HEMATOLOGY 1

Ma Enrica T Sandico, RMT

 HEMATOLOGY

• Blood – red liquid circulating in the body

• Functions:
 Respiratory
 Excretory
 Body Temperature
 Transport of Hormones
 Defense
 BASIC TERMINOLOGIES IN BLEEDING
DISORDERS
• Petechiae
• Purpura
• Ecchymosis
• Hemarthosis
• Hematemesis
• Hematoma
• Hematuria
• Hemoglobinuria
 CHARACTERISTICS OF BLOOD

 Fluid (in vivo)

 Red
 Slightly alkaline
 Sp gr of 1.055
 Thick and viscuous
 BLOOD COLLECTION
• I. Patient Identification - most critical step in any venipuncture procedure

Identify patient by: __________________________________

Mortal sin of phlebotomist: ___________________________

Two types:
 Skin puncture
 Venipuncture
 SKIN PUNCTURE
• Used only when small quantities of blood are required
• Avoid pressure/squeezing
• Recommended depth of skin puncture: _________
• Why do we need to discard 1st drop of blood?
• ____________________________________
• Remove dead epidermal cells
• Remove excess tissue fluid

 Red cell count, platelets haematocrit and haemoglobin LOWER in capillary blood
 HIGHER WBC count (15-20%) as compared to venous blood
 SKIN PUNCTURE

• Puncture sites:
 Infants - _______________
 For older children and adults - ________________________
 VENIPUNCTURE

• Major veins
 Cephalic vein
 Basilic vein
 Median Cubital vein

• Angle between the skin and the needle : _______________

• Correct distance of the tourniquet to site of puncture : ______________
• Torniquet application should not be more than: ____________
 COMPLICATIONS IN VENIPUNCTURE
• Ecchymosis/bruise
• Syncope/fainting
• Hematoma
• Failure to draw blood
• Petechiae
• Hemolysis
• IV therapy
• Burns
• Mastectomy patients
 ORDER OF DRAW
Blood collection tube No. of inversions Color

Blood culture tube 8 times Yellow

Sodium citrate 3-4 times _______________

Red top NO INVERSION Red

NEEDED If glass

5 times If plastic

_________________ 8 times Green top

EDTA 8 times Lavender top

Sodium fluoride 8 times _______________
HEMOGLOBIN STRUCTURE AND SYNTHESIS

• Primary function of hemoglobin of the red blood cell:

> manufacture hemoglobin, which in turn, transports oxygen to the tissues and carbon
dioxide from tissues to the lungs

• >Globin chains
• Produced on the specific ribosomes in the cytoplasm of RBCs. Globin in each hgb
molecule contains _______________ which determine the hemoglobin formed.
 GLOBIN CHAINS IN HEMOGLOBIN
GREEK NAME NO OF AMINO COMMENTS
ACIDS
Alpha 141
Beta 146
Delta 146 Differs from beta
chain by 10 amino
acids
Gamma 146 Differs from beta
chain by 39 amino
acids
Epsilon 146 Embryonic only
Zeta 146 Embryonic only
OXYHEMOGLOBIN DISSOCIATION CURVE

FACTOR SHIFT CAUSED BY

Factor Increase Factor Decrease
Bld temp R L
Ph L R
2,3 DPG R L
CO2 R L
Hb F admixture L n/a
 GENETIC CODING FOR GLOBIN CHAINS

• Chromosome 16
• Chromosome 11
 NORMAL HUMAN HEMOGLOBINS

Hemoglobin Molecular Structure Stage of life

Gower 1 Zeta, epsilon (2) Embryonic
Gower 2 Alpha, epsilon (2) Embryonic
Portland Zeta, gamma (2) Em bryonic
Fetal Hb Alpha, gamma (2) Newborn and adult
Hb A1 Alpha, beta (2) Newborn and adult
Hb A2 Alpha, delta (2) Newborn and adult
 HEMOGLOBIN DERIVATIVES

