You are on page 1of 2


J Clin Pathol 1993;46:963-964 963

Hypochromic macrocytes: are they reticulocytes?

B J Bain, I A J Cavill

Abstract expenditure. The prediction of an increased

Automated full blood counters measur- reticulocyte count, by using the variables of
ing the size and haemoglobin concen- an automated full blood counter could, if
tration of individual red cells by high possible, be clinically useful.
and low angle light scatter can provide The H. 1 and H.2 automated full blood
estimates of the percentage of cells which counters (Technicon Division, Bayer
are abnormal in either or both of Diagnostics, Basingstoke, England) estimate
these variables. The hypothesis that an the volume and haemoglobin concentration
increase in the number of large cells of individual red cells by measuring high and
with a reduced haemoglobin content low angle light scatter.' Such measurements
("hypochromic macrocytes") was indi- are represented graphically in a red cell
cative of a reticulocytosis was investi- cytogram (fig lA) in which volume (V) is
gated. A correlation was shown between plotted against haemoglobin concentration
the percentage of hypochromic macro- (HC). Cells of more than 120 fl are classified
cytes and the reticulocyte count. This as macrocytes with the presence of more than
correlation was too weak to allow the 4% of such cells giving rise to a "macro" flag.
actual reticulocyte percentage to be pre- Cells with a haemoglobin concentration of
dicted from the percentage of less than 280 g/l are considered to be
hypochromic macrocytes. An increased "hypochromic", with the presence of more
percentage of hypochromic macrocytes, than 4% of such cells giving rise to a "hypo"
however, often indicates an increased flag. During routine use of this instrument,
reticulocyte count and thus serves to we noted that a number of patients with
chart the haematologist to this possibility. autoimmune haemolytic anaemia had an
increase in the percentage of hypochromic
(7 Clin Pathol 1993;46:963-964) macrocytes (fig 1B). Furthermore, patients
receiving haematinic agents often showed an
increase in the percentage of this cell popu-
lation which paralleled the increase in the
An increased reticulocyte count is important reticulocyte percentage. Reticulocytes are
in the differential diagnosis of anaemia generally considered to be larger and less
because it indicates increased marrow output dense than mature red blood cells. We inves-
of red cells and, in the absence of recent tigated the hypothesis that hypochromic
administration of haematinic agents, suggests macrocytes, as detected by the H. 1 auto-
the possibility of haemorrhage or haemolysis. mated counter, might represent reticulocytes
A visual reticulocyte count, however, is not by making a systematic comparison of the
only imprecise but also time consuming and percentage of these two cell types: we sought
therefore expensive, while an automated to determine if this new variable would serve
reticulocyte count requires major capital as a flag for an increased reticulocyte count.

v v.3*.5.--*|-*----

Department of
St Mary's Hospital
Medical School,
Imperial College of
Science, Technology
and Medicine, * *: :
Norfolk Place, t- ws - :.
London W2 1PG
B J Bain
Department of
Haematology, (A) U.HCBC RBC
University of Wales
College of Medicine (A
'-'-- --'- -- '---- '-- -HC (B) .. I.. I
I A J Cavill HC
Correspondence to: Figure Red cell volume ( plotted against haemoglobin concentration (HCG for (A) a blood sample from a healthy
Dr B J Bain volunteer and (B) a blood sample from a patient with a severe autoimmune haemolytic anaemia with a reticulocyte count
Accepted for publication of 35%; (B) shows an increase of hyperchromic cells, corresponding to spherocytes, and an increase in hypochromic
17 May 1993 macrocytes.
964 Bain, Cavill

Methods wise evident that, although most of the

Reticulocyte counts were carried out for clini- patients with an increased percentage of
cal purposes. They were estimated on a hypochromic macrocytes had an increased
Sysmex R-1000 analyser (Toa Electronics reticulocyte count, not all hypochromic
Company, Milton Keynes), using auramine-O macrocytes were reticulocytes. We have
as the nucleic acid fluorochrome. Patients found that a strong drive to erythropoiesis
had a variety of diagnoses, including renal can lead to iron deficient erythropoiesis2; if
failure, autoimmune haemolytic anaemia, hypochromia is due to an inadequate supply
sickle cell anaemia, Bf thalassaemia major, of iron to the developing erythroblast the
drug induced haemolysis, and vitamin B,, or resultant red cell would be expected to
iron deficiency anaemia responding to treat- remain hypochromic throughout its lifespan;
ment. Reticulocyte counts, which ranged a cell produced when the iron supply was
from 0 5-43%, were compared with the per- adequate would be expected to increase its
centage of hypochromic macrocytes (cells haemoglobin concentration to normal as
with V >120 fl, HC <280 g/l), as determined redundant membrane was removed and it
by an H. 1 automated full blood counter. matured from a reticulocyte to a red cell.
Automated blood counts were performed Furthermore, in conditions of haemopoietic
within 6 hours of venepuncture. stress when erythropoietin concentrations are
high there is production of 'shift erythrocytes'
which are larger than normal erythrocytes;
Results such cells are likely to remain larger than
The percentage of hypochromic macrocytes normal red cells throughout their lifespan.
showed a weak but significant correlation The category of hypochromic macrocytes is
with the reticulocyte count (r = 0-35; thus likely to include cells which have lost
p < 0-001; intercept of regression line, their RNA and are therefore no longer reticu-
a = 0-56, slope of regression line, b = 0-41). locytes but are nevertheless still hypochromic
Twelve of the 150 patients had more than and macrocytic. We also observed an increase
4% hypochromic macrocytes, and in eight of in hypochromic macrocytes in patients with a
these cases the reticulocyte count was above low reticulocyte count but with dyserythro-
2%; but only five of the 13 patients with more poiesis-for example, in megaloblastic
than 5% reticulocytes had hypochromic anaemia, in the myelodysplastic syndromes,
macrocytes above 4%. and in thalassaemia major.
Our observations support the hypothesis
that an increase in the percentage of
Discussion hypochromic macrocytes is often due to an
The percentage of hypochromic macrocytes increase in the percentage of reticulocytes and
determined by the H. 1 automated full blood that reticulocytes are often hypochromic
counter showed a significant correlation with macrocytes. The correlation between these
the percentage of reticulocytes. This observa- two variables is too weak for the percentage
tion supports the hypothesis that, on average, of hypochromic macrocytes to be used to pre-
reticulocytes are larger than mature red cells dict the reticulocyte percentage. An increase
and have a lower haemoglobin concentration. in the percentage of hypochromic macro-
The correlation between the two variables cytes, however, serves to indicate the possi-
was weak, however, with only 12% of the bility of reticulocytosis or dyserythropoiesis.
variation in the percentage of hypochromic
macrocytes being explained by the variation
in the reticulocyte percentage.
It is clear from our findings that not all 1 Mohandas N, Kim YR, Tycko DH, Orlik J, Wyatt J,
reticulocytes are hypochromic macrocytes, Groner W. Accurate and independent measurement of
volume and hemoglobin concentration of individual red
and we have in fact observed that as reticulo- cells by laser light scattering. Blood 1986;68:506-13.
cytosis develops there is often also an increase 2 Macdougall IC, Cavill I, Hulme B, et al. Detection of
functional iron deficiency during erythropoietin treat-
in hypochromic normocytic cells. It is like- ment: a new approach. BMJ 1992;304:225-6.