i. e a Se FIGURE 23.13 Blood smear from a dog showing many spherocytes. Wright-Giemsa stain. in dogs, likely because they have prominent central pallor. In other species such as the cat and horse, spherocytes are difficult to identify Not all spherocytes are formed secondary to frag- mentation. Spherocytes can be caused by a molecular defectin one or more of the proteins of the RBC cytoskel- ‘etal network. Double knock-out mice with defects in actin binding proteins affect erythrocyte shape and ‘membrane infegity leading to pronounced spherocyte formation.® Spectrin deficiency has been identified in a group of Dutch Golden Retrievers (see Chapter 29).” Stomatocytes Stomatocytes are RBCs that have a narrow elongated band of central pallor resembling a mouth on dried blood smears. In actuality, these cells are more bow!- shaped in wet-mount preparations. Several breeds of dogs have been identified with hereditary stomatocyto- sis, including Alaskan Malamutes with concurrent chondrodyspiastic disease, Drentse patrijshond_ with stomatocytosis-hypertrophic gastritis and Miniature and Siandard Schnauzers (ee Chapter 29)" The ‘Drenise patrijshonds often havea normal MCV whereas the Schnauzers and Malamutes have an increased weve Hemoglobin Crystals ‘Hemoglobin crystals are unstable hemoglobin that pre- Cipitates in the RBC. These dense staining, rhomboid or rod shaped crystals lead to decreased deformablity of the cell (Fig. 23.14). Crystals may be found in human patients with Hemoglobin C disease and sickle cell anemia, particularly after splenectomy. In veterinary ‘medicine, hemoglobin crystals are infrequently reported and their cause is uncertain. Nonetheless, they have been described in dogs, llamas and horses with FAD deficiency.” CHAPTER 23: ERYTHROCYTE MORPHOLOGY 149 FIGURE 22.14 Blood smear from a dag showing hemoglobin crystals (arrow), Wright-Giemss stain FIGURE 23.15 Blood smear from a dog showing basophilic stippling. Weght-Giemsa sta Erythrocyte Inclusions Basophilic stippling represents the spontaneous aggre- gation of ribosomes and polyribosomes in RBC. In Romanowsky-stained samples, affected RBCs contain uniformly distributed punctate, basophilic structures (Fig, 23.15). Basophilic stippling may be seen in cattle and other ruminants as a part of the regenerative response to anemia, It may be associated with exuber- ant regeneration in other species including the dog and cat, However, if basophilic stippling and increased numbers of nucleated RBC (nRBC) are present in the absence of a severe anemia, lead toxicity should be considered. Nucleated RBCs in circulation can also be part of a regenerative response to anemia. These cells, depending ‘on their level of maturity, usually have polychromat- ‘philic or hemoglobinized cytoplasm and a round150 SECTION Ill ERYTHROCYTES CA a On Open | FIGURE 23.16 Blood smear from a dog showing occasional metarubrieytes as part of a regenerative response, Wright-Giemsa nucleus (Fig, 23.16). The metarubricytes have a small, pyknotic nucleus but less mature cells have a stippled chromatin pattern, When nRBCs accompany a reger.era- tive response, polychromasia and anemia should also be observed, However nRBCs may occur in the absence fof anemia in diseases affecting the spleen and bone marrow. Myeloproliferative disorders and infiltrative marrow diseases such as solid tumor metastases and. myelofibrosis can result in high numbers of nRBCs, oceasionally with less mature erythrocyte precursors, rubriblasts, and prorubricytes in circulation. Low numbers of circulating nRBCs can be observed in splenectomized animals or in dogs or cats with heman- giosarcoma, hemophagocytic histiocytic sarcoma, and. pre red cell aplasia®™ Cais, with myelodysplastic sydromes, hepatic lipidosis, upper respiratory infec- tionsand hemangiosarcoma can have normoblastemia. Lead toxicity is commonly associated with metarubri- cytosis; however, these patients are usually not anemic. Nuclear remnants, not expelled as