1. Practical of Clinical Hematology
Medical Technology Department
Islamic University-Gaza
Practical of Clinical Hematology
Collected and prepared by
Mr. Mohammed O. Jaber

2. RBCs Abnormal morphology
Peripheral Blood Morphology

3. Abnormal erythrocyte morphology
Is found in pathological states that may be abnormalities in
Red cell distribution.
Size (anisocytosis).
Hemoglobin content – Color Variation .
Shape (poikilocytosis).
The presence of inclusion bodies in erythrocyte.

4. Erythrocyte Distribution Abnormalities
Rouleaux formation Stacking of RBCs due to increased plasma proteins coating RBCs
Agglutination Antibody-mediated clumping;
temperature dependent 2

5. Erythrocyte Distribution Abnormalities
13- Rouleaux Formation:
Morphology:
Stacks of RBC's resembling a stack of coins.
Found in:
- Hyperfibrinogenaemia - Hyperglobulinaemia

6. Erythrocyte Distribution Abnormalities
14- Red cell-agglutination:
Morphology:
Irregular clumps of red cells
Found in: - Cold agglutinins - Warm autoimmune hemolysis

7. Rouleaux Formation

8. Agglutination Reaction

9. Schrier, S. ASH Image Bank 2002;2002:100344
Figure 2. The patient has autoimmune cold agglutinin disease and the red blood cells (RBC) have clumped when placed on the cold slide
Schrier, S. ASH Image Bank 2002;2002:100344

10. Variation in erythrocyte size (anisocytosis)
Normocyte: normal size of RBC, The average size of an RBC is 7.2 μm with a range of 6.8 to 7.5 μm. The nucleus of a small lymphocyte (± 8,µm) is a useful guide to the size of a red blood cell.
Anisocytosis: Variations in size e.g.
Microcyte
Macrocyte

11. A. Report RBC size
• Microcytic: smaller than the normal RBC,( <7.2 μm), and is associated with a decrease in hemoglobin synthesis
Found in:
- Iron deficiency anemia. - Thalassaemia. - Sideroblastic anemia. - Lead poisoning. - Anemia of chronic disease.

12. Variation in erythrocyte size (anisocytosis)
• Macrocyte: larger than the normal RBC (<8.2 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)

13. Macrocytic Anemia: Macro-Ovalocytes

14. Variation in erythrocyte size (anisocytosis)
Comment:
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.
Staining: MGG Magnification: x1000
1. microcyte   2. normocyte

15. 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.

16. Variation in hemoglobin content
• 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

17. Variation in hemoglobin content
• 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

18. Reticulocyte: Polychromasia

19. Polychromasia

20. Figure 2. Polychromasia may be seen in response to anemia
Maslak, P. ASH Image Bank 2004;2004:101122

21. 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,……)

22. Poikilocytosis

23. Schrier, S. ASH Image Bank 2002;2002:100513
Figure 1. This is a periperal smear of a patient with hereditary pyropoikilocytosis
Schrier, S. ASH Image Bank 2002;2002:100513

24. Shape Abnormalities of Erythrocytes
Terminology Description Condition
Target cells Central hemoglobin; target-shaped Liver disease; thalassemia: Abnormal Hgb; iron deficiency
Echinocyte Short spicules, equally-spaced Uremia, hypokalemia, artifact
Acanthocyte Spiculated, irregular Liver disease (alcohol),
Post-splenectomy
Spherocyte Spherical, no central pallor HS, Immune hemolytic anemia
Schistocyte Fragmented RBC, helmet cells MAHA, burns
Ovalocyte Oval/elliptical shaped Hereditary elliptocytosis,
Megaloblastic anemia
Sickle cell bipolar spiculated shape Hgb S-containing
“banana” shaped hemoglobinopathy
Teardrop cell single elongated extremity Myelophthistic changes
Bite cells Irregular gap in membrane G6PD deficiency 2

25. III- Variation of red cells shape (Poikilocytosis)
Target cell: 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 - Haemoglobinopathies (S and C) - Post splenectomy

