Objectives

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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
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Objectives

• Automated cell counting
• Peripheral blood morphology

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Coulter Principle
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Red Cell Parameters
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Red Cell Histogram and Count
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Calculation of the RDW
RDW Coefficient of variation of red cell
volume distribution
Normal range 11.5 - 14.5
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Red Cell Distribution Width - RDW
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Comparison of RDW in Iron Deficiency and Anemia
of Chronic Disease
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CBC Report
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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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Normal Peripheral Smear
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Normal Peripheral Smear
More information can be gained from examining
the blood smear than from any single hematologic
procedure
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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 Wrights Stain
Inclusion Composition Appearance
Condition Basophilic Precipitated Evenly
dispersed Lead poisoning stippling ribosomes fine
or coarse granules thalassemia other
anemias Howell-Jolly Nuclear Dense, round
Post-splenectomy bodies fragment blue
granule Pappenheimer Iron-containing Small blue
granules Anemias bodies granules in
clusters Organism Small blue
inclusion Malaria 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 formation Stacking of RBCs due to
  increased plasma proteins coating RBCs
• Agglutination Antibody-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

• Anisocytosis Variations in size (e.g.
  microcytes)
• Poikilocytosis Variations in shape (e.g. target
  cells)
• Hypochromia Increased 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 (a-/--)
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Microcytic Hypochromia Beta Thalassemia Major
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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
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-s
plenectomy Spherocyte Spherical, no central
pallor HS, Immune hemolytic anemia Schistocyte
Fragmented RBC, helmet cells MAHA,
burns Ovalocyte Oval/elliptical
shaped Hereditary elliptocytosis, Megalob
lastic 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
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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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Morphologic Changes in Liver Disease
Target Cells
Spur Cells
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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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Monocytes
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Small Lymphocyte
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Lymphocytes
Large
Small
Intermediate
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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 M1Myeloblasts without
Differentiation
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Acute Myeloid Leukemia M2Myeloblasts 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 M6Erythroleukemia
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Acute Myeloid Leukemia M7Megakaryocytic Leukemia
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Abnormalities of Lymphocytes
Variant Morphologic categories Atypical
lymphs Abundant cytoplasm, RBC
skirting Abnormal lymphs Nuclear
abnormalities i.e. clefts, folds,
notches Plasmacytoid lymphs Abundant
cytoplasm Hairy cells Cytoplasmic
projections Sezary cells Deeply folded
nucleus Prolymphocyte Large lymph with
prominent nucleolus
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Atypical (Reactive) Lymphocytes
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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)