HEMATOLOGY SANTOS

RBC Abnormalities and Inclusions

RBC ABNORMALITIES
 Some hemoglobinopathies

Macrocytes: cells are larger than normal (oval or round)

IN MORPHOLOGY  Megaloblastic anemia

 Folate deficiency
POIKILOCYTOSIS: variation in shape  Vitamin B12 deficiency
 Aplastic anemia
ANISOCYTOSIS: variation in shape  Autoimmune hemolytic anemia
 Alcoholism
1. Acanthocytes (Spike/Spur Cells): resemble the
 Pregnancy
spurs on cowboy boots
 Newborns
2. Codocytes (Target Cells): resemble targets or
 Cytotoxic chemotherapy
"bull's eyes"
 Chronic liver disease
3. Dacrocytes (Teardrop Cells): resemble teardrops
 Myelodysplastic syndrome
or raindrops
4. Degmacytes (Bite Cells): resemble cells that look Normocytes: cells are adequate in size
as if they have a bite taken out of them
5. Drepanocytes (Sickle Cells): resemble sickles  Early onset iron-deficiency anemia
6. Echinocytes (Burr Cells): resemble burrs  Early onset folate or vitamin B12 deficiency
7. Elliptocytes/Ovalocytes: elliptical or oval-shaped  dimorphic anemia
cells  sickle cell disease
8. Keratocytes (Horn Cells): resemble horns  chronic liver disease
9. Microspherocytes: smaller  myelodysplastic syndrome
10. Macrocytes: larger
11. Pyropoikilocytes PANCYTOPENIA
12. Schistocytes (Helmet Cells): resemble Army
helmets  All cell lines are affected: Red blood cells, White
13. Spherocytes (Microcytes): smaller blood cells, Platelets
14. Stomatocytes (Mouth Cells): cells are swollen,  This abnormal slide shows the following:
so they look as if they are mouths 1. Thrombocytopenia
 Anisocytosis means that a patient's erythrocytes are 2. Large platelet
not of equal size. 3. Giant platelet
 Red Cell Distribution Width (RDW) is a measurement 4. Pelger-Huet cell with agranulation and
of anisocytosis. vacuoles
 If the RDW is >14.5%, this indicates a heterogenous 5. Anisocytosis with schistocytes, bite cells,
population of RBC's, which means you will likely see macrocytes, microcytes, rbc aggregation,
a variety of sizes of RBC's on the slide. hypochromia, ovalocytes, one cell with
 Associated with iron deficiency, megaloblastic or Pappenheimer bodies
hemolytic anemia.
DIMORPHIC RBC POPULATION
Microcytes: cells are smaller than usual
 A dimorphic population of RBC's means that 2
 iron-deficiency anemia populations of RBC's are seen, and the RDW will be
 sickle cell anemia >14%. These are associated with:
 Thalassemia trait or thalassemia minor 1. Transfusion
 Congenital sideroblastic anemia 2. myelodysplastic syndrome
 Anemia of chronic disease 3. vitamin B12, folate or iron deficiency
 Lead poisoning
HEMATOLOGY SANTOS
RBC Abnormalities and Inclusions

HYPOCHROMIA 1. severe liver disease (hepatitis, ascites,

cirrhosis, cancer, gallstones, toxicity, etc...)
 Hypochromia means that the central pallor zone of 2. splenectomy (removal of spleen)
the red blood cell is pale. 3. malabsorption
 This central area must be > than 1/3rd of the 4. hypothyroidism
diameter of the cell before it is termed hypochromic. 5. vitamin E deficiency
 The MCHC is a gage of hypochromia unless only a 6. abetalipoproteinemia
few hypochromic cells are seen in the slide. 7. burns
 It is associated with: 8. microangiopathic hemolytic anemia
1. iron-deficiency anemia 9. hemolytic uremic syndrome
2. thalassemias 10. thrombotic thrombocytopenic purpura
3. sideroblastic anemia 11. disseminated intravascular coagulation
4. lead poisoning 12. renal graft rejection
5. chronic inflammation 13. COPD