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

27. Abnormal Shape Spherocytosis: Morphology:
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
Zieve's syndrome is an acute metabolic condition that can occur during withdrawal from prolonged alcohol abuse. It is defined by hemolytic anemia, hyperlipoproteinaemia (excessive blood lipoprotein), jaundice, and abdominal pain.[1] The underlying cause is liver delipidization. This is distinct from alcoholic hepatitis, which however may be subsequent or copresent.
microangiopathic hemolytic anemia (MAHA) :In all causes, the mechanism of MAHA is the formation of a fibrin mesh due to increased activation of the system of coagulation. The red blood cells are physically cut by these protein networks, and the fragments are identical to the schistocytes seen on light microscopy.

28. Spherocytes

29. Spherocytes: Autoimmune Hemolytic Anemia

30. Spherocytes: Hereditary Spherocytosis

31. III- Variation of red cells shape (Poikilocytosis)
8- Stomatocytosis:
Morphology: 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 - Hereditary spherocytosis

32. Stomatocyte

33. III- Variation of red cells shape (Poikilocytosis)
Ovalocyte : an elongated oval cell. They are a result of a membrane defect.
Found in:
- Thalassaemia major.
- Hereditary ovalocytosis.
- Sickle cell anemia

34. III- Variation of red cells shape (Poikilocytosis)
4- Elliptocytosis:
Morphology:
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

35. Elliptocytes: Hereditary Elliptocytosis

36. III- Variation of red cells shape (Poikilocytosis)
Schistocyte: 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: - Disseminated intravascular coagulation ( DIC ) - Micro angiopathic haemolytic anemia - Mechanical haemolytic anemia

37. Schistocytes: Microangiopathic Hemolytic Anemia

38. Schrier, S. ASH Image Bank 2001;2001:100249
schistocytes
Figure 1. Note the fragmented schistocytes, burr cells, and helmet cells
Schrier, S. ASH Image Bank 2001;2001:100249

39. III- Variation of red cells shape (Poikilocytosis)
7- Schistocytosis:
Morphology:
Fragmentation of the red cells.
Found in: - DIC - Micro angiopathic haemolytic anemia - Mechanical haemolytic anemia
Disseminated intravascular coagulation (DIC), also known as consumptive coagulopathy, is a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood vessels throughout the body.

40. III- Variation of red cells shape (Poikilocytosis)
6- Blister cell:prekeratocyte
Morphology:
Have accentric hallow area.
Resemble a women's handbag and may be called pocket-book cell.
Found in:
Microangiopathic hemolytic anemia

41. Blister cell or prekratocyte

42. III- Variation of red cells shape (Poikilocytosis)
10- Keratocytes (horn cell):
Morphology: 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

43. Keratocyte

44. Bite Cells

45. III- Variation of red cells shape (Poikilocytosis)
12- Sickle Cells:
Morphology:
Sickle shaped red cells
Found in:
Hb-S disease

46. Sickle Cell Anemia: Hgb SS

47. III- Variation of red cells shape (Poikilocytosis)
9- Burr (crenation ) cell:
Morphology:
Red cell with uniformly spaced, pointed projections on their surface.
Found in: - hemolytic anemia
- Uremia.
- Megaloblastic anemia

48. Echinocytes (Burr Cells)

49. Hepatorenal Syndrome: Burr + Spur Cells

50. III- Variation of red cells shape (Poikilocytosis)
11- Acanthocytosis:
Morphology: are 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

51. Acanthocytes (Spur Cells)

52. Lazarchick, J. ASH Image Bank 2002;2002:100507
Figure 2. Higher magnification of the same smear showing the spur cells ( arrows), target cells, and polychromasia
Lazarchick, J. ASH Image Bank 2002;2002:100507

53. III- Variation of red cells shape (Poikilocytosis)
Teardrop: resembles a tear and usually smaller than the normal RBC.
Found in:
- Bone marrow fibrosis - Megaloblastic anemia - Iron deficiency - Thalassaemia

