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Peripheral Blood Smears Department of Internal Medicine Divisions of Hematology and Laboratory Medicine
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Complete Blood Count Automated cell counting Peripheral blood morphology
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Automated Cell Counting: Deficiencies Abnormalities and inclusions in WBC RBC shape abnormalities RBC inclusions Platelet abnormalities and clumping
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Peripheral Blood Morphology
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Peripheral Smears Barnes-Jewish Hospital Daily total Total CBCs900-1100 Peripheral smears* Laboratory initiated100-200 Physician-initiated ~20 * Smears are saved for 30 days
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Normal Peripheral Smear
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“More information can be gained from examining the blood smear than from any single hematologic procedure”
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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)
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Reticulocyte: Polychromasia
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Reticulocyte Manual Count by Supravital Stain: Normal Count
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Reticulocytes: Elevated Count
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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
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Basophilic Stippling
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Howell-Jolly Body
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Malaria
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RBC Inclusions: Composite
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Erythrocyte Distribution Abnormalities Rouleaux formationStacking of RBCs due to increased plasma proteins coating RBCs AgglutinationAntibody-mediated clumping; temperature dependent
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Rouleaux Formation
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Agglutination Reaction
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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
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Hypochromic Microcytic RBC
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Normal Hypochromic microcytic
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Hypochromia without Anisocytosis: Thalassemia Trait
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Severe Hypochromia: Iron Deficiency Anemia
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Mixed Population: Treated Iron Deficiency Anemia
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Microcytic Hypochromia: Alpha Thalassemia ( -/--)
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Microcytic Hypochromia: Beta Thalassemia Major
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Macrocytic Anemia: Macro-Ovalocytes
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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
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Target Cells Diagnostic possibilities Liver disease Hemoglobinopathy Thalassemia Iron deficiency Post-splenectomy Lipid disorders
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Echinocytes (Burr Cells)
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Acanthocytes (Spur Cells)
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Target Cells Spur Cells Morphologic Changes in Liver Disease
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Hepatorenal Syndrome: Burr + Spur Cells
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Spherocytes
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Spherocytes: Autoimmune Hemolytic Anemia
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Spherocytes: Hereditary Spherocytosis
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Schistocytes: Microangiopathic Hemolytic Anemia
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Elliptocytes: Hereditary Elliptocytosis
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Sickle Cell Anemia: Hgb SS
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Hemoglobin SC Disease
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Hemoglobin S-Beta Thalassemia
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Homozygous Hemoglobin C Disease (Hgb CC)
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Teardrop Cells
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Bite Cells
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Heinz Bodies
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Morphology of Leukocytes Normal WBC populations Neutrophils (Granulocytes) Lymphocytes Monocytes Eosinophils Basophils
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Neutrophil
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Eosinophil
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Neutrophil Eosinophil
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Monocytes
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Small Lymphocyte
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Small Intermediate Large Lymphocytes
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Basophils
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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
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Dohle Bodies
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Toxic Granulation
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Toxic Granulation and Vacuole Formation
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Hypersegmented Neutrophils
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Auer Rod: Acute Myeloid Leukemia
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Ehrlichia
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Myeloid Leukemias and Leukemoid Reaction Bone marrow exam is almost always indicated Cytogenetic analysis Flow cytometry analysis
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Neutrophilia: Leukemoid Reaction
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Neutrophilia: CML
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Pelger-Huet Abnormality
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Acute Myeloid Leukemia: M1 Myeloblasts without Differentiation
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Acute Myeloid Leukemia: M2 Myeloblasts with Some Differentiation
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Acute Myeloid Leukemia: M3 Promyelocytic Leukemia
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Acute Myeloid Leukemia: M4 Myelomonocytic Leukemia
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Acute Myeloid Leukemia: M5 Monocytic Leukemia
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Acute Myeloid Leukemia: M6 Erythroleukemia
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Acute Myeloid Leukemia: M7 Megakaryocytic Leukemia
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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
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Atypical (Reactive) Lymphocytes
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Abnormal Lymphocytes
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Plasmacytoid Lymphocytes
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Plasma Cell: Plasma Cell Leukemia
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Hairy Cell: Hairy Cell Leukemia
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Sezary Cell
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Prolymphocytes
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Chronic Lymphocytic Leukemia (CLL)
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CLL: Smudge Cells
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CLL: Balloon Cells
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Acute Lymphocytic Leukemia: L1
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Acute Lymphocytic Leukemia: L2
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Acute Lymphocytic Leukemia: L3 (Burkitts)
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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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Spend time with your family and friends Enjoy activities outside of the hospital Exercise or participate in sports
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