Workshop 1

Blood smear

Blood Smear
..

Color Vote

 6 blood
smear
1. 1
2. 1
3. 1
4. 1
5.

3
6


blood smear
1. blood smear
2. blood smear
3. blood smear
4. blood smear
5.

 blood smear

1.
2.
3.
4.

 blood smear

1.
2.
3. 1 2
4. CBC blood
smear

Blood smear ...

blood smear

Malaria, Dengue
infection, TTP,

Unexplained cytopenia
Anemia
Leukopenia
Thrombocytopenia
Pancytopenia

DIC, leukemia, APDE Unexplained cytosis

Leukocytosis

Blood Smear

morphology
Tail: WBC,
large WBC,
NRBC

Normal region
Too thick region
Overspread region

RBC, WBC, Platelet, other abnormality

RBC (MCV), , ,
(polychromasia), organism, inclusion, NRBC

WBC , nucleus, granule, organism

Platelet , ,

Anisocytosis
(Vary in size, RDW)

Poikilocytosis
(Vary in shape)

Hypochromia (
microcytosis )
: thalassemia dis,
thalassemia trait,
iron def

Polychromasia
= reticulocyte

Microcytosis

Dimorphic red cells

- Blood transfusion in
iron def
- Treated iron def
- MDS
- Iron & folate def.

Schistocyte
Fragmented red cell
: TTP, DIC, Prosthetic
Valve, vasculitis,
Malignant HT, etc.

Spherocyte

Stomatocyte
: hereditary,
liver dis.

Elliptocyte / Ovalocyte
: Hereditary,
Megaloblastic anemia,
Iron def

Tear-drop cell
: myelofibrosis,
myelophthisis,
thalassemia, iron def,
megaloblastic anemia

Target cell
NRBC

Schistocyte

Acanthocyte

Target cells

Target cell
-Surface : Volume ratio
- Surface area
-Liver dis
- Volume (MCV<80)
-Thalassemia, iron def

Echinocyte (= Burr cell)

: artifact,
uremia

Acanthocyte
: liver dis
malnutrition
postsplenectomy
hypothyroidism
abetalipoproteinemia

Howell-Jolly bodies
: postsplenectomy,
acute hemolysis,
megaloblastic anemia

Basophilic stippling
: Lead poisoning
Hb CS homozygote
Thalassemia dis
Other hemolysis

Cabot rings remnants of the mitotic spindle

: Thalassemia

Plasmodium
Ring form
Platelet

Artifact
(Fixative not fully
free of water)

Air hole artifact

Blister cell
: G6PD def

Hereditary elliptocytosis

Hereditary pyropoikilocytosis

Southeast Asian ovalocytosis

Microangiopathic
hemolytic anemia
(MAHA)

Hb 8 g/dL cause? M 72 yr- DM,HTN,CKD, Cr 8 mg/dl

Anemia
Hx & PE
CBC
MCV

Reticulocyte
count

Blood
smear

Other Lab

Onset of Anemia
Acute
Blood loss
Hemolysis
Dilutional

Subacute to chronic or unknown

Pathogenesis
Bleeding
Hemolysis
Production

MCV
80-100

>100

<80

Megaloblastic:
B12 / folate def

Non-megaloblastic:
Reticulocytosis
Alc / liver dis
AA / PNH
MDS
Drug
Hypothyroidism

Iron def
Thalassemia dis
ACD
Thal. trait + anemia
from other cause

 55 3
pale, no jaundice, no organomegaly
1.
2.
3.
4.

AIHA
HS
MM
Megaloblastic
anemia
5. Iron def

AIHA, cold type

polychromasia
microspherocyte
anisocytosis

autoagglutination

Saline Agglutination Test

Rouleaux formation
: Globulin eg.
Multiple myeloma,
cirrhosis

Megaloblastic anemia
Macro-ovalocytes
anisopoikilocytosis

Tear drop
rbc

Hypersegmented
Neutrophil

1. Thalassemia
disease
2. TTP
3. MM
4. Megaloblastic
anemia
5. Myelofibrosis

72 5
Pale, no jaundice, no organomegaly

target
Few anisocytosis
Some poikilocytosis

IDA & ITP

1.
2.
3.
4.

Thalassemia
TTP
Iron def
Myelofibrosis

Hypochromia
Microcytosis

33 2 4
Pale, no jaundice, petechiae both legs, no organome

spherocytes

MCHC

Hereditary spherocytosis
1. AIHA
2. Thalassemia
disease
polychromasia 3. HS
4. G6PD def

22

Pale, mild jaundice, spleen 2 FB

Homozygous HbE

Target cells

1.
2.
3.
4.