RBCs leave the bone marrow, are termed Howell-Jolly (HI) bodies They are round, deeply basophilic structures that may vary in size (Fig. 23.17). Howell-Jolly bodies are normally removed by the spleen. However, in cats and horses, species having non-sinusoidal spleen, low numbers are normally seen in circulation. Increased numbers of H] bodies can be seen as part of a regenera- tive response fo anemia, in animals with hypofunction- ing spleens, or in splenectomized patients. There also are reports of increased numbers of H] bodies in rnon-anemic miniature and toy poodles with hereditary macrocytosis (see Chapter 30} Oxidative damage can result in a number of morpho- logic changes to the RBCs including the formation of Heinz bodies.#""**"" Heinz bodies are small aggregates of oxidized hemoglobin that can occur as hemogiobi- nized projections extending from the cell or as pale areas within the cell (Fig. 23.18A). With Romanowsky stains, the Heinz bodies are pale or hemoglobinized but FIGURE 23.17 Blood smear from a dog. Howellolly bodies ate nuclear remnants observed inthe cytoplasm of red blood cli (arrow), Weight Giemsa sain, 8 FIGURE 23.18 Blood smear from scat, (A) Wright-Giemsa stain Many Heine bodies are observed and can appedt as procctions| from the RBC membrane (large arrow) of as pale areas near the membrane (small arrow). (B) New methylene blue sai Heinz bodies ate more obvious with vital stains,with NMB, they are bluish-green and much more obvious (Fig. 23.18B). Many toxins and diseases have been reported to cause Heinz bodies (see Chapter 36) Tron observed in mature RBCs is referred to as side- rocytes or Pappenheimer bodies. With Romanowsky stain, the iron appears as irregularly shaped, pale basophilic material, whereas ferric iron forms a bright blue pigment when stained with Prussian blue. Siderocyies have been reported in the blood in associa~ tion with myeloproliferative disorders, lead toxicity, and hemolytic anemia. Sideroblasts are nucleated eryth- roid precursors with iron in their cytoplasm. These cells have been reported with myelodysplastic syndromes and myeloproliferative disorders and in inflammatory diseases in dogs and cats.”"* “Artifactual changes can occur that mimic true patho- logic fragmentation or inclusions, Stain precipitate or drying artifact can mimic red blood cell parasites or inclusions such as HJ bodies. A commonly observed artifactual change associated with prolonged drying of blood smear preparations, produces refractile RBC inclusions. Additionally, crenation of RBCs can occur as ‘an artifact of drying. Usually artifactual crenation will ‘occur in thick areas of blood smear. REFERENCES: 1. Allison 80, Artwoh J, Fortman JD, eta. avogenc emote anemia Shusendontsinen New Zeal whic abe econdary to Anode {locrune econ J Am Asse Lab rim Se 07 1658-0 2. -Riward A, Comer CA, Burton MIL Hed Maple cr drm el toxco= se ie erase revapectve study of cases) er intern Med ‘oso 119120, 9 Badylak SF, Van Vee JF, Herman EH. Polos in dogs with chronic rabies wc Arm} Vere 19656515 58 infants U, Comat 8, Palvinies Sea. Stomatocyouis 7 rated Standard sare Vet Cin Patil 004342. 5 Brown DE, Meyer DI, Wingheld WE, ea. choco assodaed wih ratenakeaneanemation iv dogs Vet Patho 198631854 57, «6 Caldin'M,Cart Faranell Ft. Retrnpectve sud 960 case of ‘Somtmoytosn the doy Vet Cin Patel 2 UaL 2H 7 Canela P) Watson AD, Katelife RC. Dysrythropre,sderblts/ ‘derocyes and hemoghsbin cysalizaton in dog, Wet Clin Pal ieereai-28 1. Ghen I, Khan A, Lia Ft a. Combined deletion of mouse demain esdpe nd betreddecn certs ence icone pecitrect ane™ ons leading erythrocyte faplity and hemolytic anema J Biol Chem auo.b aia, 5 Christopher MM, Lee SE. Red call morpho alterations in as With ‘pai cae Yet Chin Pathol 1994237 12 10. Ghuatopner MM White JG, Eaton JW. Ezytvocyte pathology and ‘Betula of Heine bady-cmdinted hecwijas ih eka. We Pal ‘iso 28-30, 11, English RV, Breltschwerd EB, Gendem CB, et al, Zollinger ison ‘iene nd myesbesn #dng