Dennis Perez Duran, RMT

Notes:

 The evaluation of leukocyte morphology is part of the

differential and can yield CLUES to an infectious versus
malignant cause.
 Any abnormalities are quantitated or noted.
Abnormalities of WBC's may arise due to abnormal
maturation of the nucleus and/or cytoplasm
(asynchronism) or are congenital anomalies.
 Most abnormalities are acquired, reactive changes that
arise due to influences from toxicity or infection.
#
Toxic Granulation of the Neutrophils

 Characteristics:
 Coarser, darker staining granules found in neutrophils
(myelo, metamyelo, band, and segmented forms). Mature
neutrophils normally contain primary granules that don’t
stain.
 With infection or toxicity, the cytoplasmic environment is
altered, causing a persistence of staining of primary
granules that can be quite heavy and may overlie the
nucleus.
 Often present with Dohle bodies or vacuolization.
 Associated with:
 Severe bacterial infection or tissue
destruction….↑ WBC count, neutrophilia
with left shift
 Drugs, especially growth factor use

#
 The extent of toxic granulation is usually graded
on a scale of 1+ to 4+, with 4+ being the most
severe.

 Grading of the granulation is dependent on the

coarseness and amount of granulation within the
cellular cytoplasm.
 Pelger – Huet Phenomenon

 Characterized by the failure of the

neutrophilic granuloclyte nucleus to
segment (appears indented
nucleus)
 Russell Bodies

 Characteristics: Pink, red or clear inclusions found in the

cytoplasm of plasma cells.
 Sites of antibody/immunoglobulin production; most often
IgG type.
 Aggregates of Russell bodies in a plasma cell are called
Mott cells or Grape cells.

 Associated with:
 Most often seen in patients with multiple myeloma.
#
 Alder’s Bodies

 Neutrophilic granulocytes contain

coarse, dark basophilic granules in the
cytoplasm
 Chediak – Higashi Syndrome

 Characterized by the presence of spherical

azurophilic granules (2-5um) found in the
cytoplasm.
 Nucleus appears bizzare or pyknotic.
 A hereditary disorder characterized by
hepatosplenomegaly, generalized adenopathy,
photophobia, pale fundi, and semi-albinism
 Reilly Bodies

 Basophilic cytoplasmic granules found in

the leukocytic series of the patients with
Gargoylism (Hurler’s Syndrome,
Lipochondrodystrophy).
 Seen in segmented neutrophils which
appear similar to the basophilic granulocytic
series.
Alder-Reilly Inclusion
 Auer Bodies

 Characteristics:
 These are red to purple rod or spindle-shaped
bodies found only in the cytoplasm of malignant
cells of the Myeloid series...usually BLAST cells.
 They appear to represent a malformation of
cytoplasmic granulation. Auer rods are composed
of fused primary granules and stain
peroxidase/SBB positive.
 Associated with:
 Presence of Auer rods suggests a diagnosis of acute myeloid
leukemia (AML).
 Multiple Auer rods are seen in blasts and promyelocytes of
acute promyelocytic leukemia (AProL)

 NOTE: Auer rods are NOT present in lymphoid cells, i.e. if

Auer rods are seen, the blast is not a lymphoblast and a
diagnosis of acute lymphocytic leukemia (ALL) is
excluded.
#
 Dohle Bodies (Amato Bodies)

 Characteristics:
 Pale blue, round, oval or irregularly shaped patches
(about 2um in diameter) in the cytoplasm of
neutrophils.
 They may be single or multiple, usually at periphery.
These are areas which are free of specific granulation
and rich in RNA; caused by abnormal cytoplasmic
maturation due to toxicity.
 Often found with high WBC, left shift, toxic
granulation or vacuoles.
 Associated with:
 Variety of toxic conditions…bacterial
infection/septicemia, scarlet fever, burns,
trauma, pregnancy, cytotoxic drugs (growth
factor).
 Large Dohle-like bodies are present in May-
Hegglin anomaly.
 May – Hegglin Anomaly

 These are irregular in size inclusions, similar to

Dohle Bodies, found in PMN cells, monocytes, and
lymphocytes.
 They are not related to infections but are
associated with abnormal giant platelets and
thrombocytopenia.
 Has no clinical significance, except for a bleeding
tendency.
 Jordan’s Anomaly

 Seen as fat-containing vacuoles in

granulocytes and monocytes.
 May be present in muscular dystrophy
and ichthyosis (allergic reaction in
muscle).
 Turk Cell

 Characteristics:
 An intermediate form of transformation between B
lymphocytes and plasma cells.
 The nucleus is more centralized (less eccentric) than
typical plasma cells and there is less cytoplasm.
 Shows an opaque deep blue cytoplasm without
granules, usually vacuolated, a pole reddish nucleus
and a coarse reticular chromatin pattern sometimes
showing plasmatoid characteristics, found in
infections, these are young lymphocytes.
 Associated with:
 Found in blood or tissues following intense
antigenic stimulation;
 Malignant cell type in Waldenstrom's
macroglobulinemia.
 Reider Cells

 A notched lobulated or segmented nucleus found

in lymphocytes in lymphatic leukemia.
 Characteristics: Buttock-shaped/clefted nucleus in
malignant cells.
 Associated with:
 Lymphoid cells of peripheralized non-Hodgkin's
lymphomas and some acute leukemias
 Barr Bodies

 Appear as small knob on lobe of the nucleus of

the neutrophil. Found normally in females.
 Characteristics: Drumstick shaped body of nuclear
material found in neutrophils…not a segment of
the nucleus.
 Associated with:
 Females only; it is the dominant X chromosome and
not reported.
 Drumstick

