilic stippling
• Fine stippling - with polychromatophilia,
• coarse stippling - impaired erythropoiesis.
Heavy metal poisoning (e.g. lead and arsenic),
hemoglobinopathies,
thalassemias,
sideroblastic anemias,
pyrimidine-5’-nucleotidase deficiency,
Dacrocytes
Dacrocytes ("tear drop cells") are red blood cells in the shape of a teardrop
• myelophthisic anemia (particularly myelofibrosis with myeloid
metaplasia),
• megaloblastic anemia,
• beta-thalassemia,
• renal failure, tuberculosis,
• hypersplenism, and other hematologic diseases.
Polychromasia ("polychromatophilia")
• slightly immature red blood cells, which are larger than normal
(increased MCV) and have a blue-gray coloration.
• due to the presence of ribosomal protein in immature red blood cells,
which pick up the basophilic component of the Wright-Giemsa stain.
• (0.5 - 2%) are normally present in the peripheral blood and signify
the presence of erythropoietic activity in the bone marrow.
• They are increased in states of increased erythropoietic activity in
response to anemia or the iatrogenic administration of erythropoietin
or another marrow stimulatory agent.
• Decreased polychromasia is seen with hypoproliferative marrow
states.
Spherocytes
• small (< 6.5 mm), dense spheroidal RBCs with normal or decreased
MCV and absent central pallor.
• Hereditary spherocytosis is likely if large numbers of spherocytes are
present and other forms of abnormal RBCs are absent.
• Small numbers of spherocytes, in combination with other abnormal
RBCs, are seen in patients with isoimmune and autoimmune
hemolytic anemias, Heinz body hemolytic anemia, hereditary
pyropoikilocytosis, microangiopathic hemolytic anemia,
hypersplenism and post-splenectomy, myelofibrosis with myeloid
metaplasia, hemoglobinopathies, malaria, liver disease, recent
transfusions, and severe burns.
These RBC's are spherocytes.
• Heinz bodies are denatured haemoglobin due to oxidative damage.
• They are never seen in normal individuals, as they are removed by the
spleen.
post-splenectomy
G6PD deficiency
Howell-Jolly bodies
nuclear remnants found in red cells normally removed by the spleen and
• after splenectomy,
• megaloblastic and
• iron-deficiency anaemias and
• rarely in cases of leukaemia.
The RBC in the center of the field contains several Howell-Jolly bodies, or inclusions of
nuclear chromatin remnants. There is also a nucleated RBC just beneath this RBC.
Abnormal and aged RBC's are typically removed by the spleen.
The appearance of increased poikilocytosis, anisocytosis, and RBC inclusions suggests that
a spleen is not present.
Target cells - also known as codocytes, leptocytes or Mexican hat cells.
• red cells with a central area of increased staining, surrounded by a ring of
hypodense staining and then a further ring of dense staining at the edge of
the cell, giving an appearance akin to an archery target.
• This occurs as a result of the shift in equilibrium between the erythrocyte
and cholesterol.
• They may be found in
liver disease,
thalassaemia or
sickle-cell disease.
They occur occasionally in small numbers in iron-deficiency
anaemia and
sometimes following splenectomy.
Sickle cells, also known as drepanocytes,
• are found in sickle cell anaemia and other sickle syndromes
• but not in sickle trait..
This is sickle cell anemia in sickle cell crisis.
This patient has hemoglobin SC disease, with hemoglobin S and hemoglobin C both
present. With SC disease, the RBC's may sickle, but not as commonly as with Hemoglobin
SS disease. The hemoglobin C leads to the formation of "target" cells--RBC's that have a
central reddish dot. In the center of the field is a rectangular RBC that is indicative of
a hemoglobin C crystal, which is also characteristic for hemoglobin C disease.
• see fragmented red cells, or schistocytes.
• the most specific type of schistocyte is the “triangulocyte”
• red cells fragmented by their passage through intravascular strands of fibrin,
• found in cases of intravascular haemolysis, renal failure and
thrombotic thrombocytopaenic purpura amongst others.
Iron-deficiency anaemia
H=hypochromic red cell; p=pencil cell; T=target cell; M=microcytic cell. ×500
Microcytosis - abnormally small red cells
• often found in association with hypochromia in iron-deficiency
anaemia.
• seen in thalassaemia trait,
• congenital sideroblastic anaemia and
• in the anaemia of chronic disorders if these are long-standing.
Hypochromia is impaired staining of red cells seen commonly in iron-deficiency
anaemia and also in thalassaemia and sideroblastic anaemias.
Pencil cell type of elliptocyte: occur where there is iron-deficiency anaemia,
thalassaemia trait and syndromes and in pyruvate kinase deficiency
Target cells -
red cells with a central area of increased staining, surrounded by a ring
of hypodense staining and then a further ring of dense staining at the edge of
the cell, giving an appearance akin to an archery target.
The RBC's here are smaller than normal and have an increased zone of central pallor. This
is indicative of a hypochromic (less hemoglobin in each RBC) microcytic (smaller size of
each RBC) anemia. There is also increased anisocytosis (variation in size) and poikilocytosis
(variation in shape).
This is normal data from a complete blood count as performed on an automated instrument,
including an automated WBC differential count.
Here is data from a CBC in a person with iron deficiency anemia. Note the low hemoglobin
(HGB). Microcytosis is indicated by the low MCV (mean corpuscular volume). Hypochromia
correlates here with the low MCH (mean corpuscular hemoglobin).
