RBC’s Morphology Practical Hematology Lab - LAB 2 -
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RBC’s Morphology
Practical Hematology Lab
- LAB 2 -
RBCS Abnormal Morphology
Peripheral Blood Morphology
RECORDING RBC MORPHOLOGY1. Scan area using ×100 (oil immersion).
2. Observe 10 fields.
3. Red cells are observed for size, shape, hemoglobin content, and the presence or absence of inclusions.
4. Abnormal morphology: Red cell morphology is assessed according to See the following sample grading system. Note that red cell morphology must be scanned in a good counting area.
Two questions should be asked
5.Is the morphology seen in every field?
6.Is the morphology pathologic and not artificially induced?
Abnormal Erythrocyte Morphology
Is found in pathological states that may be abnormalities in
I. Red cell distribution.
II. Size (anisocytosis).
III. Hemoglobin content – Color Variation .
IV. Shape (poikilocytosis).
V. The presence of inclusion bodies in erythrocyte.
I. Erythrocyte Distribution Abnormalities
Rouleaux formation
Stacking of RBCs due to increased plasma proteins coating RBCs (resembling a stack of coins)
Found in• Hyperfibrinogenaemia• Hyperglobulinaemia
AgglutinationAntibody-mediated Irregular clumping , temperature dependent
Found in• Cold agglutinins• Warm autoimmune hemolysis
Rouloux Formation Agglutination
II. Variation In Erythrocyte Size (Anisocytosis)
AnisocytosisVariations in size (Microcyte and Macrocyte)
Normocytic RBC’s Normal size of RBC (8 μm) with a range of 7 to 9 μm.
The nucleus of a small lymphocyte (± 8 µm) is a useful guide to the size of a red blood cell).
Microcytic
RBC cell smaller than the normal RBC ( <7 μm), and is associated with a decrease in hemoglobin synthesis
Found in• Iron deficiency anemia.• Thalassaemia.• Sideroblastic anemia.• Lead poisoning.• Anemia of chronic disease.
Macrocyte
RBC larger than the normal (<9 μm) and is the result of a defect in nuclear maturation or stimulated erythropoiesis. May be round or oval in shape, the diagnostic significance being different.
Found in• Folate and B12 deficiencies (oval)• Ethanol (round)• Liver disease (round)• Reticulocytosis (round)
Example : Film Study
Most erythrocytes presented in the picture are microcytes (compare with the small lymphocyte). The degree of hemoglobinization is sufficient. Normal platelets and single ovalocytes are present.
1. Microcyte
2. Normocyte
III. Variation In Erythrocyte Color
• A normal erythrocyte has a pinkish-red color with a slightly lighter-colored center (central pallor) when stained with a blood stain, such as Wright.
• The color of the erythrocyte is representative of hemoglobin concentration in the cell.
• Under normal conditions, when the color, central pallor, and hemoglobin are proportional, the erythrocyte is referred to as Normochromic.
Hypochromia
• Increased central pallor and decreased hemoglobin concentration, the central pallor occupies more than the normal third of the red cell diameter.Found in • Iron deficiency• Thalassaemia• any of the conditions leading
to Microcytosis
Polychromasia• Red cells stain shades of blue-gray as a consequence of
uptake of both eosin (by hemoglobin) and basic dyes (by residual ribosomal RNA). Often slightly larger than normal red cells and round in shape - round macrocytosis.
Found in
Any situation with reticulocytosis – for example bleeding, hemolysis or response to heamatinic factor replacement.
What Abnormal Results MeanThis test is used to diagnose the cause of anemia. The following are the types of anemia and their causes:• Normocytic/ normochromic (NC/NC) anemia is caused by
sudden blood loss, prosthetic heart valves, sepsis, tumor, long-term disease or aplastic anemia.
• Microcytic/ hypochromic anemia is caused by iron deficiency, lead poisoning, or thalassemia.
• Microcytic/ normochromic anemia results from a deficiency of the hormone erythropoietin from kidney failure.
• Macrocytic /normochromic anemia results from chemotherapy, folate deficiency, or vitamin B-12 deficiency.
IV. Shape Abnormalities of Erythrocytes• Poikilocytosis is the general term for mature
erythrocytes that have a shape other than the round, biconcave disk.
