Notes in Hematology Prepared by: Chester F.

Ebersole

Timetable Seminar 2
Subject: Hematology ( 1 and 2) – ERYTHROCYTES
WEEK 1 Erythropoiesis, Hemoglobin, NO QUIZ YET
Hematocrit
WEEK 2 Erythropoiesis, Hemoglobin, Hematocrit –
50pts
READ YOUR PREVIOUS NOTES ALSO
ESR, RBC Indices, Morphology
and Inclusion Bodies
WEEK 3 Possible Continuation

ESR, RBC Indices, Morphology and

Inclusion Bodies – 50pts
READ YOUR PREVIOUS NOTES ALSO
Assigning of new topic Anemia – Self
Study
WEEK 4 Pre-Task: Activity (20pts)
Rationalization of Pre-Task
Post Task: Quiz on Rationalized Topic ( 30pts)
TOTAL CP: 150pts / NO CP HIGHER / IN CASE OF TYPHOON, stick to the weekly plan

Erythropoiesis

Rubriblastic Normoblastic Erythroblastic

Proerythroblast
Basophilic Erythroblast
Polychromatophilic Erythroblast
Orthochromatophilic
erythroblast
Reticulocyte: stained by __________
Polychromatophilic erythrocyte = stained by _______________

Trends affecting RBC appearance as maturation progresses

1. Overall diameter of cell ___________
2. Diameter of nucleus ___________ along with the size of the cell
3. Nuclear chromatin becomes _________, clumped while nucleolus (ribosome formation
for protein synthesis) __________ among with the nucleus. Euchromatin (delicate)
becomes heterochromatin(course).
4. Cytoplasm changes ____________________ to hemoglobin formation
Rubriblast/ Pronormoblast • The earliest erythrocyte precursor identifiable by light
microscope
• 12-20um/ N:C ratio of 8:1/ With nucleoli of 1-2
• Nucleus usually occupies more than 80% of cell
• The cytoplasm stains basophilic due to high RNA content
(homogenous)
• Iron uptake and protoporphyrin synthesis are produced
including globin production
Prorubricyte/
Basophilic normoblast • 10-15um/ With 0-1 nucleolus/ N:C ratio of 6:1
• The nucleoli may be absent
• The cytoplasm is more basophilic as compared to rubriblast
• Golgi body is usually visible near the nucleus
• With hemoglobin production but masked by other cytoplasmic
organelle

P a g e | 1 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

Rubricyte/  10-12um/ N:C ratio of 4:1/ NO NUCLEOLI

Polychromatophilic  Has a round nucleus that may be eccentric
Normoblast • The nucleus is smaller while cytoplasm becomes prominent
• The RNA and hemoglobin give the cytoplasm a blue gray violet
color called polychromasia or polychromatophilia or “murky
gray blue”
• The cell may be confused with a lymphocyte
• Hemoglobin color is now visible
• Last Stage of Cell Division
Metarubricyte/ • 8-10um/ N:C ratio of 1:2
Orthochromatic • This is the last nucleated erythrocyte stage
Normoblast • The cytoplasm is polychromatophilic and more pinkish than that
of the rubricyte ( ORANGE RED LIKE MATURE RBC)
• The nucleus is degenerated and pyknotic
• Sometimes nucleus is not completely extruded resulting in
Howell-Jolly body from the digestion of macrophage from the
phosphatidylserine ( “eat me flag) of the extruded nucleus named
as pyrenocyte
• Maybe seen in peripheral circulation in times of extreme
anemia
Reticulocyte  8-10um with no nucleus
• The cytoplasm still contains small amounts of RNA which
produces varying amount of polychromasia
• The reticulocytes are retained in the bone marrow for 2 to 3
days and 1 day circulation.
• The reticulocyte contain Golgi apparatus remnant and residual
mitochondria which permit continued aerobic metabolism and
hemoglobin synthesis
Mature Erythrocyte • The mature erythrocyte is approximately 7.2 m in diameter
(120 days) • It is a biconcave disc and hence referred to as a discocyte
• In a Wright stain, a central pale area is revealed which fades
gradually into the reddish pink cytoplasm

 NOTE: On Wright Stain Basophilia:

o A. Diffuse: __________________________
o B. Punctate _________________________
 Grading of Polychromasia

Grading of Polychromasia

Slight 1+
2+ 3+
4+

Erythropoietin: 18kDA encoded by ______________ that is produced by ______ and

directed towards _______________ through signal transduction.

