1. RED BLOOD CELLS
(RBCs)
Prof. Dr. Salwa Saad

2. ILOs: The student should be able to: Define Erythropoiesis
Recognize normal RBCs and their parameters
Recognize RBCs abnormalities
Define anaemias

3. Identify morphological types of anaemias
Select appropriate investigation(s) in each anaemia (disease)‏
Integrate knowledge learnt in the course with other laboratory findings and clinical data

4. DEVELOPMENT

5. DEVELOPMENT
Complete loss of basophilic material probably occurs in the bloodstream and, particularly, in the spleen after the cells have left the bone marrow.
This maturation is thought to take 2–3 days, of which about 24 hours are spent in the circulation
Spleen
Peripheral Circulation

6. Normal RBCs

7. Reticulocyte count: Definition.....
Reticulocyte count = % of reticulocytes in PB.
Normally= %
Absolute count = x 109/L
Causes of reticulocytosis:  Hemorrhage
 Hemolysis
 In response to hematinics
Causes of reticulocytopenia:
 Aplastic anemia

8. Polychromasia

10. RBCs Parameters 11.5-14% RDW 32-35% MCHC 27-32 pg MCH 78-98 fL MCV
PCV
M: g/dL
F: g/dL Hb
M: x1012/L
F: x1012/L
RBCs count
Range
RBCs Parameter

11. RBCs Abnormalities
Size Shape Staining Inclusions

12. RBCs Abnormalities;Size:
Microcytosis = diminished MCV (small RBCs)‏
Macrocytosis = Increased MCV (large RBCs)‏
Anisocytosis = variation in RBCs size

13. RBCs Abnormalities;Shape
Poikilocytosis: variation in RBC shape
Target cells: found in:  Thalassemias and other abnormal Hbs
 Iron deficiency anemia
 Liver diseases

14. RBCs Abnormalities;Shape:
Spherocytes: Fully hemoglobinized small RBCs.
Found in:
Congenital spherocytosis
Autoimmune hemolytic an.
Hemolytic disease of newborn
 Blood transfusion

15. Normal RBCs
Microspherocyte
Target Cell

16. RBCs Abnormalities; Shape
Sickle cells: found in sickle disease
Ovalocytes: in congenital ovalocytosis
Elliptocytes: In congenital elliptocytosis

17. RBCs Abnormalities; Staining
Hypochromia: Diminished MCH
Polychromasia: in case of
Increased reticulocytic count

18. RBCs Abnormalities; Inclusions:
Malaria
Heinz bodies
Unstable Hb
Chemical/drug poisoning
G6PD def.
Post-splenectomy

19. ANEMIA
Definition:
It is a decrease in Hb concentration, RBC count and/or PCV below the average normal for age and sex

20. ANEMIA Morphological Classification of Anemias Microcytic Hypochromic
- MCV < 78 fL
- MCH < 27 pg
Normocytic Normochromic
- MCV: fL
- MCH: pg
Macrocytic
- MCV > 98 fL
Causes:
- Acute blood loss
Hemolytic an. (ex thal.)‏
An. of chronic disorder
Aplastic anemia
Causes:
- Iron deficiency anemia
Thalassemia minor/major
An. of chronic disorder
Sideroblastic anemia
Causes:
- Megaloblastic
Non Megaloblastic
* Liver disease
* Hemolytic anemia
* Aplastic anemia

21. Microcytic Hypochromic Anemia
D D of Microcytic Hypochromic anemia: N ↑ ↓
An. chronic Disorder
↑ HbA2 (β thal.)‏
N (α thal.)‏
Thals. trait
Fe def.an.
Hb electrophoresis
Ring sideroblasts
BM iron stores
s. Ferritin
TIBC
s. Iron
Sideroblastic an.

22. Microcytic Hypochromic Anemia
Thalassemias:
Definition: Genetically determined familial defect in globin chain synthesis  imbalance in globin chain production  abnormal erythropoiesis + hemolytic anemia
β-thalassemia:
Defect in β chain production:
β0  total absence
β+  partial ↓
Phenotypically:
β-th. Major
β-th. Minor
α-thalassemia:
Defect in α chain production:
Phenotypically:
Silent carrier
α-th. trait
Hb H
Hb Barts

23. Microcytic Hypochromic Anemia
Thalassemias:
Thalassemia major:
- Marked degree of microcytic hypochromic anemia
- Increased serum iron, ferritin.
- PB : normoblastemia, target cells, anisopoikilocytosis, reticulocytosis
- Hb electrophoresis: Hb F in β thalassemia
Hb H in α thalassemia

24. Macrocytic anemias - Aplastic an. ↓ Retics Hemolytic an. ↑ Retics
Differential Diagnosis of Macrocytic anemias: -
Aplastic an.
↓ Retics
Hemolytic an.
↑ Retics
Megaloblastic an.
Liver disease
Normal Retics