54. Maslak, P. ASH Image Bank 2002;2002:100453
Figure 1. Dacryocytes (tear drop poikilocytes) are seen in the peripheral blood of a patient with idiopathic myelofibrosis
Maslak, P. ASH Image Bank 2002;2002:100453

55. Envelope form cell
Found in
thalassemia
Sickle cell anemia

56. Erythrocyte Inclusions with Wright’s Stain
Inclusion Composition Appearance Condition
Basophilic Precipitated Evenly dispersed Lead poisoning
stippling ribosomes fine or coarse granules thalassemia
other anemias
Howell-Jolly DNA in origin Dense, round Post-splenectomy
bodies Nuclear fragment blue granule
Pappenheimer Iron-containing Small blue granules Anemias
bodies granules in clusters
Heinz bodies Denatured round blue precipitates G6PD
hemoglobin
Cabot Rings remnants of Reddish-blue threadlike Severe anemia,
nuclear membrane rings Lead poisoning
Organism Small blue inclusion Malaria
Babesiosis

57. Erythrocyte inclusion bodies
1- Howell-Jolly Bodies:
Morphology: Small round cytoplasmic red cell inclusion with same staining characteristics as nuclei
Found in: - Post splenectomy - Megaloblastic anemia

58. Howell-Jolly Body

59. Maslak, P. ASH Image Bank 2005;2005:101350
Figure 1. Howell-Jolly bodies are small dense particles seen in the cytoplasm of this erythroid precursor
Maslak, P. ASH Image Bank 2005;2005:101350

60. Erythrocyte inclusion bodies
2- Siderotic Granules (Pappenheimer Bodies)
RBCs which contain no hemoglobin iron granules. They appear as dense blue, irregular granules which are unevenly distributed in Wright stained RBCs. Pappenheimer bodies can be increased in hemolytic anemia, infections and post-splenectomy.

61. Lazarchick, J. ASH Image Bank 2004;2004:101168
Figure 2. Multiple RBCs containing Pappenheimer bodies are seen in htis view
Lazarchick, J. ASH Image Bank 2004;2004:101168

62. Erythrocyte inclusion bodies
3- Basophilic stippling:
Morphology: Considerable numbers of small basophilic inclusions in red cells.
Found in: - Thalassaemia - Megaloblastic anemia - Hemolytic anemia - Liver disease - Heavy metal poisoning.

63. Tear Drop Cells

64. Schrier, S. ASH Image Bank 2002;2002:100344
Figure 3. There is extensive course basophilic stippling of the red blood cells (RBC) in this patient who has had exposure to toxic levels of lead
Schrier, S. ASH Image Bank 2002;2002:100344

65. Basophilic Stippling

66. Erythrocyte inclusion bodies
4- Heinz Bodies:
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.

67. Heinz Bodies

68. Figure 2. Heinz Body Preparation
Figure 2. Heinz Body Preparation. RBC are incubated supravitally in new Methylene blue to identify precipitates of oxidatively denatured hemoglobin.

69. IV -Erythrocyte inclusion bodies
5- Cabot Rings:
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.

70. Cabot rings

71. Erythrocyte inclusion bodies
6- Parasites of Red Cell:
Two organisms are have a tendency to invade the RBCs.
All 4 species of the malaria parasite will invade RBCs. We will see the Plasmodium of different species in RBCs.
Bebesia microti

72. Malaria

73. 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 and (D) Heinz's bodies.

74. Normal Peripheral Smear

75. Reticulocyte Manual Count by Supravital Stain: Normal Count

76. Reticulocytes: Elevated Count

77. RBC Inclusions: Composite

78. Hypochromic Microcytic RBC

79. Normal Hypochromic microcytic

80. Severe Hypochromia: Iron Deficiency Anemia

81. Mixed Population: Treated Iron Deficiency Anemia

82. Microcytic Hypochromia: Alpha Thalassemia (a-/--)

83. Morphologic Changes in Liver Disease
Target Cells
Spur Cells