Peripheral Blood Smears Department of Internal Medicine Divisions of Hematology and Laboratory Medicine

Complete Blood Count Automated cell counting Peripheral blood morphology

Automated Cell Counting: Deficiencies Abnormalities and inclusions in WBC RBC shape abnormalities RBC inclusions Platelet abnormalities and clumping

Peripheral Blood Morphology

Peripheral Smears Barnes-Jewish Hospital Daily total Total CBCs Peripheral smears* Laboratory initiated Physician-initiated ~20 * Smears are saved for 30 days

Normal Peripheral Smear

“More information can be gained from examining the blood smear than from any single hematologic procedure”

Clinical Indications for Examination of a Blood Smear Anemia, unexplained jaundice or both Features of thrombocytopenia or neutropenia Features suggestive of possible lymphoproliferative disorder Feature suggestive of a myeloproliferative disorder Suspicion of DIC Acute or recent onset renal failure Suspicion of a bacterial or parasitic disease that can be diagnosed on a smear Features of a non-hematopoietic cancer (weight loss, bone pain) General ill health (malaise, fever)

Reticulocyte: Polychromasia

Reticulocyte Manual Count by Supravital Stain: Normal Count

Reticulocytes: Elevated Count

Erythrocyte Inclusions with Wright’s Stain InclusionCompositionAppearance Condition Basophilic PrecipitatedEvenly dispersedLead poisoning stipplingribosomesfine or coarse granulesthalassemia other anemias Howell-Jolly Nuclear Dense, round Post-splenectomy bodiesfragmentblue granule PappenheimerIron-containingSmall blue granulesAnemias bodiesgranulesin clusters OrganismSmall blue inclusionMalaria Babesiosis

Basophilic Stippling

Howell-Jolly Body

Malaria

RBC Inclusions: Composite

Erythrocyte Distribution Abnormalities Rouleaux formationStacking of RBCs due to increased plasma proteins coating RBCs AgglutinationAntibody-mediated clumping; temperature dependent

Rouleaux Formation

Agglutination Reaction

Variations in RBC Size and Shape AnisocytosisVariations in size (e.g. microcytes) PoikilocytosisVariations in shape (e.g. target cells) HypochromiaIncreased central pallor due to decrease in hemoglobin

Hypochromic Microcytic RBC

Normal Hypochromic microcytic

Hypochromia without Anisocytosis: Thalassemia Trait

Severe Hypochromia: Iron Deficiency Anemia

Mixed Population: Treated Iron Deficiency Anemia

Microcytic Hypochromia: Alpha Thalassemia (  -/--)

Microcytic Hypochromia: Beta Thalassemia Major

Macrocytic Anemia: Macro-Ovalocytes

Shape Abnormalities of Erythrocytes TerminologyDescriptionCondition Target cellsCentral hemoglobin; target-shapedLiver disease; thalassemia: Abnormal Hgb; iron deficiency EchinocyteShort spicules, equally-spacedUremia, hypokalemia, artifact AcanthocyteSpiculated, irregularLiver disease (alcohol), Post-splenectomy SpherocyteSpherical, no central pallorHS, Immune hemolytic anemia SchistocyteFragmented RBC, helmet cells MAHA, burns OvalocyteOval/elliptical shapedHereditary elliptocytosis, Megaloblastic anemia Sickle cellbipolar spiculated shapeHgb S-containing “banana” shapedhemoglobinopathy Teardrop cellsingle elongated extremityMyelophthistic changes Bite cellsIrregular gap in membrane G6PD deficiency

Target Cells Diagnostic possibilities Liver disease Hemoglobinopathy Thalassemia Iron deficiency Post-splenectomy Lipid disorders

Echinocytes (Burr Cells)

Acanthocytes (Spur Cells)

Target Cells Spur Cells Morphologic Changes in Liver Disease

Hepatorenal Syndrome: Burr + Spur Cells

Spherocytes

Spherocytes: Autoimmune Hemolytic Anemia

Spherocytes: Hereditary Spherocytosis

Schistocytes: Microangiopathic Hemolytic Anemia

Elliptocytes: Hereditary Elliptocytosis

Sickle Cell Anemia: Hgb SS

Hemoglobin SC Disease

Hemoglobin S-Beta Thalassemia

Homozygous Hemoglobin C Disease (Hgb CC)

Teardrop Cells

Bite Cells

Heinz Bodies

Morphology of Leukocytes Normal WBC populations Neutrophils (Granulocytes) Lymphocytes Monocytes Eosinophils Basophils

Neutrophil

Eosinophil

Neutrophil Eosinophil

Monocytes

Small Lymphocyte

Small Intermediate Large Lymphocytes

Basophils

Granulocyte Inclusions or Variants Terminology Description Condition Dohle bodies Pale blue areas in Infections, pregnancy, cancer neutrophil cytoplasm Toxic Large purple granules Infection Granulation in neutrophil cytoplasm Vacuoles Transparent areas Infection, Toxin in neutrophil cytoplasm Hypersegmented ≥ 6 nuclear lobes Megaloblastic anemia Auer rods Reddish long needle-like Acute myeloid leukemia inclusions Ehrlichia Blue inclusions in Ehrlichia sp. monocytes/neutrophils

Dohle Bodies

Toxic Granulation

Toxic Granulation and Vacuole Formation

Hypersegmented Neutrophils

Auer Rod: Acute Myeloid Leukemia

Ehrlichia

Myeloid Leukemias and Leukemoid Reaction Bone marrow exam is almost always indicated Cytogenetic analysis Flow cytometry analysis

Neutrophilia: Leukemoid Reaction

Neutrophilia: CML

Pelger-Huet Abnormality

Acute Myeloid Leukemia: M1 Myeloblasts without Differentiation

Acute Myeloid Leukemia: M2 Myeloblasts with Some Differentiation

Acute Myeloid Leukemia: M3 Promyelocytic Leukemia

Acute Myeloid Leukemia: M4 Myelomonocytic Leukemia

Acute Myeloid Leukemia: M5 Monocytic Leukemia

Acute Myeloid Leukemia: M6 Erythroleukemia

Acute Myeloid Leukemia: M7 Megakaryocytic Leukemia

Abnormalities of Lymphocytes VariantMorphologic categories Atypical lymphsAbundant cytoplasm, RBC “skirting” Abnormal lymphsNuclear abnormalities i.e. clefts, folds, notches Plasmacytoid lymphsAbundant cytoplasm Hairy cellsCytoplasmic projections Sezary cellsDeeply folded nucleus ProlymphocyteLarge lymph with prominent nucleolus

Atypical (Reactive) Lymphocytes

Abnormal Lymphocytes

Plasmacytoid Lymphocytes

Plasma Cell: Plasma Cell Leukemia

Hairy Cell: Hairy Cell Leukemia

Sezary Cell

Prolymphocytes

Chronic Lymphocytic Leukemia (CLL)

CLL: Smudge Cells

CLL: Balloon Cells

Acute Lymphocytic Leukemia: L1

Acute Lymphocytic Leukemia: L2

Acute Lymphocytic Leukemia: L3 (Burkitts)

Blood smears - The future Long-term storage - digital imaging of abnormal smears Increased education (Featured in journals) Image-recognition technology Tele-hematology for remote interpretation or second opinions

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