LABORATORY DIAGNOSIS

RED BLOOD CELLS

PRONORMOBLASTPRONORMOBLAST

Size: 12-20 umSize: 12-20 um Nucleus: round; Nucleus: round;

nucleoli (1-2); fine nucleoli (1-2); fine chromatinchromatin

Cytoplasm: dark blueCytoplasm: dark blue N/C ratio: 8:1N/C ratio: 8:1 Reference interval:Reference interval:

BM: 1%BM: 1% PB: 0%PB: 0%

BASOPHILIC NORMOBLAST

• Size: 10-15 um

• Nucleus: round; nucleoli 0-1; slightly condensed chromatin

• Cytoplasm: dark blue

• N/C ratio: 6:1

• Reference interval:

BM: 1-4%

PB: 0%

POLYCHROMATIC NORMOBLAST

• Size: 10-12 um

• Nucleus: round; nucleoli 0; quite condensed chromatin

• Cytoplasm: gray blue

• N/C ratio: 4:1

• Reference interval:

BM: 10-20%

PB: 0%

ORTHOCHROMIC NORMOBLASTORTHOCHROMIC NORMOBLAST

Size : 8-10 umSize : 8-10 um Nucleus : round ; Nucleus : round ;

nucleoli = 0 ; fully nucleoli = 0 ; fully condensed chromatincondensed chromatin

Cytoplasm : blue to Cytoplasm : blue to salmonsalmon

N/C ratio : 0.5:1N/C ratio : 0.5:1 Reference interval : Reference interval :

BM : 5-10%BM : 5-10%PB : 0%PB : 0%

Size : 8-8.5 umSize : 8-8.5 um Nucleus : absentNucleus : absent Cytoplasm : blue to Cytoplasm : blue to

salmonsalmon N/C ratio : NAN/C ratio : NA Reference interval : Reference interval :

BM : 1%BM : 1%PB : 0.5% - 2%PB : 0.5% - 2%

POLYCHROMATIC ERYTHROCYTEPOLYCHROMATIC ERYTHROCYTE

Size : 7-8 umSize : 7-8 um Nucleus : absentNucleus : absent Cytoplasm : salmonCytoplasm : salmon N/C ratio : NAN/C ratio : NA Reference interval : Reference interval :

BM : NABM : NAPB : PredominantPB : Predominantcell typecell type

ERYTHROCYTEERYTHROCYTE

ASSOCIATED WITH: ASSOCIATED WITH: iron def. anemia, iron def. anemia, sideroblastic anemia, sideroblastic anemia, thalassemia minor, thalassemia minor, chronic disease chronic disease (occasionally), lead (occasionally), lead poisoning, some poisoning, some hemoglobinopathieshemoglobinopathies

ERYTHROCYTE: VARIATIONS IN SIZEERYTHROCYTE: VARIATIONS IN SIZE

MICROCYTE

Normal erythrocytes Normal erythrocytes are approximately the are approximately the same size as the same size as the nucleus of a small nucleus of a small lymphocytelymphocyte

NORMOCYTE

ASSOCIATED WITH: ASSOCIATED WITH: liver disease, vitamin liver disease, vitamin B12 deficiency, folate B12 deficiency, folate deficiency, neonatesdeficiency, neonates

MACROCYTES

ASSOCIATED WITH: ASSOCIATED WITH: transfusion, transfusion, myelodysplastic myelodysplastic syndromes, vit. B12, syndromes, vit. B12, folate, or iron folate, or iron deficiencies – early in deficiencies – early in treatment processtreatment process

DIMORPHIC POPULATION OF ERYTHROCYTESDIMORPHIC POPULATION OF ERYTHROCYTES

Normochromic Normochromic erythrocyteserythrocytes

HEMOGLOBIN CONTENT OF ERYTHROCYTESHEMOGLOBIN CONTENT OF ERYTHROCYTES

ASSOCIATED WITH: ASSOCIATED WITH: iron deficiency iron deficiency anemia, anemia, thalassemias, thalassemias, sideroblastic anemia, sideroblastic anemia, lead poisoning, some lead poisoning, some cases of chronic cases of chronic diseasedisease

Hypochromia

ASSOCIATED WITH: ASSOCIATED WITH: acute and chronic acute and chronic hemorrhage, hemorrhage, hemolysis, effective hemolysis, effective treatment for anemia, treatment for anemia, neonatesneonates

Polychromasia

VARIATIONS IN SHAPE AND COLORVARIATIONS IN SHAPE AND COLOR

Acanthocyte (Spur Cell)

ASSOCIATED WITH: abetalipoproteinemia, severe liver disease, splenectomy, malabsorption,

hypothyroidism, vit. E deficiency

Echinocytes (Burr Cell)

ASSOCIATED WITH: uremia, pyruvate kinase def., microangiopathic hemolytic anemia, artifact

Spherocytes

ASSOCIATED WITH: hereditary spherocytosis, some hemolytic anemias, transfused cells, severe

Codocyte (Target cell)

ASSOCIATED WITH: hemoglobinopathies, thalassemia, iron deficiency anemia, splenectomy,

obstructive liver disease

Drepanocyte (Sickle cell)

ASSOCIATED WITH: Homozygous hemoglobin S disease

Stomatocyte

ASSOCIATED WITH: Hereditary stomatocytosis, alcoholism, liver disease, Rh null phenotype,

artifact

Elliptocytes

ASSOCIATED WITH: Hereditary elliptocytosis or ovalocytosis, thalassemia major, iron deficiency

anemia, megaloblastic anemias (macro ovalocytes), myelopthisic anemias

Ovalocytes

Schizocyte (Schistocyte)ASSOCIATED WITH: Microangiopathic hemolytic

anemia (DIC), severe burns, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura,

renal graft rejection

Dacryocyte (Tear Drop Cell)ASSOCIATED WITH: Myelofibrosis with myeloid

metaplasia, thalassemias, myelophthisic anemias, other causes of extramedullary hematopoiesis