 Regulated by Janus-activated tyrosine kinase 2 ( JAK2) and maintained by

prostaglandin and renin
 Stimulates CFU-E and RNA synthesis
 With three actions

P a g e | 2 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

o A. Allowing early release of reticulocytes from bone marrow including

nucleated RBC ( Orthochromatophilic normoblast)
 Shift reticulocytes – _____________________________
 Stress reticulocytes – ___________________________
o B. Preventing apoptosis
o C. Reducing time of maturation from bone marrow
 Anti-EPO is described in Diamond Blackfan and SLE
 Reference range 4-27 mU/L
o ↑ = most patients with anemia. EXCEPT: ______________________
 RBC COUNT IS HIGHER IN MALES THAN FEMALES DUE TO

Gallery of Erythrocytic series

Pronormoblast Basophilic normoblast Polychromatophilic

Normoblast

Orthochromatophilic Reticulocyte Erythrocyte

Normoblast

Radioisotopic Evaluation

Iron(59) Long term Radiation, Very high energy that do not permit good image
Iron(52) Excellent for imaging, tandem with cyclotron
Tc(99m) Most used, Low radiation, must be linked with sulfur, for Medullary Hematopoiesis
Cr(51) or Random Method for Red Cell Survival
In (111)

P a g e | 3 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

HEMATOPOIESIS

P a g e | 4 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

RBC Metabolic Pathways

Embden Meyerhof Pathway

 Generates ___________ of energy needed by RBC’s
 Associated with ____________________
 Affected in patients with _____________________
 Glucose is metabolized and generates two molecules of ATP (energy).
 Functions in the maintenance of RBC shape, flexibility and the cation pumps
Hexose Monophosphate Shunt (HMP)/ Pentose Phosphate Shunt
 Metabolizes ______ of glucose in which NADPH is end product
 Detoxifies peroxide (H2O2) from O2 reduction that destroys heme, iron and lipids containing
thiol groups
 Protects the _____________________.
 Affected in patients with _________________________________
 If the pathway is deficient, intracellular oxidants can’t be neutralized and globin denatures
then precipitates. The precipitates are referred to as _________ which lead to RBC to
become bite cells after splenic pitting.
Rapaport Luebering
 Allows the RBC to ______________ during conditions of hypoxia or acid-base imbalance.
 __________________________ which is essential for maintaining normal oxygen
tension, regulating hemoglobin affinity
Methemoglobin Reductase Pathway
 Maintains ______________________________
 In the absence of the enzyme (methemoglobin reductase/ cytochrome b5 reductase),
methemoglobin accumulates and it cannot carry oxygen.
 NOTE : _________________________________________
Hemoglobin: 64, 458 daltons and associated with 95% cytoplasmic content of RBC

 Red-iron bearing protein contained within the erythrocytes in normal blood for
transportation of oxygen and carbon dioxide and regulation of acid base balance

Hemoglobin Structure: with ____ heme molecules and ___ different pairs of globin

Heme Structure
 With Carbon, Hydrogen and Nitrogen( Protoporphyrin IX) with central divalent
ferrous iron which reversibly combines with one oxygen

Globin Chains
Chromosome __ Chromosome __
___ amino acids ___ amino acids
Alpha(α), Zeta(δ) Beta(β) Gamma A(γa), Gamma G(γg),
Delta(δ), Epsilon(ε)
Heme Biosynthesis

 Occurs in mitochondria and cytoplasm of pronormoblast up to reticulocyte. Once

ribosome and mitochondria lose, hemoglobin cannot be synthesized

Hemoglobin Synthesis

 65% of cytoplasmic hemoglobin is synthesized in erythroblast while 35% is

synthesized in the early reticulocyte
 Two genes per diploid cell. Except: Alpha and Gamma (4)
 Alpha chain has highest affinity to beta chain followed by gamma and delta.
Major hemoglobin in adult comprised of ____________________

P a g e | 5 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

Chromosome 16 Chromosome 11 Normal Value in Adult

Zeta Epsilon Embryonic Hemoglobin
Alpha Epsilon
Zeta Gamma
Alpha Gamma At birth: 60-90%
Adult: 1-2%
Alpha Beta At birth: 10-40%
Adult: >95%
Alpha Delta Adult: < 3.5%
Hemoglobin Reference Range

Men: 14 to 18 g/dL ( 140 to 180g/L)