Soh Net Me Noe 12 Ete MA, Wehausen CE, Jesen CR, et a. Discrinatd irovascl ‘Stugltin lat Vet intra Med 06205890109 ™ a 4 CHAPTER 23: ERYTHROCYTE MORPHOLOGY 151 Ferman FR, ives AP, Texou Yea Vain Kinde hee Sepa ene 0 Teo oa i es Salnf Lind we Weaeof cycler ce 0, JA Siete are Seats tanh Se Rey a Evian of nly 18 Seat Rater woes ie Hand, Welt ice and nomeblen a Sota] as antite ance DT ST Bast ur eee pag setbaln and ochensal Hen ena Rane Mean se Sint ey Sains Sred Se Dogs enone ess ooh T Mere stints 3 Seattaea Mcteep eens te Se Yotancpaton de Msc Ya facbaey Mls A rnepcive sty f ane Hee tars) fy lin iS Dinas” Cn We OE me vat gpl mca apy reba anata cepa retinas mtedpeted soutanek veka Commun SBasn/ Sa Ta CSR SNS nce ac a abe IREINC Kon CS. Shape chang in capene ec epee itprenaine wales fa Ca Pend Sse se a Sar net eee es Saar tarag a Ra as oe ‘in RCT re Te Spare of tania MLSE ASG lan be dip hs Ans ap at sesatte Maer oye fa iin np as ES eee ee ee nd Sent hone, aie bere SNCS} nebong ff sng cnvronon wut conary Titans ack op a ee oki tsmnoatbcna nte ed ee Roger yee Cfack | Sects i eae sel maple eat Meee eins ae ‘Shea Mf ta amr nec ano mesa oft tS hy ose sos ae Kae ess ur se ppendl Rena W de Bj J Neral an nd tral 2eehrchplenge tha if om hmasemsss, see ee SE Rogie aPem cca ke ete M ta Hen pectin SeEiaay ln cottrog |Senan ed aa ee Stites fm cL Heelys i prea SES titel nae steht dehydiopnan defo. Va Fabel oasis SURE Nee Bt Chat a rata Cain of anemia Tidal Chae Neen stains ocanay Hens Snr Pabeph Latte ane Wits bs Fr icy peak og ee Peeluct ace nna WD) ina pe Steps adap 9 ese 1996200, An Worms NUS) Seba nema a7 dos (HNN Jet Med nen tetas ot Topsy spate sol Gaede hedge Ch Pata SE ES in 0, Thal MA a body ane ina dg tat ad ben Sa ar ane aesast Laboratory and Clinical Diagnosis of Anemia HAROLD TVEDTEN Clinical Manifestations of Anemia Presence and Severity of Anemia Classification Systems Classification by Strength of Erythropoiesis Classification by Erythrocyte Volume and Hemoglobin Concentration ‘Acronyms and Abbreviations Classification by Blood Smear Morphology Classification by Etiology Diagnostic Approaches Blood Loss Anemia Non-Regenerative Anemia Bone Marrow Evaluation ‘Advia, Siemens Advia 21200 hematology system; CBC, complete blood count; CRP, corrected reticulocyte percent- age; EDTA, ethylenediaminetetraacetic acid; ELA, equine infectious anemia; FeLV, feline leukemia virus; IL, fem- toliter; Het, hematocrit; Hgb, hemoglobin; MCHC, mean corpuscular hemoglobin concentration; MCV, mean corpuscular volume; NRBC, nucleated red blood cell; PCV, packed cell volume; PRCA, pure red cell aplasia; RBC, red blood cell; RDW, red ceil distribution width; RPI, reticulocyte production index; Sysmex, Sysmex XT 2000iV® hematology system; WBC, white blood cell. is chapter discusses diagnosis of anemia based primarily on laboratory findings. Erythrocyte morphology (see Chapter 23) and specific causes of anemia are described elsewhere, except for blood loss anemia which will receive more attention in this chapter. Diagnosis of the cause of anemia uses certain character- istics of blood to place the anemia into pre-established, classes or categories useful for diagnosis. Several clas- sification systems are used and are based on various tests and observations. The systems overlap and clas- sifications by one system (e.g. macrocytic hypochromic anemia) may be identifying the same change or process in red blood cells (RBCs) as another classification (eg reticulocytosis and regenerative anemia). Thus differ- tent names frequently mean the same in terms of diag- nosis. Despite the classification system used, the goal of diagnosis should be to provide the most specific and correct diagnosis to allow apy other action by the attending cli CLINICAL MANIFESTATIONS OF ANEMIA ‘The clinical signs that prompt an animal's owner to seck a clinician to diagnose and then treat an anemia include weakness, lack of stamina, pale mucous membranes, 182 icterus and hemoglobinuria (red urine). The purpose of laboratory testing is to provide unbiased evidence that supports or refutes a clinical or tentative diagnosis. Laboratory diagnosis of the cause of anemia should be based first on laboratory conclusions founded on test results and interpretation of cell morphology in blood smears and graphics from hematology instruments. Only after making those conclusions should clinical signs, age, breed, and other clinical information be con- sidered and allowed to influence the conclusions or diagnosis. This permits laboratory results to indicate new possibilities and avoid “premature closure” too carly in diagnosis. Additional, more specific testing, may then be needed. PRESENCE AND SEVERITY OF ANEMIA The first step in evaluation is to determine ifthe animal has anemia and, if present, to evaluate severity (Iable 24.1). Laboratory parameters routinely used. include hematocrit (Het), total erythrocyte count (RBC count), and hemoglobin (Hgb). concentration. Packed cell volume (PCV) is essentially the same as Hct, though implies a centrifugal method of analysis. These values (Ht, RBC count or Hgb concentration) should be simi-CHAPTER 24: LABORATORY AND CLINICAL DIAGNOSIS OF ANEMIA 153 Dog CayRuminant Mis 3037 30-33 20-28 Moderate 20-29 20-29 1619 Severe 13.19 1319 10-13 Very S <3 <3 <10 larly reduced in proportion to the reduction of eryth- roid mass and should similarly reflect the severity of anemia in the animal. Hematocrit will be used in this chapter to describe severity of anemia but Hgb concen- tration is used more frequently in Europe and also in human medicine, If Het, RBC count, and Hgb concentration are not similarly decreased in anemia, then erythrocytes are not znormal in size and Hgb content. Changes in erythrocyte indices (MCV, MCHC) should help explain any dis- cordance in relative decreases (see section on classifica- tion by erythrocyte volume and Hgb concentration later in this chapter). For example, in iron deficiency anemia with severe mierocytosis, RBC count will not be decreased as much as Hgb concentration or Het and, therefore not reflect the severity of the anemia as well. Even normal numbers of microcytic erythrocytes will not contribute to a normal Hgb concentration per unit volume of blood and the smaller erythrocytes will be packed into a smaller volume of the blood (PCV). Pre-analytical and analytical errors may also cause discordance among Hct, Hgb concentration, and RBC count. For example, Heinz bodies may make erythro- cytes more fragile so they lyse in the microhematocrit centrifuge, lowering the PCV. Heinz, bodies remaining in suspension after erythrocytes are lysed, increase the optical density and falsely increase Hgb concentration. ‘Heinz bodies in erythrocytes make them more optically dense to laser hematology instruments also causing a falsely increased cell Hgb concentration and MCHC. Severity of an anemia is useful in diagnosis. Table 24.1 provides some guidelines for classifying severity. Moderate to severe anemias are more likely important or primary problems. For example, primary bone marrow disorders like chronic myelofibrosis can cause very severe anemia (e.g. Het 6-8%) while secondary suppression of bone marrow (eg. anemia of inflamma- tion) is characteristically mild to moderate. Severe anemia or rapid decline in erythroid mass should stim- ulate more aggressive diagnosis and treatment, while mild to moderate anemia in animals with severe inflam- ‘matory or neoplastic disorders is expected as secondary problems. Clinical information such as breed and age affect interpretation (see Chapter 131). Sight hounds like greyhounds normally have higher Hct (about 50-65%) Compared to other dog breeds (37-55%) and, therefore a mild anemia in a greyhound will have a Fet within the reference intervals for dogs in general. Puppies have Canine Aggregate Punctate Swrngh ot _—Reticulocyes——Reticulocyes —_—Reticuloeytes cm (ol io Y os 110" 1a 052 10-20 5-20 34 20-50 ‘Strong 2180 8 