2. CBC and Peripheral Blood Smears Morey A. Blinder, M.D. Associate Professor of Medicine and Laboratory Medicine Department of Internal Medicine Divisions of Hematology and Laboratory Medicine

3. Objectives Automated cell counting Peripheral blood morphology

4. Coulter Principle

5. Red Cell Parameters

7. Red Cell Histogram and Count

8. Calculation of the RDW RDW = Coefficient of variation of red cell volume distribution Normal range = 11.5% - 14.5% RDW = X 100 S.D. Mean

9. Red Cell Distribution Width - RDW

10. Comparison of RDW in Iron Deficiency and Anemia of Chronic Disease

17. CBC Report

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

20. Peripheral Blood Morphology

21. Normal Peripheral Smear

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

23. Reticulocyte: Polychromasia

24. Reticulocyte Manual Count by Supravital Stain: Normal Count

25. Reticulocytes: Elevated Count

26. 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

27. Basophilic Stippling

28. Howell-Jolly Body

29. Malaria

30. RBC Inclusions: Composite

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

32. Rouleaux Formation

33. Agglutination Reaction

34. 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

35. Hypochromic Microcytic RBC

36. Normal Hypochromic microcytic

37. Hypochromia without Anisocytosis: Thalassemia Trait

38. Severe Hypochromia: Iron Deficiency Anemia

39. Mixed Population: Treated Iron Deficiency Anemia

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

41. Microcytic Hypochromia: Beta Thalassemia Major

43. Macrocytic Anemia: Macro-Ovalocytes

44. 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

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

46. Echinocytes (Burr Cells)

47. Acanthocytes (Spur Cells)

48. Target Cells Spur Cells Morphologic Changes in Liver Disease

49. Hepatorenal Syndrome: Burr + Spur Cells

50. Spherocytes

51. Spherocytes: Autoimmune Hemolytic Anemia

52. Spherocytes: Hereditary Spherocytosis

53. Schistocytes: Microangiopathic Hemolytic Anemia

54. Elliptocytes: Hereditary Elliptocytosis

55. Sickle Cell Anemia: Hgb SS

56. Hemoglobin SC Disease

57. Hemoglobin S-Beta Thalassemia

58. Homozygous Hemoglobin C Disease (Hgb CC)

59. Teardrop Cells

60. Bite Cells

61. Heinz Bodies

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

63. Neutrophil

64. Eosinophil

65. Neutrophil Eosinophil

66. Monocytes

68. Small Lymphocyte

69. Small Intermediate Large Lymphocytes

70. Basophils

71. 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

72. Dohle Bodies

73. Toxic Granulation

74. Toxic Granulation and Vacuole Formation

75. Hypersegmented Neutrophils

76. Auer Rod: Acute Myeloid Leukemia

77. Ehrlichia

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

79. Neutrophilia: Leukemoid Reaction

80. Neutrophilia: CML

81. Pelger-Huet Abnormality

82. Acute Myeloid Leukemia: M1 Myeloblasts without Differentiation

83. Acute Myeloid Leukemia: M2 Myeloblasts with Some Differentiation

84. Acute Myeloid Leukemia: M3 Promyelocytic Leukemia

85. Acute Myeloid Leukemia: M4 Myelomonocytic Leukemia

86. Acute Myeloid Leukemia: M5 Monocytic Leukemia

87. Acute Myeloid Leukemia: M6 Erythroleukemia

88. Acute Myeloid Leukemia: M7 Megakaryocytic Leukemia

89. 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

90. Atypical (Reactive) Lymphocytes

92. Abnormal Lymphocytes

93. Plasmacytoid Lymphocytes

94. Plasma Cell: Plasma Cell Leukemia

95. Hairy Cell: Hairy Cell Leukemia

96. Sezary Cell

97. Prolymphocytes

98. Chronic Lymphocytic Leukemia (CLL)

99. CLL: Smudge Cells

100. CLL: Balloon Cells

101. Acute Lymphocytic Leukemia: L1

102. Acute Lymphocytic Leukemia: L2

103. Acute Lymphocytic Leukemia: L3 (Burkitts)