Women: 12 to 15 g/dL ( 120 to 150g/L)
Newborn: 16.2 to 21.5 g/dL ( 165 to 215g/L)
Hemoglobin Function

 To efficiently bind oxygen in the lungs with high oxygen affinity and to unload
oxygen in the tissues with low oxygen affinity
 Approximately ______ of oxygen is bound by ________ of hemoglobin
 Relationship of oxygen is described in oxygen dissociation curve which is
_______ in shape
 Low oxygen tension leading to low affinity for oxygen = TISSUES
o Shift to the left = higher oxygen affinity than normal
 Lower body temperature
 Multiple transfusion with low 2,3 DPG
 Alkalosis ( High pH)
 High Affinity to Oxygen Hemoglobin ( HbF, COHb, Hb Chesapeake)
o Shift to the right = lower oxygen affinity than normal
 Increased body temperature
 Increased 2,3 DPG ( Hypoxia, Anemia, High Altitude)
 Acidosis ( Low pH)
 Low Affinity to Oxygen hemoglobin ( Hb Kansas)
 Bohr effect = A shift that is due to ___ ( Hydrogen concentration)
 Haldane effect = Oxygenation of blood in the lungs displaces ___________ from
hemoglobin which increases the removal of carbon dioxide.

Forms of Hemoglobin

Oxyhemoglobin  Bound to oxygen, carried by arteries

 Gives pinkness to skin and mucous membrane
Deoxyhemoglobin  Unbound to oxygen, carried by veins

P a g e | 6 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

Carboxyhemoglobin  Combination of CO2 to heme with higher affinity ( _____) as

(COHb) compared to oxygen
 Smokers may have as high 15%
 Detected at 540nm
 (+) rose red or cherry red color in blood or skin
Methemoglobin  Formed by reversible oxidation of heme iron to ferric
( MetHb)  Only 1% of Total Hemoglobin
 Some have cytochrome b5 reductase deficiency or named as ____
 Also known as ______________ that can be removed by
methylene blue or direct removal
 It shows absorption peak at 630nm and produced chocolate
brown color even after oxygen exposure
 Irreversible oxidation of drugs
Sulfhemoglobin  Maybe due to exposure from sulfur in environment
(SHb)  May also be due to prolonged constipation, Clostridium perfringens
and ETEC
 Sulfur has a greenish pigment
 Sulhemoglobin has same absorption peak to methemoglobin but
spectral curve does not shift when cyanine is added
 Mauve lavender blood
Hemoglobin Determniation
1. Copper sulfate / Gravitational method: Specific gravity of _______ and is associated with
hgb of ___________.
2. Gasometric method (oxygen capacity method): Measured by _______________

 Blood is hemolyzed with saponin to liberate hemoglobin

 1.34mL oxygen per gram of hemoglobin

3. Chemical method (iron content method): 1gm of hgb is equal to 3.47mg of iron
Colorimetric methods
A. Visual
A1. Direct matching = tallquist, dare ( Acid hematin and Alkali hematin)
Acid hematin Alkali hematin
Ex. Sahli’s Hellige, Sahli-Adams, Osgood Ex. Clegg and King
Newcomer, Haldane, Haden-Hausser

Color Produced in Visual Reaction = brown to be compared in comparator block

B.Photoelectric
B1. Oxyhemoglobin method: ______________ for measuring plasma hemoglobin. It uses
20ul blood + n/150 ammonia solution / 0.1% Na2CO3.
B2. Cyanmethomoglobin or HiCN method: ___________________. It uses Drabkin’s
reagent + 20ul blood, read at 540nm. Sodium lauryl sulphate may be used to produce SLS-
methemoglobin which is non toxic
Principle:

Blood is diluted in an alkaline Drabkin solution of __________________, potassium

cyanide, _________________, and a surfactant. The hemoglobin is oxidized to
methemoglobin (Ferric) by the potassium ferricyanide. The potassium cyanide (KCN) then
converts the methemoglobin to cyanmethemoglobin.