POLYCHROMASIA ELLIPTOCYTES / OVALOCYTES

 Polychromasia is a lavender-bluish color to RBC's due  Cigar shape

to RNA retained in larger,  Associated with
 immature cells (macrocytes). 1. Hereditary elliptocytosis
 Associated with 2. Spherocytic elliptocytosis
1. acute and chronic hemorrhage 3. Southeast Asian ovalocytosis
2. hemolysis 4. Thalassemia major
3. neonates 5. Iron deficiency anemia
4. treatment for anemia 6. Myelophthisic anemias
7. Megaloblastic anemias
ACANTHOCYTES (SPUR CELLS): resemble cowboy boots
spurs CODOCYTES / TARGET CELLS

 Acanthocytes are red blood cells with irregular  Codocytes are called "target cells" because they look
projections varying in width, length and number. like "bull's eyes" with a central concentration of
They are also called "spur cells" or "spike cells", hemoglobin surrounded by a colorless zone with a
because they resemble spurs on cowboy boots. They peripheral ring of hemoglobin.
are characterized by the following:  Associated with
 3-20 spicules with narrow bases that are distributed 1. : Iron-deficiency anemia
unevenly 2. Liver disease
 spicules are sharp or knobby 3. Thalassemia
 microcytes 4. Hemoglobin C Disease
 lack central pallor, which differentiates them from 5. Sickle Cell Anemia, if spleen removed due to
echinocytes 6. Post-splenectomy
 seen in older blood cells or older samples 7. Hemoglobinopathies
 found in post-splenectomy states very commonly
STOMATOCYTES / MOUTH CELLS / SLIT CELLS
 always associated with pathological conditions
 large numbers seen in abetalipoproteinemia or  Associated with
advanced liver disease 1. Hereditary stomatocytosis
 cell membrane damaged due to a decrease in 2. Hemolytic anemia
membrane cholesterol 3. Overhydration (too much water, edema,
 Associated with: too much IV fluid)
HEMATOLOGY SANTOS
RBC Abnormalities and Inclusions

4. Also referred to as "volume overload" 8. pyruvate kinase deficiency,

5. Alcoholism 9. low levels of magnesium and/or low levels
6. Liver disease of phosphate (decreased Mg/Phos on
7. Rh-null phenotype Chemistry tests)
8. Artifact 10. microangiopathic hemolytic anemia
11. myeloproliferative disorders
DACROCYTES / TEARDROP CELLS 12. heparin therapy
13. post-transfusion
 Associated with 14. artifacts
1. Myelophthisic anemia-a severe anemia that
is seen with some diseases affecting the DREPANOCYTES / SICKLE CELLS
bone marrow, such as granulomas, tumors
2. Myelofibrosis-seen with myeloproliferative  Associated with
disorders, such as leukemia, lymphoma,  Sickle Cell Disease
myeloma, metastatic carcinoma  Homozygous hemoglobin S disease
3. Thalassemias  Hemoglobin SC (RBCs may look like they
4. Myelophthisic anemias have 1-2 "finger-like" projections
5. I see these a lot in organ failure, hypoxemia,  Sickle Cell Anemia
respiratory distress, liver failure  Sickle Cell Crisis
 Vaso-occlusive Crisis
DEGMACYTES / BITE CELLS  Splenic Sequestration
 Aplastic Crisis
 Bite cells are caused by the removal of hemoglobin
by the spleen.  Hemolytic Crisis
 Glucose-6-phosphate dehydrogenase deficiency also  Hemoglobin CC crystals are found in
causes the formation of bite cells as hemoglobin homozygous hemoglobin C disease
breaks down and Heinz bodies form.
SICKLE CELL
 Bite cells may contain one or more "bites".
 Sickle cell disease is actually a
ECHINOCYTES / BURR CELLS group of genetic blood disorders.
Sickle cell anemia is the most
 Echinocytes are red blood cells with abnormal cell
common type of sickle cell disease.
membranes that cause them to appear "spiked" or
Oxygen-carrying hemoglobin found
like a sea urchin. For this reason, they are also called
in red blood cells is abnormal and
Burr cells.
misshapen, resulting in the rigid
 Have short, evenly spaced projections.
sickled red blood cells.
 This condition is reversible  The genetics behind sickle cell
 Side effect of the EDTA anticoagulant coating in the disease results when an individual
vacutainer used to collect to blood to prevent it from inherits two abnormal copies of
clotting. the hemoglobin gene on
 These cells are crenated (shrunken). chromosome 11, one from each
 Associated with parent. It is an autosomal
1. uremia (kidney problems) and renal failure recessive disease. Sickle cell trait
2. hypokalemia is simply when an individual
3. bleeding peptic ulcers inherits just one copy of the
4. liver disease abnormal hemoglobin gene from
5. deficiency of vitamin E one parent. Such an individual is
6. hyperlipidemia referred to as a carrier, even if
7. hemolytic anemia, asymptomatic, and may pass the
HEMATOLOGY SANTOS
RBC Abnormalities and Inclusions