360 60° 1s" 200" 160 50 500 300 100 1000 3500 2200 1500 aluee re percontage of non nlontes ABC thet ar reticloeyae. The shine retculoeyos or feline aggropate aiculseyes alae ‘conver the petcentage af plyehvomatophis ona blood fe strength of selenfomass and tus erthropcioe lgtes 0 orroteuoytes WL. lower Het than adult dogs (as well as lower plasma protein and higher reticulocyte numbers). For example 2 6-week-old puppy can have a Het of 26-30%, reticu- locytes of 4.5% and plasma protein of 5.0-5.6g/dL. ‘Thus a normal puppy can appear to have a regenera- tivesbloodloss-ype anemia when using adult reference intervals. Hydration status must be considered. Hematocrit reflects severity of anemia only when the animal has normal hydration and blood volume. It may take 1-2 days after blood loss before blood volume is restored to normal and the Het shows the severity of the anemia.? Even acute hemolytic anemia may not have a Het reflecting the severity of anemia at the time of presenta- tion to a clinic. CLASSIFICATION SYSTEMS Classification by Strength of Erythropoiesis Evaluation of bone marrow function divides anemia into those with variably reduced or ineffective erythro- poiesis (non-regenerative) or with active and effective erythropoiesis (regenerative) (Table 24.2). Anemia not caused by primary or secondary bone marrow dysfunc- tion should have appropriate evidence of erythropoie- sis (regeneration or responsive). The anemia is classified as regenerative if signs of increased erythropoiesis seem adequate for the severity of anemia, duration, species characteristics, treatments, and likelihood of multiple etiologies. fencrative anemias are caused by loss of erythro- cytes fom the bay (external Hood los) or psi ofthe erythrocytes within the body (hemolytic anemia and internal blood loss). These are easier fo diagnose than the non- regenerative anemias154 SECTION Ill: ERYTHROCYTES Bone marrow regeneration in species that display consistent reticulocyte responses (e.g. dog, cat, pig, and ral) is primarily evaluated by the reticulocyte response (see chapters on individual species characteristics). The strength of increase in the absolute reticulocyte count per unit volume of blood best reflects how effective bone marrow erythropoiesis is in the patient (Iable 24.2), The percentage of reticulocytes is a relative value affected by the severity of anemia and number of mature erythrocytes remaining, Absolute counts (% reticulo- cytes x erythrocytes) are preferred for interpretation. ‘The corrected reticulocyte percentage (CRP) and reticu- locyte production index (RPD) are other methods for interpreting the reticulocyte response when the total erythrocyte count is not available to calculate an abso- lute reticulocyte count. Guidelines for and the clinical usefulness of CRP or RPI are not well established in veterinary species. Reticulocyte numbers are best interpreted at the time of an expected peak of reticulocytes at 48 days after onset (see Fig 245A). Guidelines for interpretation of reticulocyte numbers are for the peak reticulocyte response and may be misleading early in an anemia (ie pre-regenerative) when reticulocyte numbers have not increased yet, or late in an anemia when reticulocyte numbers decline (10-14 days). Late in an anemia the number of macrocytic hypochromic erythrocytes (Fig. 2A) is more reflective of fe strength of primary regen. erative response than the reticulocyte number, which may be dectining or back to normal, Feline punctate reticulocytes have a long half-life in blood and therefore may accumulate in large numbers (Table 24.2). The kinetics of feline aggregate reticulocyte responses are similar to those of other species but maximal responses are weaker (Table 242) than txpected in dogs’ Aggregate reticulocytes may not be released unless the anemia is severe. Microscopic identification of aggregate and punctate reticulocytes is time consuming and subjective when many reticulocytes are present (see Chapter 136). The