• Carboxyhemoglobin
• Methemoglobin
• Sulfhemoglobin
 CARBOXYHEMOGLOBIN

• Carbon monoxide will bind with hemoglobin even if its concentration in the air is
extremely low
• Cannot bind and carry oxygen
• Causes anoxia
 METHEMOGLOBIN/HEMIGLOBIN (HI)

• Ferrous iron oxidized to the ferric state

• Spectrophotometry
 SULFHEMOGLOBIN

• Mixture of oxidized, partially denatured forms of hemoglobin that form during

oxidative hemolysis
• Sulfur (oxidation ) is incorporated into heme rind of hemoglobin, resulting in a
green hemochrome
• Cannot be reduced back to hemoglobin, and it remains in the cells until they break
down
 FUNCTIONAL CLASSIFICATION OF
HEMOGLOBIN VARIANTS
• Hb S – Severe hemolytic anemia, sickling
• Hb C – mild hemolytic anemia
• Hb D punjab – no anemia
• Hb E- Mild microcytic anemia
 HEMATOLOGIC PROCEDURES

• Complete Blood Count (CBC)

• WBC count
• RBC count
• Hemoglobin
• Hematocrit
• WBC differential count
 HEMOGLOBIN

• At birth: 15-20g/dL
• Women: 12-16 g/dL
• Men: 13-18 g/dL
•
• Higher in the morning and lower in the evening
• Increased in strenuous muscular activity
 HEMOGLOBIN DETERMINATION
• Colorimetric
• Direct/Visual Observation
• Acid Hematin
• Alkali Hematin
• Indirect/Photoelectric
• Cyanmethemoglobin (manual or
automated)
• Gasometric (Van Slyke)
> 1 gm hgb = ______ ml O2
• Sp gr mtd ( copper sulfate)
• Chemical (Kennedy’s, Wong’s)
> 1 gm Hgb = ______ mg iron
 CYANMETHEMOGLOBIN METHOD

Reagent: ______________
• Color intensity is measured at _____
• All forms of hgb are measured except ________
• ___________ does not affect result
• ___________ will cause falsely elevated result
• High WBC count _____________
• Lipemic blood ____________
 RULE OF THREE

> 3 X RBC = Hb
> 3 X Hb = Hct +/- 3%
 HEMATOCRIT

• At birth = 45-60%
• Female = 36 -48%
• Male = 40-55%

• Decreased in anemia
• Increased in polycythemia
 MACROMETHODS

• Wintrobe and Landsberg

• Van Allen
• Sanford Magath
• Bray
 MICROMETHODS

• Adams
 ERYTHROCYTE SEDIMENTATION RATE

• Nonspecific measurement used to detect and monitor an inflammatory

response to tissue injury

Elevated ESR: acute and chronic infections, pregnancy (after 3rd month),
rheumatic fever, rheumatic arthritis, menstruation

Decreased ESR: polycythemia, congestive heart failure, presence of

RBC abnormalities (poikilocytosis, spherocytes, sickle cells)
 TECHNICAL FACTORS THAT INFLUENCE
ESR

1. Tilting = increases ESR

A 3 degree angle = 30% error

2. Increased temperature = increases ESR

 ERYTHROCYTE INDICES

• MCV
• MCH
• MCHC
 MCV (MEAN CORPUSCULAR VOLUME)
NV: 80-100 fl
Macrocytic: megaloblastic anemia, nonmegaloblastic anemia (liver disease,
hypothyroidism
Microcytic: IDA, defective iron utilization (chronic disease), thalassemia

MCV = Hct %
------------- x 10
RBC
 MCH (MEAN CORPUSCULAR HEMOGLOBIN)

• NV : 27-31 pg
Increased: found in macrocytic anemias because RBCs are larger and carry more Hb
Decreased: found in hypochromic anemias and microcytic anemias unless RBCs are
also spherocytic

MCH = Hgb (g/dl)

---------------- X 10
RBC X 10^12/L
 MCHC (MEAN CORPUSCULAR HEMOGLOBIN
CONCENTRATION)
NV: 31-36% (31-36 g/dl)
Increased: Hyperchromic – Spherocytes
Decreased: Hypochromic – IDA, Thalassemia, defective iron utilization
 COUNTING METHODS