abnormal gene on to their own 5. Inflammatory and Connective Tissue

offspring. Disorders
6. Cancers
KERATOCYTES / HORN CELLS 7. Diabetes Mellitus
8. Occlusion in Diabetic retinopathy
 Formed when the nucleus is removed by the spleen 9. Increased concentrations of globulins or
paraproteins
SPHEROCYTES
10. Clumping may be seen in antigen-antibody
 Associated with reactions (such as a transfusion reaction)
1. Auto-hemolytic anemia
2. Warm hemolytic anemia
3. Microangiopathic hemolytic anemia
4. Hereditary spherocytosis
5. Autoimmune hemolytic anemia
6. Severe burns
7. Transfused RBC's

SCHISTOCYTES / HELMET CELLS

 Fragmented rbcs
 Associated with
1. Microangiopathic Diseases
2. Disseminated Intravascular Coagulation
(DIC)
3. Thrombosis
4. Trauma
5. Severe burns
6. Hemolytic Anemia
7. Consequence of an artificial mechanical
heart valve
8. Hemolytic Uremic Syndrome (HUS), a
complication of stool pathogen E.coli
0157:H7 (Enterohemorrhagic E. coli), which
damages the kidneys
9. TTP
10. Aortic stenosis
11. Atherosclerosis

ROULEAUX

 Stacked coins appearance

 Increase in proteins
 Associated with
1. Multiple Myeloma (MM, a type of blood
cancer)
2. Plasma cell myeloma
3. Lymphoplasmacytic lymphoma
4. Infections
HEMATOLOGY SANTOS
RBC Abnormalities and Inclusions