automated reticulocyte counts of the Advia 21208 and. Sysmex XT 2000® detect primarily feline aggregate reticulocytes and not punciate reticulocytes.” A time saving approach is to use automated feline reticulocyte Facwe recor cod & Hac vorOnE SSC VOCONE. BC YOCOM ROORC. RBCS. A FACT. A 8 © FIGURE 24.1 Advia 2120 RBC cytograms, RBC volume histograms and Hb concentration histograms from twee dogs illustrating the ‘ree main types of anemia based on size and hemoglobin concentration of RBCS. (A) The fist dog had non-regenerative IMHA and had no reticulocytes or macroeytic eels. It was # normocyti normochroric anemia with almost all RBCs inthe central box of the Mbox RBC {ytogram.(B) This dog had phosphofructoknase deficiency and hemolytic anemia. Almast all RBCs were macrocytic hypochromic due t a ‘marked regenerative anemia. Few RDCs remained inthe central box ofthe 9-box RBC cytogram. (C) Dog with ion deficiency and microcytic Ihypochomic anemia. ts erythrocytes were more hypochromie than microcytc Is reliculocytes were also micrcytcCHAPTER 24: LABORATORY AND CLINICAL DIAGNOSIS OF ANEMIA 155 counts for accurate aggregate reticulocyte counts and a quick screening of a new methylene blue-stained blood smear for an estimate of punctate reticulocyte percentages. It is important that laboratories indicate the type of feline reticulocyte reported. Sometimes only “reticulo- cytes” are reported without specifying the type. Note in Table 242, that the number of aggregate reticulocytes indicating a’ strongly regenerative anemia is the same ‘number as the number of punctate reticulocytes indicat- ing no regeneration. Duration of the feline regenerative response may be interpreted by pattern of changes in the two types of reticulocytes. A strong increase in aggregate reticulocytes but mild increase in punctate reticulocytes indicates an early response (3-6 days after onset of anemia), while late in a response (9-20 days) there may be many punctate reticulocytes but no increase in aggregate reticulocytes.? Other indicators of an appropriately active bone marrow in anemia are less specific for erythropoiesis than reticulocytosis; however, these may be useful in species without consistent reticulocyte responses. ‘Nucleated RBCs (NRBCS) are useful indicators in rumi- nants (eg. cattle, llamas) to reflect regeneration.® NRBC numbers are frequently reported as a relative ratio of NRBC/100WBC, so marked changes in WBC count can affect this ratio. Basophilic stippling, especially in rumi- nants, and Howell-Jolly bodies suggest a regenerative anemia, RBCs produced during increased erythropoie- sis are’ larger; thus macrocytosis and_anisocytosis| suggest active erythropoiesis and may be the only indi- calors in peripheral blood of horses that release very few reticulocytes into circulation, Macrocytosis and ani- socytosis can be detected by the MCV (e.g. >52fL in horses), RBC cytograms and histograms (Fig. 24.2) or blood smear evaluation, RBC distribution width (RDW) indicates the amount of anisocytosis. NRBC, macrocy- tosis, Howell-Jolly bodies and anisocytosis are caused by factors other than regenerative anemia such as gli- cocorticoid treatment, heat stroke, dysmyclopoicsis, myeloproliferative disorders, prolonged. storage of EDTA blood etc,, and are thus not specific indicators of regeneration. Classification by Erythrocyte Volume and Hemoglobin Concentration Erythrocyte volume changes are microcytic (smaller), normocytic or macrocytic (larger). Erythrocyte ‘hemoglobin concentration changes are hypochromic (reduced) and normochromic (normal concentration) ‘Hyperchromic changes indicate an erroneous result and not a disease-related change. Pre-analytic and ana- lytic errors, such as hemolysis or Heinz bodies, cause artifacts that imply the erythrocytes contain. more ‘hemoglobin per unit volume than a normal cell filled with hemoglobin. ‘The three important diagnostic patterns are macro- cytic hypochromic anemias (regenerative anemias with