• Cross sectional/Crenellation
• Longitudinal
• Battlement
BLOOD SMEAR
PREPARATION
Wedge Method
BLOOD SMEAR PREPARATION
 Specimen : EDTA blood within 2 to 3 hours &
collected to the mark on tube.
 Note : May change RBCs morphology such as
Spiculated (crenated) cells if :
1. Excessive amount of anticoagulant to specimen
2. Old blood - long standing.
3. Warm environment (room temperature) may
hasten changes.
BLOOD SMEAR PREPARATION
 Specimen : AC-free blood
 Advantages:
Made at the patient’s side
Some artifacts may be prevented

Disadvantages:
Platelet clumping
Few films can be made
STEPS FOR BLOOD FILM
CHARACTERISTICS OF A
GOOD SMEAR
1. Thick at one end, thinning out to a smooth rounded
feather edge.

2. Should occupy 2/3 of the total slide area.

3. Should not touch any edge of the slide.

4. Should be margin free, except for point of

application.
3. The thickness of the spread
1. If the hematocrit is increased, the
angle of the spreader slide should be
decreased.
2. If the hematocrit is decreased, the
angle of the spreader slide should be
increased
COMMON CAUSES OF A POOR BLOOD
SMEAR
1. Drop of blood too large or too small.

2. Spreader slide pushed across the slide in a jerky manner.

3. Failure to keep the entire edge of the spreader slide against the
slide while making the smear.

4. Failure to keep the spreader slide at a 30° angle with the slide.

5. Failure to push the spreader slide completely across the slide.

6. Irregular spread with ridges and long tail

7. Holes in film

8. Cellular degenerative changes

EXAMPLES OF UNACCEPTABLE
SMEARS
 EXAMPLES OF
UNACCEPTABLE SMEARS
 COVERSLIP TECHNIQUE

• Glass slide coverslip Method

• Two cover slip method

AUTOMATED METHODS
 Miniprep
 Centrifugal (Spinner Type)
SLIDE FIXATION AND
STAINING
 II- FIXING THE FILMS
 To preserve the morphology of the cells, films
must be fixed as soon as possible after they
have dried.
 Methyl alcohol (methanol) is the choice,
although ethyl alcohol ("absolute alcohol") can
be used.
 To fix the films, place them in a covered
staining jar or tray containing the alcohol for 2-
3 minutes.
 NOTES
• It is important to prevent contact with
water before fixation is complete.
 PRINCIPLE
 The main components of a Romanowsky stain
are:
A cationic or basic dye

 An anionic or acidic dye

pH value of phosphate buffer is very important.

 CHARACTERISTICS OF A WELL-STAINED
BLOOD SMEAR
• Macroscopic: pink to purple
• Microscopic
RBC
WBC
Neutrophil cytoplasm
Eosinophils
STAINING CHARACTERISTICS OF A CORRECTLY
STAINED NORMAL FILM
• Nuclei Purple
• Cytoplasm
• Erythrocytes Deep pink
• Neutrophils Orange-pink
• Lymphocytes Blue; some small lymphocytes
deep blue
• Monocytes Grey-blue
• Basophils Blue
• Granules
• Neutrophils Fine purple
• Eosinophils Red-orange
• Basophils Purple-black
• Monocytes Fine reddish (azurophil)
• Platelets Purple
 Eosinophilic granules

Blue nucleus Basophilic granules

CAUSES & CORRECTION
 Too Acid Stain:
1. insufficient staining time
2. prolonged buffering or washing
3. old stain
 Correction:
1) lengthen staining time
2) check stain and buffer pH
3) shorten buffering or wash time
 Too Alkaline Stain:
1. thick blood smear
2. prolonged staining
3. insufficient washing
4. alkaline pH of stain components
 Correction :
1) check pH
2) shorten stain time
3) prolong buffering time
TOO ACIDIC SUITABLE TOO BASIC
CHARACTERISTICS OF BLOOD CELLS
Erythrocyte:
• Shape & size: Biconcave disc , size like
lymphocyte nucleus.
• Nucleus : lost.
• Cytoplasm: pinkish hue, small area of central
pallor.
• Number in man varies between 5 and 5.5 million
per cubic mm of blood.