Hb H dis
Iron def
Cirrhosis
Hb E
homozygote

30 3
Not pale, no jaundice, no organomegaly
Hb 11 g/dl, MCV 61 fL

Thalassemia disease

microcytosis
hypochromia
spherocyte
Aniso-poikilocytosis

Female 28 yr, No underlying dis, Fever 2 wk & drowsy 3 days

T 38 c, drowsiness, moderately pale, mild jaundice, no edema,
few petechiae, liver&spleen -ve, LN ve, no focal neuro. deficit

CBC: Hb 6, Hct 18%, MCV 96, Wbc 7000, Plt 10,000

Reticulocyte 9%
Most likely Dx?
A. Sepsis + DIC
B. ITP + intracranial
hemorrhage
C. TTP
D. Evans syndrome

Schistocyte

TTP/HUS (thrombocytopenia)
Heart valves (mechanical , infected)
DIC
Vasculitis
Etc.

Infectious diseases
Atypical Lymphocyte
viral, malaria,
rickettsia (typhus),
leptospirosis ; drug
reaction

Toxic granulation
Toxic granulation appears as
dark blue-black granules in the
cytoplasm of neutrophils. These
granules are thought to be
primary granules. Artifactual
heavy granulation caused by
poor staining is seen evenly
spread throughout each cell and
in all granulocytes, whereas
toxic granulation is unevenly
spread throughout the cytoplasm
of certain cells. Large amounts
of toxic granulation can give the
neutrophil a bluish appearance.
Toxic granulation is a stress
response to acute infections,
burns, and drug poisoning.

Dhle bodies
Dhle bodies appear as
a small, light blue-gray
staining area in the
cytoplasm of the
neutrophil. They are
found in poisoning,
burns, infections, and
following chemotherapy

Leukocytosis
Leukemia
Acute :
AML (myeloblast, monoblast)
ALL (lymphoblast)

Chronic :
CML : all stages of myeloid series, basophil,
eo.
CLL : mature lymphocyte, some prolymph.

Reactive, Leukemoid reaction (wbc

>50,000)
mature neutrophils with left shift

ALL

AMoL

APL

CLL

CLL

CML

PSEUDO PELGER-HUET ANOMALY MDS

M 49 yr , no underlying disease
Fatigue 3 mo, no blood loss, no other symptom
Pale, no jaundice, liver 1 FB, spleen 7 FB
Hb 6.7, Hct 20%, MCV 90, Wbc 8000, Plt 300,000

Giant platelet

Tear-drop

M 49 yr , no underlying disease
Fatigue 3 mo, no blood loss, no other symptom
Pale, no jaundice, liver 1 FB, spleen 7 FB
Hb 6.7, Hct 20%, MCV 90, Wbc 8000, Plt 300,000
Most likely Dx?
A.Thalassemia
B.Cirrhosis
C.Myelofibrosis
D.CML

NRBC

Metamyelocyte

Primary Myelofibrosis
Blood smear

Leukoerythroblastosis:
NRC , metamyelocyte /
myelocyte; teardrop rbc

Bone marrow

Leukoerythroblastic blood picture

Myelophthisis Bone marrow study

NRBC
Metamyelocyte

M 75 yr, anemia for 1 month, weight loss, petechiae

No organomegaly

Thrombocytopenia and Errors in PLT. count

Platelet satellitism

Platelet clumping
Candida
Pseudoplatelet
Fibrin strands

Petechiae thrombocytopenia

Spurious platelets

F 25 yr, Thalassemia major

Petechiae 1 wk, CBC platelet 120,000/uL

F 10 yr, bruise 1 wk
Platelet 180,000, Eo 15%
APDE

Anemia
Hx & PE
CBC
MCV

Reticulocyte
count

Blood
smear

Other Lab

Thin area artifact

F 50 yr Anemia 3 wk
Spleen 2 FB
Q: Dx?
A. CLL
B. ALL
C. Plasma cell
leukemia
D. CML
E. Aplastic anemia

Chronic Neutrophilic Leukemia

Bite cell, G6PD def

Blister cell, polychromasia
G6PD def

HS

 25 5 , 2 ,

Contracted Hb
Blister cell

1. AIHA
2. Thalassemia
disease
3. G6PD def
4. HS
5. TTP
6. Lead poison
7. MM
8. Megaloblastic
anemia
9. Iron def
10. Myelofibrosis