P a g e | 7 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

Advantages:
1. Can measure almost all forms of Hgb except __________
2. Sample can be directly compared with HiCN standard
Disadvantages:
1. Affected by lipemia due to turbidity: corrected by adding 0.01mL of plasma to 5mL of
cyanmethemoglobin reagent and used it as patient blank
2. May affect leucocytosis ( >20,000) or thrombocytosis (> 700,000): corrected by the
reagent-sample solution can be centrifuged and the supernatant measured.
3. May affect by hemoglobins such as HbS and HbC which are resistant. This can be
corrected by making a 1:2 dilution with distilled water (1 part diluted sample plus 1 part
water) and multiplying the results from the standard curve by 2.
4. Also affected by globulinemia such as multiple myeloma and waldenstrom
macroglobulinemia due to increase in protein. To remedy, add 0.1 g of potassium
carbonate to the cyanmethemoglobin reagent. This is now modified by adding potassium
hydrogen phosphate in the reagent.
5. Cyanmethemoglobin reagent is sensitive to light
6. Carboxyhemoglobin takes 1 hour to be converted to HiCN

4 Layers of Blood After Centrifugation

Top layer : Fatty layer ( Maybe absent)
2nd layer : __________
3rd layer: ___________
Bottom layer: _______________

Hematocrit or _______________ or volume percent erythrocytes

 Uses Anticoagulated Blood

 In using capillary blood, __________ contains anticoagulant which is _______
whereas the _______ does not contain anticoagulant
 READ the level of red cell packing while do not include buffy coat

A. Macromethod
Method Anticoagulant
Wintrobe method Double oxalate
Haden’s modification method 1.1% sodium oxalate
Van Allen’s method 1.6% sodium oxalate
Sanford-Magath method 1.3% sodium oxalate
Bray’s method Heparin

B. Micromethod: Reference method for haematocrit is _____________

Point of difference Macro Micro
Method Venipuncture Skin puncture
Relative centrifugal force 2,000 – 2,300 g 10,000 – 12,000 g
(RCF)
Time of centrifugation Longer Shorter
(30 minutes) (4 – 5 minutes)
ESR Can be performed in the Cannot be performed
Wintrobe tube
Spilling / leakage/ Not common Common
breakage
Separation of buffy coat Complete Not complete

P a g e | 8 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

Factors to be considered
1. Trapped plasma causes ______________ in cases of sickle cell anemia, macrocytic
anemias, hypochromic anemias, spherocytosis, and thalassemia by 1% to 3%.
2. Not recommended after blood loss due to false decrease
3. Dehydration and hemoconcentration causes false increased
4. Hemolysis and interstitial fluid false decreased

False Increased False Decreased

Insufficient centrifugation and delay of reading Improper sealing
Low anticoagulant High conc. of anticoagulant
Improper mixing Improper mixing
Buffy coat reading
Hematocrit Reference Range
Men: 40-54% ( L/L)
Women: 35-49% (L/L)
Newborn: 48% to 68% (L/L)

QUIZ 1 up to this
READ PREVIOUS NOTES ALSO associated with the topics assigned

Erythrocyte Sedimentation Rate ( ESR)

 ___________ of the erythrocytes to _________ from their plasma

 Reported in mm at the end of _________________
 The ESR is directly proportional to the red blood cell mass and inversely
proportional to plasma viscosity.
Ways of measuring ESR
1. Measuring the length of fall from top of the column of RBC in a specified period of time
2. Determining the time required for the red cells to reach a specified point
Stages of ESR
A. Agglomeration stage/ lag phase
 Initial period, about 10 minutes
 Rouleaux formation takes place
B. Stage of fast settling/ decantation phase
 Approximately 40 minutes and at faster rate
C. Final phase of packing
 slower rate of fall, 10 minutes packing of the sediment cells
Methods of ESR determination
A. Micromethod
Examples: Micro Landau , Smith, Hellige – Voimer / crista
B. Macromethod
Examples: Wintrobe – Landsberg, Westergren, Graphic And Cutler and Linzenmeir

Point of difference Wintrobe – Landsberg Westergren

Anticoagulant Double oxalate 3.8 sodium citrate (Black)
Calibration Up to 100mm Up to 200mm
Length 115mm 300mm
Bore 3mm 2.5mm
# of reading One reading only Two readings
(after 1hr) (after 1hr & 2hrs)

P a g e | 9 Seminar 2 ( Hematology Notes)

Notes in Hematology Prepared by: Chester F. Ebersole

Dilution No dilution Involves dilution ( 4:1)

Sensitivity Less sensitive More sensitive
Correction for anemia Applicable Not applicable
Additional tests may be Hematocrit, bilirubin None
performed determination, icterus index
Disadvantages Short column of tube and Dilution and large amount of blood used
oxalate that retards ESR
Normal values M: 0-7mm/hr M: 0-15 mm/hr
W: 0-17mm/hr (7-15mm/2hrs)
C: 1-15mm/hr W: 0-20 mm/hr
(12-20 mm/2hrs)