Platelet ( Thrompocytes)
• Nucleus: No nucleus.
• Cytoplasm: small amount bluish cytoplasm &
contains reddish – purple granules
 WHITE BLOOD CELLS
Granulocytes
Neutrophils, eosinophils, basophils
Agranulocytes
Lymphocytes and monocytes
 Leukocytosis
 Leukocytosis, a WBC above 10,000 is usually
due to an increase in one of the five types of
white blood cells and is given the name of the
cell that shows the primary increase.

1. Neutrophilic leukocytosis = neutrophilia

2. Lymphocytic leukocytosis = lymphocytosis

3. Eosinophilic leukocytosis = eosinophilia

4.Monocytic leukocytosis =monocytosis

5.Basophilic leukocytosis = basophilia

 1. Neutrophils
 Neutrophils are so named because they are
not well stained by either eosin, a red
acidic stain, or by methylene blue, a basic
or alkaline stain.
 Neutrophils are also known as "segs",
"PMNs" or "polys" (polymorphonuclear).
 They are the body's primary defense against
______________
Stab Neutrophil (Band)

 Diameter:12-16
 Cytoplasm : pink
 Granules: primary,
secondary
 Nucleus: dark purple
blue
 dense chromatin
Segmented Neutrophil

 Diameter: 12-16
 Cytoplasm : pink
 Granules: primary,
secondary
 Nucleus: dark purple blue,
dense chromatin, 2-5
lobes.
Increased neutrophils count (neutrophilia)
1. Acute bacterial infection.
2. Granulocytic leukemia.

Decreased neutrophil count (neutropenia)

1. Typhoid fever
2. Brucellosis
3. Viral diseases, including hepatitis, influenza,
rubella, and mumps.
 Band Neutrophil Segmented Neutrophile

Shift to left  Increased bands mean acute infection,

usually bacterial.
Shift to right  Increased hypersegmented neutrophile.
2. Eosinophil

 Diameter: 14-16
 Cytoplasm : full of granules
 Granules: large refractile
orange-red.
 Nucleus: blue, dense
chromatin, 2 lobes like a
pair of glass.
 The most common reasons for an
increase in the eosinophil count are :
1. Allergic reactions such as hay fever, asthma,
or drug hypersensitivity.
2. Parasitic infection
3. Eosinophilic leukemia
3. Basophil
 Diameter: 14-16
 Cytoplasm : pink
 Granules: dark blue –black
obscure nucleus
 Nucleus: blue
4. Lymphocyte

 Diameter: small 7-9, large

12-16
 Cytoplasm: medium blue
 Granules: small agranular,
large a few, primary
granules
 Nucleus: dark blue, round
dense chromatin
Lymphocytes increase (lymphocytosis)
in:
1. Many viral infections
2.Tuberculosis.
3.Typhoid fever
4.Lymphocytic leukemia.

2. A decreased lymphocyte (lymphopenia)

count of less than 500 places a patient at
very high risk of infection, particularly
viral infections.
5. Monocyte
 Diameter: 14-20
 Cytoplasm : grey blue
 Granules: dust-like lilac color
granules
 Nucleus: blue, large irregularly
shaped and folded
 Diseases that cause a monocytosis
include:
•Tuberculosis
•Brucellosis
•Malaria
•Monocytic leukemia
 Band Segmented
Eosinophil
Neutrophil Neutrophil

basophil lymphocyte Monocyte

 Discussion
1. Do not count cells that are
disintegrating
• eosinophil with no cytoplasmic
membrane and with scattered
granules
•smudge cells • Pyknotic cell (nucleus extremely
condensed and degenerated, lobes
condensed into small, round
clumps with no filaments
interconnecting).
• smudge cells
• Basket cells
•Basket cells
3-Morphologic Changes Due To
Area Of Smear
 Thin area- Spherocytes which are really
"spheroidocytes" or flattened red cells. True
spherocytes will be found in other (Good)
areas of smear.
 Thick area - Rouleaux, which is normal in
such areas. Confirm by examining thin
areas. If true rouleaux, two-three RBC's
will stick together in a "stack of coins"
fashion..
Tail Body Head
 HEMATOPOIESIS

