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

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

Anemia
Hx & PE CBC
MCV

Blood smear

Reticulocyte count

Other Lab

Onset of Anemia Acute Blood loss Hemolysis Dilutional Subacute to chronic or unknown Pathogenesis Bleeding Hemolysis Production 80-100 MCV >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

AIHA, cold type

1. 2. 3. 4.

AIHA HS MM Megaloblastic anemia 5. Iron def

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

target Few anisocytosis Some poikilocytosis

IDA & ITP

1. 2. 3. 4.

Thalassemia TTP Iron def Myelofibrosis

Hypochromia Microcytosis

33 2 4

spherocytes

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

MCHC

22

Homozygous HbE
1. 2. 3. 4. Hb H dis Iron def Cirrhosis Hb E homozygote

Target cells

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)

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 Bone marrow

Leukoerythroblastosis: NRC , metamyelocyte / myelocyte; teardrop rbc

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

Blood smear

Reticulocyte count

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