Rouleaux formationASSOCIATED WITH: Increased concentrations of

globulins and/or paraproteins

AutoagglutinationASSOCIATED WITH: Antigen/ antibody reactions

INCLUSIONS IN ERYTHROCYTESINCLUSIONS IN ERYTHROCYTES

Color : Dark blue to purpleColor : Dark blue to purple Shape : round to ovalShape : round to oval Size : 1 umSize : 1 um Number per cell : usually Number per cell : usually

1; maybe multiple1; maybe multiple Composition : DNAComposition : DNA Associated with : Associated with :

Splenectomy, Splenectomy, hyposplenism, hyposplenism, megaloblastic anemia, megaloblastic anemia, hemolytic anemiahemolytic anemia

Howell-Jolly bodies

Color : Dark blue to purpleColor : Dark blue to purple Shape : fine or coarse Shape : fine or coarse

granulesgranules Number per cell : Number per cell :

numerous with fairly even numerous with fairly even distributiondistribution

Composition : RNAComposition : RNA Associated with : Lead Associated with : Lead

intoxication, thalassemia, intoxication, thalassemia, abnormal heme synthesisabnormal heme synthesis

Basophilic stippling

Color : light blueColor : light blue Shape : fine irregular Shape : fine irregular

granules in clustersgranules in clusters Number per cell : usually one Number per cell : usually one

clusters; may be multiples. clusters; may be multiples. Often at periphery of cellOften at periphery of cell

Composition : IronComposition : Iron Associated with : Associated with :

Splenectomy, hemolytic Splenectomy, hemolytic anemia, sideroblastic anemia, sideroblastic anemia, megaloblastic anemia, megaloblastic anemia, hemoglobinopathiesanemia, hemoglobinopathies

Pappenheimer bodies (Siderotic granules)

Color : dark blue to purpleColor : dark blue to purple Shape : loop, ring, or Shape : loop, ring, or

figure of eight; may look figure of eight; may look like beads on a stringlike beads on a string

Number per cell : 1-2Number per cell : 1-2 Composition : thought to Composition : thought to

be remnants of mitotic be remnants of mitotic spindlespindle

Associated with : Associated with : Myelodysplastic syndrome, Myelodysplastic syndrome, megaloblastic anemiamegaloblastic anemia

Cabot ring

Stained with New Stained with New Methylene BlueMethylene Blue

Cell : anuclear Cell : anuclear immature erythrocytesimmature erythrocytes

Composition : Composition : precipitated RNAprecipitated RNA

Number : Number : ≥2/cell≥2/cell Color : dark blueColor : dark blue Associated with: Associated with:

erythrocyte maturationerythrocyte maturation

Reticulocytes

Stained with New Stained with New Methylene BlueMethylene Blue

Cell : mature RBCCell : mature RBC Composition : precipitated Composition : precipitated

hgbhgb Number : single or Number : single or

multiple, generally multiple, generally membrane boundmembrane bound

Color : dark blue to purpleColor : dark blue to purple Associated with: Unstable Associated with: Unstable

hgb, some hgb, some hemoglobinopathies, some hemoglobinopathies, some RBC enzyme deficienciesRBC enzyme deficiencies

Heinz bodies

DISEASES AFFECTING ERYTHROCYTESDISEASES AFFECTING ERYTHROCYTES

Iron Deficiency Anemia

Thalassemia minorPB : microcytosis, slight hypochromia, codocytes, basophilic stippling

Thalassemia majorPB : numerous nucleated RBC’s, microcytes, hypochromia, codocytes, basophilic stippling, many dacyocytes, many schizocytes, polychromasia

Macrocytic anemia (nonmegaloblastic type)PB : round macrocytes (MCV = 112 fl), leukocyte and platelet counts usually normalBM : no megaloblastic changes

Megaloblastic anemiaPB : pancytopenia, oval macrocytes, Howell-Jolly bodies, nucleated RBC’s, basophilic stippling, hypersegmentation of neutrophils, giant platelets, codocytes, schizocytes, spherocytes, dacrocytes

Aplastic anemiaPB : pancytopenia, normocytic, normochromic (occasional macrocytes)BM : hypocellular; lymphocytes may predominate

PB : spherocytes, schizocytes, polychromasia, nucleated RBC’s

Immune Hemolytic Anemia

PB : increased number of nucleated erythrocytes, macrocytic/normochromic, polychromasia, spherocytes

Hemolytic Disease of the Newborn

PB : Spherocytes (variable in number), polychromasia; nucleated erythrocytes possible

Hereditary Spherocytosis

PB : >25% elliptocytes, usually >60% elliptocytes; indices are normocytic, normochromic

Hereditary Elliptocytosis

PB : Codocytes, spherocytes, microcytes, polychromasia, intracellular or rod-shaped crystals possible

Hemoglobin CC disease

PB : Drepanocytes (in crises), codocytes, nucleated rbc’s, schizocytes, Howell-Jolly bodies, basophilic stippling,

polychromasia, increased leukocyte count with neutrophilia, increased platelet count

Hemoglobin SS disease

PB : Few sickle cells, codocytes, intraerythrocytic crystals. Crystalline aggregates of hemoglobin SC may protrude from the

erythrocyte membrane

Hemoglobin SC disease

LABORATORY DIAGNOSIS

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