Two related theories (Origin of the Hematopoietic Progenitor

Cells)
• Polyphyletic Theory – each of the blood cell lineages is
derived from its own unique stem cell
• Monophyletic Theory – all blood cells are derived from a
single progenitor cell called a Pluripotential stem cell; most
widely accepted theory among experimental haematologists
 HEMATOPOIESIS
Three Phases:
• Mesoblastic/Megaloblastic Stage
Chief site of hematopoiesis: ____________________
• Hepatic Stage
• Chief site of hematopoiesis: __________________ with
contributions from spleen, thymus and lymph glands
Medullary/Myeloid Stage
Chief site of hematopoiesis: ________________
*begins in the 5th month of gestation
 MAIN SITES OF HEMATOPOIESIS

• RSVP
 MARROW CELLULARITY

• Ratio of normal cells to fat

• Normocellular – marrow has 30-70% hematopoietic stem
cells
• Hypercellular/Hyperplastic – marrow has >70% HSC
• Hypocellular/Hypoplastic – marrow has <30% HSCs
• Aplastic __________________________
 NORMAL MARROW CELLS
• Macrophages
• Mast Cells
• Osteoblasts
• Osteoclasts
• Megakaryocytes

• Marrow differential: count at least 500 cells (preferably 1000)

• 500 cells in 2 slides
• M:E ratio in adults should be 2:1 to 4:1
RBCS ABNORMAL
MORPHOLOGY
RED BLOOD CELL MORPHOLOGY

• NORMAL RED BLOOD

CELLS
 PROERYTHROBLAST

• No hemoglobin

• Nucleus 12 um

• Contain nucleoli
 BASOPHIL ERYTHROBLAST
• Early normoblast

• Nucleoli disappear

• Show mitosis

• Cytoplasm deep blue

• Increase in RNA

• Hemoglobin starts
appearing – Little Hb
POLYCHROMATOPHIL ERYTHROBLAST

• Late normoblast

• Nucleus smaller

• Coarse Chromatin

• Hemoglobin increase
ORTHOCHROMATIC ERYTHROBLAST

• Normoblast

• Nucleus smaller
• Pyknosis

• Nuclear lysis and

• Nuclear extrusion
 RETICULOCYTE

• Reticulum
• Remnant of ER & GA
• Synthesize Hb

• Few Mitochondria
• Young RBCs
• 1 % of Red Cells
 ERYTHROCYTES

• Round, biconcave, disc

shaped.
• Smooth contours
• Diameter 7.8 um.
• Normally no variation in size
and shape.
• Stain with EOSIN.
• More stain at periphery
• Can deform easily.
 STRUCTURE OF RBC.
• Negative surface charge.
• Bag of fluid with dissolved substances and
hemoglobin
• Membrane –
• Outer glycoprotein coat
• Lipid bilayer (PL 55%,Cholesterol 45%)

• Inner protein molecules cytoskeleton

• Spectrin, Actin, Ankyrin etc.

• No sub cellular particles

Erythropoiesis

Erythrocytes No nucleus and red cytoplasm

Reticulocytes No nucleus and blue - grey cytoplasm

Orthochromatophilic Dark, small, spherical nucleus

erythroblasts blue – grey cytoplasm

Darkening, fractured ,spherical

Polychromatophilic nucleus and mixed pools of grey and
erythroblasts blue cytoplasm

Basophilic erythroblasts Fractured, spherical nucleus and

thin rim of dark blue cytoplasm

Uniformly light, spherical

Proerythroblasts nucleus with thin rim of medium
to dark blue cytoplasm
 NOTES TO REMEMBER!