• Poikilocytes can be seen in many shapes.(e.g. Acanthocyte, Spherocytosis,…)
Shape Abnormalities of ErythrocytesTerminology Description Condition
Target Cells Central Hemoglobin; target shaped
Liver Disease; Thalassaemia, Abnormal Hb; Iron Deficiency
Echinocyte Short specula's, equally-spaced
Uremia, Hypokalemia, Artifact
Acanthocyte Speculated, Irregular Liver disease (Alcohol), Post-spleenoctomy.
Spherocyte Spherical, no central pallor HS, immune Hemolytic anemia
Shistocyte Fragmented RBC, Helmet cells
MAHA, burns
Ovalocyte Oval / Elliptical shaped Hereditary elliptocytosis, Megaloblastic anemia.
Sickle Cell Bipolar speculated shape “ banana” shaped
Hb S-containing hemoglobinopathy
Teardrop cell Single elongated extremity Myelophthistic changes
Bite cells Irregular gap in membrane G6PD deficiency
Red cell with a “target” or bull’s-eye appearance. The cell appears with a central bull’s eye that is surrounded by a clear ring and then an outer red ring.
Found in
• Obstructive liver disease• Severe iron deficiency• Thalassaemia• Post splenectomy• Lipid disorders• Haemoglobinopathies (S and C)
Target cell
Red cells are more spherical. Lack the central area of pallor on a stained blood film.
Found in• Hereditary spherocytosis• Immune haemolytic anemia• Zieve's syndrome• Microangiopathic haemolytic
Spherocytosis
Red cells with a central linear slit or stoma. Seen as mouth-shaped form in peripheral smear.
Found in• Alcohol excess• Alcoholic liver disease• Hereditary stomatocytosis
Stomatocyte
Ovalocyte
An elongated oval cell. They are a result of a membrane defect.
Found in• Thalassaemia major.• Hereditary ovalocytosis. • Sickle cell anemia
Elliptocyte
The red cells are oval or elliptical in shape. Long axis is twice the short axis.
Found in• Hereditary elliptocytosis• Megaloblastic anemia• Iron deficiency• Thalassaemia• Myelofibrosis
Red cell fragments that are irregular in shape and size. They are usually half the size of the normal RBC; therefore, they have a deeper red color.
Found in• DIC • Micro angiopathic haemolytic
anemia• Mechanical haemolytic anemia
Schistocyte
Have accentric hallow area. Resemble a women's handbag and may be called pocket-book cell.
Found in
Microangiopathic hemolytic anemia
Blister cell: pre keratocyte
Part of the cell fuses back leaving two or three horn-like projections. The keratocyte is a fragile cell and remains in circulation for only a few hours.
Found in
• Uraemia
• Severe burns
• EDTA artifact
• Liver disease
Also called helmet cells
Keratocytes (horn cell)
Degmacyte "bite cell"• An abnormally shaped red blood cell with one or more
semicircular portions removed from the cell margin. • These "bites" result from the removal of denatured
hemoglobin by macrophages in the spleen.
Found In• G-6-PD deficiency, in which
uncontrolled oxidative stress causes hemoglobin to denature and form Heinz bodies, is a common disorder that leads to the formation of bite cells.
Sickle shaped red cells.
Found in
Hb-S disease and trait
Sickle Cells
Red cell with 30 or more, short blunt projections which are regularly distributed on their surface
Found in
Usually artifactual— the result of slow drying under humid conditions.
Sometimes are non - artifactual, indicating uremia or pyruvate kinase deficiency.• Hemolytic anemia• Uremia.• Megaloblastic anemia
Cells retain the central pallor.
Echinocyte “Burr” (crenation ) cell:
Echinocytes (Burr Cells)
Red blood cells with irregularly spaced projections, these projections very in width but usually contain a rounded end
Found in• Liver disease • Post splenectomy• Anorexia nervosa and starvation
Acanthocytosis (Spur Cells):
Acanthocytes (Spur Cells)
Resembles a tear and usually smaller than the normal RBC.
Found in• Bone marrow fibrosis• Megaloblastic anemia• Iron deficiency• Thalassaemia
Dacryocytes (Teardrop)
Envelope Form Cell
Found in• Thalassaemia • Sickle cell anemia
V. Erythrocyte Inclusions with Wright’s StainInclusion Composition Appearance Condition
Basophilic stippling Precipitated ribosomes
Evenly dispersed fine or coarse
granules
-Lead poisoning-Thalassaemia ,
other anemia.
