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Practical of Clinical Hematology

Practical of Clinical Hematology. Collected and prepared by BMS Dzamesi Anthony Dela. RBCs Abnormal morphology. Peripheral Blood Morphology. Abnormal erythrocyte morphology.

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Practical of Clinical Hematology

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  1. Practical of Clinical Hematology Collected and prepared by BMS Dzamesi Anthony Dela

  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

  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. 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 RBCsize • • 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. microcyte2. normocyte

  15. Variation inerythrocyte 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. ShapeAbnormalities of Erythrocytes • Poikilocytosisis 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. Figure 1. This is a periperal smear of a patient with hereditary pyropoikilocytosis Schrier, S. ASH Image Bank 2002;2002:100513

  24. ShapeAbnormalities of Erythrocytes TerminologyDescriptionCondition Target cells Central hemoglobin; target-shaped Liver disease; thalassemia: Abnormal Hgb; iron deficiency Echinocyte Short spicules, equally-spaced Uremia, hypokalemia, artifact AcanthocyteSpiculated, 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

  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- Microangiopathichaemolytic

  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 angiopathichaemolytic anemia- Mechanical haemolytic anemia

  37. Schistocytes: Microangiopathic Hemolytic Anemia

  38. 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 angiopathichaemolytic anemia- Mechanical haemolytic anemia

  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

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