25. Laboratory Findings in Megaloblastic anemia
Macrocytic anemias
Laboratory Findings in Megaloblastic anemia
Pancytopenia
PB: ovalocyte macrocytes, anisopoikilocytosis,, hyper segmented neutrophils
Hypercellular marrow with megaloblastic changes
Decrease s. B12 & folate.
Positive antiparietal cell Abs & intrinsic factor Abs in pernicious an.
Therapeutic trials: Giving B12 & folate and testing the response by reticulocyte count on the 3rd day & peak on 7th day

26. Laboratory Findings in Megaloblastic anemia
Macrocytic anemias
Laboratory Findings in Megaloblastic anemia

27. Normocytic Normochromic Anemia
Differential Diagnosis : -
Aplastic an.
↓ Retics
Anemia of chronic disorder
Normal Retics
Hemolytic Anemia
Acute Hge
↑ Retics

28. Normocytic Normochromic Anemia
Hemolytic Anemia
Definition:
It is anemia due to increased
rate of RBCs destruction.

29. Normocytic Normochromic Anemia
Hemolytic Anemia:
Laboratory evidence of hemolysis:
- ↑ indirect bilirubin
- ↑ reticulocyte count (polychromasia)‏
- ↑ urine urobilinogen
- BM erythroid hyperplasia
- Absent haptoglobin. +
- Hemoglobinemi & Hemoglobinuria in I.V hemolysis

30. Polycythemia Definition: Classification:
Primary or secondary (usually d.t. hypoxia)
Lab Findings:
Hb, RBCs count, PCV increased ( RBCs) erythrocytosis
Normal pO low pO2
TLC normal TLC
Platelets normal platelets
Uric acid normal NAP score
Vitamin B increased erythtropoietin
Neutrophil alkalin phosphatase
Decreased serum erythropoietin

31. Case Study

32. To reach proper diagnosis, 3 basic questions should be answered:
Is the patient anemic ?
A: Hb level
2. What is the type of anemia?
A: RBCs parameters: MCV; MCH
3. What is the cause of anemia?
A: CBC ; cell morphology; reticulocytic count; other confirmatory tests

33. Case 1
Male child, 7ys old, C/O weakness, easy fatigue, underweight
CBC:
TLC: 12,000/ul
(5, ,000)‏
Hb: 8g/dL (11- 14)
RBC: 2.50 million/ul (4- 5.2)
PCV: 24% (35- 45)
MCV: 55 fl (78- 98)
MCH: 22pg (27- 32)
MCHC: 30% (30-35)‏
Plat: 200,000/ul
Blood Film: Eosinophilia

34. Case 2
Pregnant female, 30 ys old, C/O weakness, fatigue
CBC:
TLC: 3,900/ul
(4, ,000)‏
Hb: 9 (12- 16)‏
RBC: 3.00 ( ) MCV: 105 (78- 98)‏
MCH: 29 (27- 32)
MCHC: 35 (30- 35)‏
Plat: 50,000/ul
Blood Film: retics: 0.5%; macrocytes, ovalocytes, hypersegmented neutrophils

35. Case 3
Male infant, 4 months old, presented by jaundice, splenomegaly
CBC:
TLC: 10,000/ul
(6, ,000)‏
Hb: 8.0 g/dL ( )
RBC: 3.50 million/ul ( )
MCV: 88 fl (88- 93)
MCH: 28 pg (25- 35)
MCHC: 36% (30- 36)‏
Plat: 400,000/ul
Blood Film: Spherocytes and polychromatic cells
Chemistry: Total bilirubin: 3 mg/dL, Direct bilirubin: 0.2 mg/dL

36. Female patient, 18 years old, presented with renal troubles, skin rash & jaundice
Case 4
CBC:
TLC: 15,000/ul
(4, ,000)‏
Hb: 7 g/dL (12- 16)
RBC: 2.30 million/ul ( )
MCV: 90 fl (78- 98)‏
MCH: 30 pg (27- 32)‏
Plat: 180,000/ul
Blood Film: Polychromasia, microspherocytes, normoblastemia, fragmented cells, neutrophilia
Chemistry: Total bilirubin: 4 mg/dL, Direct bilirubin: 0.3 mg/dL

37. Male patient, 50 years old, treated for joint pain 2 yrs ago.
Case 5
CBC:
TLC: 8,000/ul
(4, ,000)‏
Hb: 9 g/dL (13- 18)
RBC: 3.80 million/ul ( )‏
MCV: 76 fl (78- 98)‏
MCH: 25 pg (27- 32)‏
Plat: 250,000/ul

38. Male patient, 18 years old, in routine preoperative investigation.
Case 6
CBC:
TLC: 6,000/ul
(4, ,000)‏
Hb: 11 g/dL (13- 18)‏
RBC: 5.50 million/ul ( )‏
MCV: 68 fl (78- 98)‏
MCH: 22 pg (27- 32)‏
RDW: 14.0 ( )‏
Plat: 300,000/ul

39. THANK YOU