Howell-Jolly bodies DNA in originNuclear Fragment
Dense, round blue granule
Post – Splenectomy
Pappenheimer bodies
Iron-containing granules
Small blue granules in clusters
Anemia's
Heinz bodies Denatured Hemoglobin
Round blue precipitates
G6PD
Cabot Rings Remnants of Nuclear membrane
Reddish-blue thread like rings
Severe anemia, Lead poisoning.
Organism Small blue inclusion
MalariaBabesiosis
Small round cytoplasmic red cell inclusion with same staining characteristics as nuclei
Found in• Post splenectomy• Megaloblastic anemia
Howell-Jolly Bodies
These are iron containing granules in red blood cells that are seen because the iron is aggregated with mitochondria and ribosomes. They appear as faint violet or magenta specks, often in small clusters, due to staining of the associated protein. They are associated with severe anemias and thalassemias. Pappenheimer bodies can be increased in hemolytic anemia, infections and post-splenectomy.
Siderotic Granules (Pappenheimer Bodies)
Considerable numbers of small basophilic inclusions in red cells.
Found in• Thalassaemia• Megaloblastic anemia• Hemolytic anemia• Liver disease• Heavy metal poisoning.
Basophilic stippling
Represent denatured hemoglobin (methemoglobin - Fe+++) within a cell.
With a supravital stain like crystal violet, Heinz bodies appear as round blue precipitates.
Presence of Heinz bodies indicates red cell injury and is usually associated with G6PD-deficiency.
Heinz Bodies
Heinz Body Preparation. RBC are incubated supravitally in new Methylene blue to identify precipitates of oxidatively denatured hemoglobin.
Reddish-blue threadlike rings in RBCs of severe anemia's. These are remnants of the nuclear membrane or remnants of microtubules and appear as a ring or figure 8 pattern. Very rare finding in patients with • Megaloblastic anemia. • severe anemia's.• lead poisoning.• Dyserythropoiesis.
Cabot Rings
A - Cabot ringB - Howell-Jolly body
Two organisms are have a tendency to invade the RBCs.
1. All 4 species of the malaria parasite will invade RBCs. We will see the Plasmodium of different species in RBCs.
2. Theileria microti (Bebesia microti)
Parasites of Red Cell
Malaria
RBCs Abnormal morphology
Depiction of red blood cell morphologies that may appear on a peripheral smear, showing:
(A)basophilic stippling,
(B)Howell-Jolly bodies,
(C)Cabot's ring bodies
(D)Heinz's bodies.
RED BLOOD CELL MORPHOLOGY
A normal red blood cell should be approximately the same size as a normal lymphocyte nucleus or 2 normal sized red blood cells should fit side by side across a normal sized poly (not a hypersegmented poly).
Grade Degree of abnormality NO. of Field/ Oil imm.
1+ 1-6 per oil imm. field
2+ 7-10 per OIF
3+ 11-20 per OIF
4+ > 20 per OIF
REPORTING RESULTS Where possible use macrocytic and microcytic,
rather than simply anisocytosis alone, when describing red cell morphology.
Use specific cell morphology when possible, rather than simply reporting poikilocytosis.
When red cells are normocytic, normochromic, report out as NORMAL. When abnormal morphology has been noted, DO NOT indicate normal on the report form.
EXAMPLE: 7-10 microcytic RBC's/OIF is reported out as: 2+ microcytosis or Moderate microcytosis.
Determine A Quantitative Scale
1
Grading Inclusions
2
Blood Film In Some Cases
Normal Peripheral Smear
Autoimmune Hemolytic Anemia
Spherocytes
Hereditary Spherocytosis
Spherocytes
Hereditary pyropoikilocytosis
Microangiopathic Hemolytic Anemia
Schistocytes
Sickle Cell Anemia
Hb SS
Idiopathic myelofibrosis
Dacryocytes
Iron Deficiency Anemia
Severe Hypochromia
Treated Iron Deficiency Anemia
Mixed Population:
Alpha Thalassaemia (a-/--)
Microcytic Hypochromia
Target Cells Spur Cells
Morphologic Changes in Liver Disease
Hepatorenal Syndrome
Burr + Spur Cells
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