• Last stage capable of mitosis: _________

• Last Nucleated stage: _______________
• Index of BM activity or effective erythropoiesis:
_____________
• Lifespan of RBC: ________________________________
 RED BLOOD CELL MORPHOLOGY
Abnormal erythrocyte morphology is
found in pathological states that
may be :
- abnormalities in size
- - In shape
- -In hemoglobin content or the
presence of inclusion bodies in
erythrocyte.
 RED BLOOD CELL
MORPHOLOGY
Hypochromic:
A descriptive term applied to a red blood cell with a
decreased concentration of hemoglobin.
Normochromic:
A descriptive term applied to a red blood cell with a
normal concentration of hemoglobin.
Normocytic:
A descriptive term applied to normal size of RBC
Macrocytic:
A descriptive term applied to a larger than normal
red blood cell.
 1-VARIATION IN ERYTHROCYTE
SIZE (ANISOCYTOSIS)

1-Microcytosis:
Morphology:
- Decrease in the red cell size.

- Found in:
- Iron deficiency anemia.
- Thalassemia.
- Sideroblastic anemia.
- Lead poisoning.
- Anemia of chronic disease.
1-VARIATION IN ERYTHROCYTE SIZE
(ANISOCYTOSIS)
 1-VARIATION IN ERYTHROCYTE
SIZE (ANISOCYTOSIS)

2-Macrocytosis:
Morphology:

Increase in the size of a red

cell.
Found in:
- Folate and B12 deficiencies
(oval)
- Ethanol (round)
- Liver disease (round)
- Reticulocytosis (round)
 II-VARIATION IN HEMOGLOBIN
CONTENT
1-Hypochromasia:
Morphology:
Increase in the red cells' central
pallor which occupies more than the
normal third of the red cell diameter.
Found in:
- Iron deficiency
- Thalassaemia
any of the conditions leading to
Microcytosis
 II-VARIATION IN HEMOGLOBIN
CONTENT
2- Polychromasia:
Morphology:
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 haemostatic factor
replacement.
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)
RBCs may have different shapes:
1- 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
- Microangiopathic haemolytic anemia
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

2-Target Cells:
Morphology:
Red cells have an area of increased
staining which appears in the area of
central pallor.

Found in:
-Obstructive liver disease
- Severe iron deficiency
- Thalassaemia
- Haemoglobinopathies (S and C)
- Post splenectomy
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)
3- Ovalocytes:
Morphology:
oval shape red blood cell
Found in:

- Thalassaemia major.
- Hereditary ovalocytosis.
- Sickle cell anemia
 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
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

5- Tear Drop Cells:

Morphology:

Red cells shaped like a tear

drop or pear
Found in:

- Bone marrow fibrosis

- Megaloblastic anemia
- Iron deficiency
- Thalassaemia
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

6- Blister cell:
Morphology:
Have accentric hallow area.
Found in:
Microangiopathic hemolytic
anemia
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

7- Schistocytosis:
Morphology:

Fragmentation of the red

cells.
Found in:
- DIC
- Micro angiopathic haemolytic
anemia
- Mechanical haemolytic anemia
 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
 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
 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
 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
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

12- Sickle Cells:

Morphology:
Sickle shaped red cells
Found in:
Hb-S disease
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

13- Rouleaux Formation:

Morphology:
Stacks of RBC's resembling a
stack of coins.
Found in:

- Hyperfibrinogenaemia
- Hyperglobulinaemia
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)

14- Red cell-agglutination:

Morphology:
Irregular clumps of red cells
Found in:
- Cold agglutinins

- Warm autoimmune
hemolysis
 III- VARIATION OF RED CELLS
SHAPE (POIKILOCYTOSIS)
15- Nucleated red blood cells.
These red blood cells are
released from the bone
marrow early into the blood
stream, due to the need for
oxygen. Normal red blood
cells do not contain a
nucleus on a peripheral
smear.
 IV -ERYTHROCYTE INCLUSION
BODIES
1- Howell-Jolly Bodies:
Morphology:
Small round cytoplasmic
red cell inclusion with
same staining
characteristics as nuclei
Found in:
- Post
splenectomy
- Megaloblastic anemia
 IV -ERYTHROCYTE INCLUSION
BODIES