RBC INCLUSIONS HEINZ BODIES

 Heinz Bodies are precipitated, denatured

HOWELL-JOLLY BODIES hemoglobin in erythrocytes
 associated with hemolytic anemia.
 Howell-Jolly Bodies are remnants of nuclear DNA in
 They are large inclusions ranging from 1-3
red blood cells.
micrometers in size.
 During the maturation process, erythrocytes exude
 They are round towards the periphery of the red
their nucleus in the bone marrow just before
blood cell.
becoming reticulocytes
 Bite cells are evidence that a Heinz Body had been
 This is a reflection of abnormal mitosis.
formed then removed by the spleen.
 During the journey through the spleen, the spleen
 May be stained with a supra vital stain such Brilliant
typically removes the Howell-Jolly Body, therefore,
Cresyl Blue stain or Crystal Violet stain in order to be
its presence in a peripheral blood smear usually
seen since they cannot be visualized with Wright's
represents the absence of the spleen or a damaged
stain. They result from unstable hemoglobin
spleen.
variants or oxidative stress.
 1-2 of the round, dark, deep purple structures per
 Associated with
cell.
1. NADPH deficiency
 They are only about 1-2 micrometers in size.
2. G6PD deficiency
 Only see them when erythropoiesis is rushed. The
3. Hemoglobin Zurich
Howell-Jolly Body could be a remnant of the nucleus
4. Any other unstable hemoglobin diseases
of the orthochromic normoblast as it is extruded
5. Chronic liver disease
from the cytoplasm. In certain anemias, however,
6. Alpha-thalassemia
the spleen cannot keep up the pace since the bone
7. Asplenia or damaged spleen
marrow is responding too quickly to replace lost red
blood cells. PAPPENHEIMER BODIES
BASOPHILIC STIPPLING  Pappenheimer bodies are light blue-to-purple fine,
irregular granules in clusters found in RBCs.
 Coarse, dust-like dots represent ribosomes and
 They are composed of iron.
polyribosomes (RNA in precipitated aggregates).
 They are also referred to as siderotic granules.
 Cells containing these granules are often
 They are seen in the iron loading processes and iron-
polychromatophilic, so they may be difficult to
overloading, such as hereditary hemochromatosis
distinguish.
and iron-loading anemias.
 It is seen whenever erythropoiesis is rushed, or in
 They are tiny, light purple, beaded inclusions found
lead poisoning.
along the periphery of the red blood cells.
 They may be normal, or they may be a result of the
 Prussian Blue staining is often used to confirm this.
following conditions:
 Be careful not to mix these up with Gram-positive
1. Sideroblastic anemia
cocci bacteria, which look similar.
2. Myelodysplastic syndrome
 Associated with:
3. Lead poisoning
1. Splenectomy
4. Arsenic poisoning
2. Hemolytic anemia
5. Beta thalassemia
3. Sideroblastic anemia
6. Alpha thalassemia
4. Megaloblastic anemia
7. Hereditary Pyrimidine 5'-Nucleotidase
5. Hemoglobinopathies
Deficiency
8. Thrombotic Thrombocytic Purpura (TTP)
HEMATOLOGY SANTOS
RBC Abnormalities and Inclusions

CABOT RINGS HEMOGLOBIN H CRYSTALS

 dark blue to purple loops, rings or figure-eights
found in RBCS
 associated with remnants of the mitotic spindle
 Associated with
1. myelodysplastic syndrome
2. megaloblastic/pernicious anemia
3. postsplenectomy
RINGED SIDEROBLAST
 abnormal deposition of iron in erythrocytes within
the mitochondria (ATP energy-producers of the cell).
 The result is a ring around the nucleus.
 Conditions these are seen in include:
1. Iron-overloading disorders (Hereditary
hemochromatosis)
2. Sideroblastic anemia (Congenital or
Acquired)
3. Refractory Anemia with Ringed Sideroblasts
(RARS)
4. In this type, 15% or more of RBC precursors
are ringed sideroblasts
5. Bone marrow: erythroid hyperplasia, <5%
myeloblasts, iron overload, and
hepatosplenomegaly
6. Myelodysplastic disorder
7. Acute myelogenous leukemia (AML)
8. Megaloblastic anemia
 Hemoglobin H crystals are associated with
Hemoglobin H disease.
 Stained with Brilliant Cresyl Blue stain which stain
Hemoglobin H bodies composed of beta globin
chains in tetrads.
 This is indicative of alpha-Thalassemia.
 An impaired formation of alpha-chains leads to an
overage of beta-chains. This results in a moderately
severe anemia.
 Symptoms may include jaundice, fatigue, gallstones,
high blood pressure, and/or a pronounced forehead.
 This is an autosomal recessive genetic disorder.
 Serum iron and serum ferritin are other chemistry
tests used to rule out iron-deficiency anemia since
symptoms are similar.
HEMOGLOBIN SC CRYSTALS
 Hemoglobin SC crystals are composed of hemoglobin
S and hemoglobin C, and they resembled a gloved
hand.
 They are referred to as glove cells.
 Hemoglobin SC is a type of sickle cell disease.
 It affects the shape of the red blood cells.
 Anemia, fatigue, and severe pain are symptoms of
this disease.

HEMOGLOBIN C CRYSTALS

 These dark red, hexagonal crystals are shaped like

bacilli rods
 stain pink-red, are thick, and sometimes can be
confusing to new techs who may mistake them for
bacteria.
 They are composed of hemoglobin C and are
associated with homozygous hemoglobin C disease.
 They may have a Washington Monument
appearance.
 This abnormal hemoglobin is a glutamic acid
substitution for lysine at the 6th position on the
Beta-chain.
 Commonly found along with target cells and
microspherocytes