The CBC here shows a markedly increased MCV, typical for megaloblastic anemia. The
MCV can be mildly increased in persons recovering from blood loss or hemolytic anemia,
because the newly released RBC's, the reticulocytes, are increased in size over normal
RBC's, which decrease in size slightly with aging.
The CBC of a patient with microangiopathic hemolytic anemia (MAHA) demonstrates a
markedly increased RDW (red cell distribution width) due to the marked variation in size and
shape of the RBC population.
This CBC demonstrates findings suggestive of spherocytosis, a condition in which the RBC's
are small and round (rather than the normal biconcave appearance) with increased
hemoglobin content. This is indicated here by the increase MCHC (mean corpuscular
hemoglobin concentration).
Here is the CBC of a person with a severe anemia who underwent transfusion. This
accounts for the dual RBC population as seen in the graph at the lower left.
A reticulocytosis in response to anemia has also increased the MCV.
Here is a hypersegmented neutrophil that is present with megaloblastic anemias. There are
8 lobes instead of the usual 3 or 4.
The WBC's seen here are lymphocytes, but they are blasts--very immature cells with larger
nuclei that contain nucleoli. ALL
Here are very large, immature myeloblasts with many nucleoli. A distincitve feature of these
blasts is a linear red "Auer rod" composed of crystallized granules. These findings are typical
for acute myelogenous leukemia (AML) that is most prevalent in young adults.
ALL
they are blasts--very immature cells with larger nuclei that contain nucleoli.
AML
LYMPHOBLAST MYELOBLAST
More
Myeloblast with auer rods
They are atypical because they are larger (more cytoplasm) and have nucleoli in their nuclei.
The cytoplasm tends to be indented by surrounding RBC's. Such atypical lymphocytes are
often associated with infectious mononucleosis.
Reactive lymphocytes are lymphocytes that become large as a result of antigen stimulation.
the nucleus of a reactive lymphocyte can be round, elliptic, indented, cleft or folded. Thecytoplasm is
often abundant and can be basophilic. Vacuoles and/or azurophilic granules are also sometimes
present. Most often the cytoplasm is gray, pale blue or deep blue in colour.
Reactive lymphocytes are usually associated with viral illnesses, however, they can also be present
as a result of drug reactions (such as phenytoin), immunisations, radiation, hormonal causes (such
as stress and Addison's disease) as well as some auto-immune disorders (such as rheumatoid
arthritis).
Some pathogen-related causes include:
• Epstein-Barr virus
• Cytomegalovirus
• Toxoplasma
• Treponema pallidum (Syphilis)
• Streptococcus agalactiae (Group B Streptococci),
• Hepatitis C
[4]
• Hantavirus
Acanthocytes
• spiculated (spikey) red cells
that are found in some cases of α-β-lipoproteinaemia,
chronic liver disease and
α-thalassaemia trait.
There is also an hereditary acanthocytosis.
Reticulocytes
These are young, oversized red cells that are present when the marrow is actively producing
red cells.
They are the intermediary between the nucleated red blood cell and the mature red blood
cell. Small numbers of reticulocytes are found in normal peripheral blood. They are usually
expressed as a percentage of total red cells.
• Increased count –
• they are present after haemorrhage, haemolysis, severe hypoxia, in
polycythaemia of any cause and in marrow infiltration.
• Reticulocytes may rise during marrow recovery
following chemotherapy or radiotherapy.
• They may also be seen following treatment of deficient patients with
haematinics when they are a useful measure of response to the
treatment.
• Decreased count –
• reticulocyte levels drop where there is marrow infiltration (leukaemia,
myeloma, lymphoma or other malignancies) or
• due to marrow underactivity such as in iron, folate or B12 deficiency
or
• due to autoimmune disease, malnutrition, uraemia, drugs, aplastic
anaemia and red cell aplasia.
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Hematopoietic elements in this bone marrow biopsy are markedly reduced. This is a case of
aplastic anemia. Of course, besides, RBC's the platelets and granulocytes will often be
diminished. Sometimes a drug or toxin is the cause and sometimes infection. When no
known cause can be found, it is termed idiopathic aplastic anemia.
In contrast to aplastic anemia, leukemia results in a highly cellular marrow. The marrow
between the pink bone trabeculae seen here is nearly 100% cellular, and it consists of
leukemic cells of acute lymphocytic leukemia (ALL) that have virtually replaced or
suppressed normal hematopoiesis. Thus, though the marrow is quite cellular, there can be
peripheral cytopenias. This explains the complications of infection (lack of normal
leukocytes), hemorrhage (lack of platelets), and anemia (lack of red blood cells) that often
appear with leukemia.
If most of the neutrophils appear bilobed, this is indicative of an
uncommon condition known as Pelger-Huet anomaly, an inherited
condition. This is the heterozygous form. The homozygous form is
fatal. Just be aware of this condition when you get back a manual
differential count with mostly bands, but the WBC count is normal or
the patient shows no signs of infection or inflammation.
The red blood cells here are normal, happy RBC's. They have a zone of central
pallor about 1/3 the size of the RBC. The RBC's demonstrate minimal variation in
size (anisocytosis) and shape (poikilocytosis). A few small fuzzy blue platelets are
seen. In the center of the field are aband neutrophil on the left and a segmented
neutrophil on the right.
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DOUBTS ???
Lymphoblasts vs myeloblats
Crohns
HJ HEINZ RETIC