2- Siderotic Granules
(Pappenheimer Bodies)
RBCs which contain no
hemoglobin iron granules.
They appear as dense blue,
irregular granules which are
unevenly distributed in
Wright stained RBCs.
Pappenheimer bodies can be
increased in hemolytic
anemia, infections and post-
splenectomy.
 IV -ERYTHROCYTE INCLUSION
BODIES

3- Basophilic stippling:
Morphology:
Considerable numbers of
small basophilic inclusions in
red cells.
Found in:
- Thalassaemia
- Megaloblastic anemia
- Hemolytic anemia
- Liver disease
- Heavy metal poisoning.
 IV -ERYTHROCYTE INCLUSION
BODIES

4- Heinz Bodies:
Represent denatured hemoglobin
(methemoglobin - Fe+++) within
a cell. With a supravital stain
like crystal violet, Heinz bodies
appear as round blue
precipitates. Presence of Heinz
bodies indicates red cell injury
and is usually associated with
G6PD-deficiency.
 IV -ERYTHROCYTE INCLUSION
BODIES

5- Cabot Rings:
Reddish-blue threadlike rings
in RBCs of severe anemia's.
These are remnants of the
nuclear membrane and
appear as a ring or figure 8
pattern. Very rare finding in
patients with Megaloblastic
anemia, severe anemia's,
lead poisoning, and
dyserythropoiesis.
 IV -ERYTHROCYTE INCLUSION
BODIES

6- Parasites of Red Cell:

Transmitted by mosquitoes,
infection with Plasmodium
can be a cause of
hemolytic anemia
 RBCS ABNORMAL MORPHOLOGY

.
 WHITE BLOOD CELLS
Nucleated cells that function in body’s defense.
Reference range: 4.5 -11.5 x 10^9/L (SI) or 4,500- 11,500/mm^3
(conventional)

WBC Classifications:
• Granulocyte /Agranulocyte
• Polymorphonuclear/Mononuclear
• Phagocyte/Immunocyte
WBC ANOMALIES
 SMUDGE CELLS

-nuclear remnants of lymphoid

cells.
“Thumbprint” in appearance
May be seen in normal blood
smears
and increased in CLL (Chronic
Lymphocytic Leukemia).
 HYPERSEGMENTED NEUTROPHILS

• Neutrophils with 5 to 10 lobes, may

be seen in megaloblastic
anemia/pernicious anemia.
 PELGER-HUET ANOMALY

• HYPOSegmented neutrophils,
inherited condition characterized by
granulocytes with dumbbell-shaped
(Pince-nez/spectacle) appearance of
nucleus
 LE CELL

• Uses a neutrophil that has ingested a

homogenous, globular mass of
destroyed cells
 RIEDER CELLS

• Lymphocyte with ____________ nucleus

• May be seen in Chronic Lymphocytic
Leukemia
 FLAME CELLS

• Abnormal plasma cells with intensely

eosinophilic cytoplasm
• Seen in IgA myelomas
• Known as _____________
 GRAPE CELL

• Also known as mott cell/morula cell

• Abnormal plasma cells whose
cytoplasm completely filled with
Russel bodies
seen in Multiple Myeloma
 ALDER-REILLY BODIES

• Densely azoruphilic granules seen in all

types of leukocytes/wbcs.
• Granulations from abnormal deposition
and storage of mucoplysaccharides.