large, young RBCs that are not fully hemoglobinized), normocytic normochromic anemia (non-regenerative REC VAC. fF RBC VOLUME RBC He FIGURE 24.2 Regenerative response in horse with immune ‘mediated hemolytic anemia. Thee isa macroeyic nemochromie population of RBCs seen in the Advi 2120 RUC graphics. This horse did not have reticulocytes detected by the Advia 2120 anemias with residual normal erythrocytes), and micro- cytic hypochromic anemias, that are usually iron defi- ciency anemias. ‘The MCV and MCHC have been used for this classification. MCV and MCHC are unfortunately too insensitive and frequently fail to correctly differentiate the three main patterns. The numbers of abnormal erythrocytes are usually small and values for MCV or MCHC frequently remain within reference intervals Computer graphics of the Advia 2120® are more sensitive and specific in detecting diagnostic changes in volume or Figb concentration of RBCs than the MCV or, MCHC (Fig. 24.1), especially with small populations of abnormal RBCs. Advia’s two dimensional RBC cyto- ‘gram displays and records each RBC by individual cell volume and cell hemoglobin concentration. Advia’s volume and Hgb concentration histogram show well156 SECTION Ill: ERYTHROCYTES the relative size of populations of erythrocytes. Percentages of macrocytic, microcytic, or hypochromic RBCs or reticulocytes are also available from the Advia (unfortunately the somewhat round groups of different types of RBCS are not confined to the square shaped, nine counting boxes in the RBC cytograms and these percentages still must be subjectively interpreted while looking at the histograms; Fig. 24.1). However, these are exceptionally good tools in anemia diagnosis. For example, microcytic hypochromic cells can be seen in iron deficiency when the MCV and MCHC are normal. Inhorses, that have only minimal reticulocyte responses, the Advia cytograms and histograms still demonstrate macrocytosis in strongly regenerative anemias (Fig 24.2), Cats have relatively weak aggregate reticulocyte responses, Which often fail to correctly affect MCHC and MCV, but may be noted in Advia’s RBC graphics (ig. 243) Macrocytic normochromic anemia is the normal regenerative response of horses (Fig. 24.2) In cats mac- roeytic normochromic erythrocytes in the absence of polychromasia suggests feline leukemia virus (FeLV) FIGURE 24.3 Composite of four sets of V [RBC eytograms and histograms over 1 week fom a ct with Heing body anemia frm tating baby food containing onion powder. The thie set ower let looks the most rrmal and may be used for comparison. The RBC cytogram has one dark, ound cluster that is the normocytie normochromie tenythrocytes. The cells shouldbe in the center box but the grid was not aligned well. The lightly dispersed dots extending to the right are RACS with Heinz bodies ‘hat appeared hyperchromic: Note on the fist set (upper let) this extension is very RBC: Cat dark indicating many RBCs appeared hyperchromic because 4% contained large Hes bodies. The MCHC ws falsely high (44g/dL) on that doy. The Hgb ‘concentration histogram was bimodal. The ‘smaller left peak was normochromi cells (pi as offset) an the large, wider right peak sas the hyperchromic appearing cells. “The final set of graphics (lower right) shows a good regenerative response with mainly ‘macroeytic and slightly hypochromic RBCS extending up and to the let ofthe nermal ‘lls The RBC volume histogram shows, Ae RBC volume (o-200t} RBC volume (2008) HB concentration (oso gra) HB concentration (O50 gt). ‘many ofthe ells were macrocytie. The v GB histogram shows esentally no yperchromic cells (RBCS with Heinz bodies dropped to 17%) and a small. population of hypachromie cells (Le reticulocytes) The sequence shows well the loss of hyperchromie erythrocytes with Heinz bodies and the developing regenerative response with youn, smacrocytic els. REC: Cat RBC: Cat He fic RBC volume (o-200t} RBC volume (o-200'0) HB concentration (oso gra) HB concentration (50g).