RBC INCLUSIONS

INCLUSIONS APPEARANCE/ DESCRIPTION COMPOSITION CLINICAL SIGNIFICANCE PICTURE

Coarse densely stained purple granules,
1. HOWELL-JOLLY BODIES eccentrically located on periphery of
membrane
Megaloblastic anemia
Severe hemolytic process
Nuclear remnants of DNA; (+) Fuelgen
Thalassemia
Accelerated erythropoiesis

Lead poisoning
Dark blue granules DISTRIBUTED IN THE
Pyrimidine-5-nucleotidase
CELL; punctuate basophilia
deficiency
Heavy metal poisoning
2. BASOPHILIC STIPPLINGS In lead poisoning – coarse basophilic Precipitation of ribosomes and RNA
Thalassemia
stippling
Pica in children – associated w/ lead
In increased red cell production – fine
poisoning
basophilic stippling
Pica in adult – associated with IDA

Dyserythropoiesis
Remnant of microtubules of mitotic
3. CABOT RINGS Rings, loops, figure of eight, red to purple Megaloblastic anemia
spindle
Severe anemia

Precipitated, denatured hemoglobin due Hereditary defect in Hexose

4. HEINZ BODIES
to oxidative injury. Monophosphate Shunt
(Golf ball – multiple Heinz Deep purple irregularly shaped inclusion
Cannot be seen in Wright’s stain G6PD deficiency
bodies)
Requires supravital stain (crystal violet) Unstable hemoglobins

Tetragonal, Rectangular rod shaped dense

5. HEMOGLOBIN C CRYSTALS hemoglobin C disease
staining crystals (bar of gold, clam shell)

Clarence Witty H. Mendoza, RMT

RBC INCLUSIONS
6. HEMOGLOBIN SC CRYSTALS
7. RINGED SIDEROBLAST
(Siderocyte – non-nucleated
cell containing hemosiderin iron
granules)
8. PAPPENHEIMER BODIES
9. MALARIA
10. BABESIA
1. ROULEAUX
2. AUTOAGGLUTINATION
“Washington monument” shape; finger-
like or quartz like crystal of dense
Hemoglobin SC disease
hemoglobin protruding from the RBC
membrane
Iron overload in mitchondria of
normoblast.
Nucleated RBC that contains non-heme iron Sideroblastic anemia
Due to defective heme synthesis.
particles (hemosiderin) Myelodysplastic syndrome (MDS)
Hemosiderin – Needed for
identification
Sideroblastic anemia
Basophilic inclusions that aggregate in small Hemoglobinopathies
clusters NEAR THE PERIPHERY with Unused iron deposits Thalassemia
Wright’s stain. Megaloblastic anemia
MDS
Protozoan transmitted by bite of female
Anopheles mosquito
Protozoan inclusion (B. microti), transmitted
from deer to humans by tick bite.
MISCELLANEOUS (VARIATIONS IN RED BLOOD CELL PATTERN/DISTRIBUTION)
“Stacking or “coining” pattern of red blood Multiple Myeloma/ Waldenstrom's
A property of plasma, due to abnormal
cells on the blood smear. macroglobulinemia
or increased proteins (plasma globulins);
Blue background on smear microscopically Chronic inflammation (high
Increased ESR
and may look very blue macroscopically. fibrinogen)
Cold autoimmune hemolytic anemias -
Clumping of RBC's with no pattern.
cold-reacting autoantibodies
Clarence Witty H. Mendoza, RMT
RBC INCLUSIONS

PARASITIC INCLUSIONS IN RED BLOOD CELLS

Plasmodium species Size Inclusion Cytoplasm Merozoites
P. vivax Enlarged Schuffner dots Blue discs with red nucleus 12 – 24
Accole forms
Signet-ring forms
P. falciparum Normal Maurer dots Minute rings 6 – 32
Two chromatin dots
Accole forms
Gametes crescent shape
P. malariae Enlarged Ziemman stippling One ring with one dot 6 – 12
P. ovale Normal Schuffner dots One ring form 6 – 14

Additional information:

 Normally, there are NO red cell inclusions visible when the smear is stained with Wright's stain;
 Any red cell inclusions are pitted out by the spleen as the red cells pass through.
 The presence of inclusions decreases red cell deformability and shortens red cell survival.

Structures needing SUPRAVITAL STAIN:

 Reticulum of reticulocytes
 Heinz bodies
 Hemoglobin H

Clarence Witty H. Mendoza, RMT