• Seen in:
 Hunter and Hurler Syndrome
 Mucopolysaccharidoses
 San Filipo Syndrome
 CHEDIAK HIGASHI SYNDROME

• _______________ responsible for granule

assembly
• Giant cytoplasmic granules in the
phagocytes and lymphocytes (Lysosomal
granules)
• Can be tested for ___________
• Positive: abnormal granules in phagocytes
• Negative: abnormal granules in
lymphocytes
 GAUCHER DISEASE

Gaucher cell, a macrophage living in the

bone marrow
Nucleus: Eccentric, small
Cytoplasm: crumpled tissue paper
appearance – accumulation of enzyme
“Pale basophilic cytoplasm and fibrillar
cytoplasmic inclusions.”
 NIEMANN-PICK DISEASE

• Enzyme deficiency:________________
• Also called Foam Cells/Pick cells
• Appears to be swollen
 HAIRY CELLS

• Small lymphocytes with little

cytoplasmic projections
• ______________________
• TRAP stain (+) – Tartrate resistant acid
phosphatase
 TOXIC GRANULATIONS

• Usually found in _______________

• Altered primary granules, colored dark
blue/black after wright’s staining.
• Seen in:
• Bacterial infections
• Lead Poisoning
 TART CELLS

• Monocyte/histiocyte with engulfed

viable nuclear material
• Nucleus with identifiable nuclear
chromatin
• (+) Drug sensitivity
• Should not be confused with LE cells
 AUER BODIES

• Linear projections of azurophilic

granunles seen in malignancies, certain
types of leukemia

• ___________n- abnormal wbc with

bundles of auer rods in their cytoplasm.
 MYELOPEROXIDASE DEFICIENCY

• Most common neutrophil abnormality

• Relatively mild symptoms
 POPCORN CELLS

• Also known as L and H cells

• Seen in NLPHL (Nodular, Lymphocyte
predominant Hodgkin’s Lymphoma)
 REED-STERNBERG CELLS

• Cells usually seen in ___________

• Owl’s eye appearance
 LACUNAR CELLS

• Artifactual retraction of cytoplasm seen

in Nodular sclerosis
• Characterized by lobulated nucleus
 SEZARY CELLS

Seen in ________________
• Has cerebriform nucleus “brain-like”,
lymphocytic in origin.
 LAZY LEUKOCYTE SYNDROME

• Neutropenia
• Neutrophils that respond poorly to
chemotactic agents
• abnormal inflammatory response
 JOBS SYNDROME

• Abnormal neutrophil
• Poor directional motility
 CHRONIC GRANULOMATOUS DISEASE

• (+) Nitroblye tetrazolium tests

/Chemiluminescence
• Phagocytes which fails to produce
superoxides
• w/ frequent bacterial/fungal infections
 JORDAN’S ANOMALY

• Characterized by ganulocyte/monocyte
having FAT containing granulations
• Seen in ichthyosis, muscle dystrophy
 DOHLE BODIES

• Round cytoplasmic inclusion usually

BLUE in color arranged in parallel rows
• Made of ribosomal RNA
• PAS (+)
• Seen in burns, severe infections
 MAY HEGGLIN ANOMALY

• Characterized by WBCs with spindle-

shaped inclusions, messenger RNA
• PAS (-)
• (+) Giant, hypogranular platelets

Found in monocytes, neutrophils,

eosinophils and basophils
DOHLE BODIES VS MAY HEGGLIN ANOMALY

INCLUSIONS PAS reaction Size Shape RNA

Dohle Bodies Positive Smaller Round Ribosomal RNA

May Hegglin Negative Larger Spindle shaped Messenger RNA

LEUKEMIAS AND
LYMPHOMAS
 LEUKEMIA

• Malignant neoplasm of the blood forming tissues of the bone marros, spleen and
lymphatic system
• General rule: More blasts Shorter, more fatal disease

• FAB Classification:
 Based on morphology of cells in Romanowsky stained smear
 Based on cytologic and histochemical characteristics of cells involved
 LYMPHOMA

• Hodgkins Lymphoma
 NLPHL
 Popcorn cells
• Classical Lymphoma
• Characterized by ______________ (owl’s eye appearance)
• Non-Hodgkin’s Lymphoma
1. Burkitt’s Lymphoma
2. Cutaneous T Cell Lymphoma – most common subtype
THANK YOU!