 A drumstick-like appendages attached to one of

the main lobes of the nucleus of the neutrophils,
eosinophils, and basophils.
 Found in females as a sex-linked characteristics.
 An irregular tags, clubs, pole rocket bodies
attached to a lobe of nucleus is seen in males but
not drumstick figure.
 Hair Cells

 MAC (Malignancy Associated Change) seen in 88%

of patient with cancer.
 Seen in PMN cells and monocytes, as thin
threadlike, pointed excressences arising from the
granulocyte nuclei and a small inclusions
surrounded by nucleus by halos within the
cytoplasm of monocytes.
 About the size of Dohle Bodies.
Granulocytic Anomaly in D trisomy

 Raised level of fetal hemoglobin and

morphologic changes in neutrophils consisting
of clumping of nuclear chromatin,
hypersegmentation, and hook-like
appendages.
 The syndrome is seen in abnormalities
involving the heart, soft tissues, and nervous
system.
 Twinning Deformity

 Tetraploid neutrophils with diploid nucleoli.

 Twice the size of neutrophils, round and
has two nuclei in one cell.
 Found in pernicious anemia and in
myeloproliferative states.
Reactive/Atypical Lymphocytes

 Response to a variety of viral and non-viral stimuli

produce diverse nuclear and/or cytoplasmic
changes in the lymphocytes. Often present with a
lymphocytosis (↑ # lymphs).

 These are morphologic variants of lymphocytes in

various stages of activation that are neither
normal or leukemic in nature. Virocytes can be
seen with normal lymphocyte values.
 Characteristics:
1. Irregular shape of cytoplasm and/or nucleus
2. Abundant dark blue cytoplasm; overall bigger cell
3. Cytoplasmic tags, sharp ridges; indented by red
cells
4. Vacuoles in cytoplasm; increased #s of reddish
granules
5. Fine chromatin pattern; nucleoli in nucleus (can
resemble blasts)
 Associated with:
 Many viral infections, e.g. Epstein-Barr virus
(EBV), cytomegalovirus (CMV), viral hepatitis
 Drug reactions or non-viral stimuli…e.g.,
toxoplasmosis

 The lymphs seen in healthy children may appear

somewhat reactive as compared to adult
lymphs.
5 - minute break!
Other Abnormalities and
Irregularities Found in
Blood Smears
 Distorted Lymphocytes

 Squashed or distorted lymphocytes

caused by excessive pressure on
the cells during the process of
making the smear
Should be recorded as NORMAL
 Accumulated White Cells

 A bunch of white cells that may be seen

on the edge of the blood smear.
 Due to improper spreading during the
process of making the smear.
 Should NOT be counted or reported.
 Smudge Cells

 Bare nucleus of ruptured white cells, may be seen

in normal blood smear.
 Caused by heavy pressure on the cells during the
process of making the smear.
 Seen in leukemia.
 Presence may indicate an increasing fragility of
cells or abnormal destruction of the cells.
 Neither counted nor recorded.
Disintegrated Cells (Eosinophil)

 Ruptured cells; both nucleus and the

cytoplasm are seen.
 Found in blood smears which have been
improperly prepared.
 Found in blood smears which have been
made from old oxalated blood (over 2
hours old)
 Poorly Stained Eosinophils

 Caused by:
1. Incorrect pH of the buffer
2. Improper mixing of the stain and
buffer solution
3. Too short staining time
 Precipitated Stain

 Caused by failure to properly flush

the excess stain off the slide during
the staining process.
 NOT reported.
Neutrophil with Toxic Granules

 Granules are large and appear coarse in the

cytoplasm.
 Caused by overstaining the smear or using a
buffer solution with a pH value above 6.8
 Also seen in severe infections, chemical
poisoning, and malignant neutrophils with
toxic granules.
 Reported as miscellaneous white cell.
 Hypersegmented Neutrophil

 Neutrophil broken up to 5 – 10
segments.
 Often referred to as “P.A. Poly”
cells
May be seen in pernicious anemia
 Vacuolated Cell

 Cells that has holes or vacuoles in the

cytoplasm.
 Vacuoles are signs of degeneration.
 From smear made from oxalated blood.
 Also seen in severe infections, chemical
poisoning, and leukemia.
 Tissue Cells

 Cells that have been squeezed out of the

tissue during the finger puncture.
 Resemble a monocyte.
 Cells have revealed or fragmentory outer
edges and often tail is present.
 Basket Cells

 A net like nucleus from a ruptured

white cells.
 May be found in a normal blood
smear, probably older forms of
smudge cells.
 Crescent Bodies

 Also known as “Semilunar Bodies”

 Believed to be remains of old
erythrocytes.
 Also seen in malaria and hemolytic
anemias.
 NOT recorded nor reported.
 Pyknotic Cells

 Nucleus become smaller and dense

so as chromatin bridges of
segments disappear, leaving several
small balls of dense chromatin.
Seen in infections.
 Snapper – Soheid Bodies

 Seen in plasma cells as inclusion

bodies immediately after therapy
with aridine drugs
 Tart Cells

Phagocytic cells which are

usually a monocyte or a
lymphocyte with an engulfed
nucleus
 Ferata Cells

Phagocytic cells associated with

subacute bacterial endocarditis
 L.E. Cells

 A phagocytic two nuclei cell usually

a PMN with a homogenous material
engulfed in itself appearing
rosettes
The End!
Study today’s lesson for a quiz
next meeting!
 Assignment: ½ CW

1. What are the growth factors for

megakaryocyte maturation?
2. Trace the maturation series of
the megakaryocyte and describe.