Transcript Normal and abnormal Barrett W. Dick, M.D. Director, Hematology Laboratories Memorial Medical Center Springfield.

Normal and abnormal
Barrett W. Dick, M.D.
Director, Hematology Laboratories
Memorial Medical Center
Springfield. IL
Clinical Professor, Pathology and Medicine
Southern Illinois School of Medicine
Increasing cytoplasmic hemoglobin
Decreasing cytoplasmic RNA
Immature red cells are bigger, bluer and have less
central pallor than mature rbc.
NOTE: On the left is a diagrammatic representation of a young red cell, usually described as “polychromatophilic”.
Note that it is larger and bluer than a mature red cell on the right. This is due to its RNA content.
Reticulocytes require special techniques for
measurement
 The two terms are not equivalent but
frequently, but incorrectly, used as equivalent
 Estimating polychromasia from a stained blood
smear is not a substitute for performing a
reticulocyte count. The correlation is poor.
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Polychromatophilic Rbc
Too thick
Too thin
Area behind “feather edge”Just right.
Thin Area
Feather Edge
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Performed at 10X magnification
Evaluate quality of smear- appropriate thin area
Check for increased rouleaux formation
Scan for white cell distribution- even
With practice can estimate the white count and
differential: at very least make sure they correlate
with machine count and/or manual diff
10X mag
Red cells close, evenly spaced without significant overlapping
50X Oil
Some degree of rouleaux formation is normal; this is increased
Scan performed at no lower than 40X coverslipped
smear or 50X oil
 Estimate the differential and look for qualitative
Wbc abnormalities
 Rbc morphology
 Platelet estimate
 Perform a differential at 100X if specimen has been
flagged as being abnormal- 200 cells.
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Anisocytosis- Variation in size
Poikilocytosis- Variation in shape
 Slight variation of size and shape is normal.
When abnormalities are reported, what it
should mean is that more than normal
variation is present.
RBC
50
100
200
NOTE: This illustrates a normal red cell distribution with the horizontal scale
representing cubic micra. The RDW is by convention a mathematical expression of
the width of the curve near the base.
Red cell size can only be measured accurately
using electronic instrumentation to measure
the volume (MCV).
 On blood smear examination, the size estimate
is based on diameter, which is not very accurate
and does not correlate well with the MCV
 Small lymphocyte nuclei are a rough guide to
normal Rbc diameter
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7.5 mu
Avr.diameter of normal Rbc= 7.5 mu
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Hypochromia is the most frequently
overcalled abnormality on blood smears,
usually due to technical factors
When real, usually due to advanced iron
deficiency
 Men: Hgb<10g/dl
 Women: Hgb<8g/dl
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Rarely in our population- thalassemia
major
This smear also illustrates increased variation in size (anisocytosis) and
increased variation in shape (poikilocytosis).
Elliptocytes are a common non-specific abnormality. Hereditary elliptocytosis
is also relatively common and is usually not hemolytic. The hereditary form is
more common in peoples of African origin
Burr Cell
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Acanthocyte
Crenated Rbc
Terms that are frequently, but incorrectly, used
interchangeably. When strictly defined the
terms can have specific clinical correlations.
Burr cells have rounded, blunt projections at the edges and have
central pallor
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Uremia
Liver disease
Metabolic imbalance
Acanthocytes look like spherocytes with irregularly spaced, thin, spiny projections
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Liver Disease
Post-Splenectomy
aBeta lipoproteinemia
Crenated red cells have the appearance of sea urchin eggs: short, evenlyspaced, broad-based spikes projecting in three dimensions. They are seen in
some severely ill patients with marked electrolyte abnormalities. In a
reference laboratory setting, they are a frequent manifestation of a poorly
preserved specimen..
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Howell-Jolly Bodies
Acanthocytes
Target Cells
Lymphocytosis
Howell-Jolly Body
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Liver disease and/or hyperbilirubinemia
Post-splenectomy
Hemoglobinopathies
 Hemoglobin C syndromes:
▪ AC, SC, C-thal
▪ NOT thalassemia minor, <1% of cases
The cells are small in diameter but not in volume. Because
of their spherical shape they do not flatten on the slide.
Hereditary Spherocytosis
Autoimmune hemolysis
Alloimmune hemolysis Newborns with ABO incompatibility
 Delayed transfusion reactions
 Thermal injury- burn patients
 Occasionally- non-specific with transfused red
cells
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Common in disorders associated with marrow
infiltration and splenomegaly
Coarse stippling is usually associated with some form of
dyserythropoeisis.
TTP /HUS
Vasculitis
Partially thrombosed vessels including heart
chambers
 Sever cardiac valve abnormalities or
malfunctioning prosthesis
 DIC- rarely; most often associated with chronic
DIC
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These cells look like spherocytes
with bites in the edges, aka, “bite”
cells. This is due to removal of
denatured hemoglobin by the
pitting function of the spleen
Heinz Bodies are denatured hemoglobin usually due an
oxidant. They are removed by the spleen causing
deformed rbc- “pitted” rbc, aka “pocked” or “bite” cells
 Hereditary
 G6PD deficiency: hemolysis is usually drug induced or
can be induced non-specifically by stress, such as
infection
 Unstable hemoglobins
 Acquired: oxidant drug-induced without a hgb or
enyzmatic abnormality
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Thalassemia minor- microcytosis with mild or no
anemia; worldwide in distribution
Hemoglobin AC- Target cells, sometimes
spherocytes (few); from West Africa
Hemoglobin AE or EE- Microcytosis and target
cells with minimal or no anemia: from SE Asia
Hemoglobin SS- Sickle cells with variable anemia
Hemoglobin SC- Target cells, spherocytes,
sometimes sickle cells depending on the
severity; may be asymptomatic
Mild or no anemia with microcytosis. The prevalence of target cells in this disorder is
markedly overstated in texts and in the literature
SC crystals have a characteristic appearance with blunted, rhomboidal ends
Thal minor CANNOT be diagnosed by Hgb
electrophoresis in the overwhelming majority
of patients; it is a diagnosis of exclusion: R/O
iron deficiency
 Hemoglobin electrophoresis is the procedure of
choice for testing for other hemoglobin
abnormalities; quick tests are not
recommended
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A F S A2
D C
G E
These are frequently mistaken for malaria parasites