Factor which causes faster ESR

Intrinsic factors
Plasma factors Increased fibrinogen concentration
Increased globulin concentration
Cholesterol
Red cell Macrocytes
factors Less number of red cells / anemia
Hemolysis
Extrinsic factors
A. Temp above 270c E. Longer sedimentation tube
B. Hemolysis F. Larger bore
C. Presence of air bubbles G. Increased dilution of blood
D. Inclination or tilting H. Wet glasswares
Factors which slows ESR

Intrinsic factors
Plasma factors Increased albumin
Increased lecithin
Defibrination
Red cell factors Microcytosis
Spherocytosis
Polycythemia
Increased sickle cells and poikilocytes
Extrinsic factors
A. Temperature below 200c E. Long standing of blood

B. Dry anticoagulant F. Short bore

C. More blood specimens G. Under anticoagulant
D. Presence of blood clots H. Dirty glasswares
RBC Indices or Blood Constants: To differentiate morphological type of anemia

A. MCV ( Mean Corpuscular Volume)

 Indicates normal average volume of RBC that is expressed in fL

 MCV =
 NV : 80-100fL

< 80fL ( microcytic) >100fL ( macrocytic) >120fL ( megalocytic)

P a g e | 10 Seminar 2 ( Hematology Notes)

Lecture Notes in Seminar 1 Chester F. Ebersole

B. MCH ( Mean Corpuscular Hemoglobin)

 Indicates average weight of hemoglobin

 Less valuable index
 Expressed in pg
 MCH =
 NV : 26-32pg

< 26pg ( hypochromic) >32pg ( hyperchromic)

C. MCHC ( Mean Corpuscular Hemoglobin Concentration)

 Indicates expression of hemoglobin in RBC

 Ratio of hgb to volume of cells which is expressed in g/dL or %
 MCHC =
 NV : 32% - 36%

<32% hypochromia >36% ( hyperchromic)

NOTES: MCHC more than 38% should not occur. It means incorrect calculation or cold
agglutinins producing false low RBC due to high HCT. It may also due to lipemia or
abnormal hemoglobin such as (C or S) producing high hemoglobin

Red Cell Size/ Anisocytosis – variation in __________________

RDW – It is used to assess the ______________________

 If two cell population is present, RDW is increased, Decreased RDW has little
significance, NV: 11.5% to 14.5%

Red Cell Type Morphologic Defect or Associated

Appearance Change Conditions
Normal size NA NA
6-8um
Anucleated

120 days
survival rate

Same size of
a small
lymphocyte

11
Lecture Notes in Seminar 1 Chester F. Ebersole

Larger RBCs Impaired DNA Megaloblastic

> 8um synthesis anemia
MCV > 100 fL
Stress Liver disease
erythropoiesis
Alcoholism
Excess
surface Reticulocytosis
membrane
Newborns
( NORMAL)
Smaller RBCs, Abnormal size Iron deficiency
less than 6 due to the anemia
um failure of
hemoglobin Thalassemia
Can Result synthesis
due to Anemia of
fragmentation Chronic
Disease
MCV <80 fl
Lead
Poisoning

Sideroblastic
Anemia
Red Cell Hemoglobin Content: due to the shape of the cell and to degenerative changes
or abnormalities of cell formation, particularly HEMOGLOBIN SYNTHESIS

Red Cell Type Morphologic Defect or Associated

Appearance Change Conditions
Normal in NA NA
color

Central Pallor
is about 1/3

Central pallor Reduced Iron

exceed 1/3 of Mean deficiency
the diameter Corpuscular anemia
of the cell hemoglobin
content Thalassemia
(MCHC)
Lead
Poisoning

Anemia of
Chronic
disease

12
Lecture Notes in Seminar 1 Chester F. Ebersole

No central MCHC is Spherocytosis

pallor increased

Dual Dimorphic
Population/ anemia
Heterogenous
population Post
Transfusion

Degree of Hypochromia

Hypochromasia Grading
+1 ½ of central pallor
+2 2/3 of the central pallor
+3 ¾ central pallor
+4 Thin rim of hemoglobin
Due to:
A. Lowered hemoglobin conc. B. Abnormal thinness
B. Morphologic

RBC Morphology Anemia

Acute Blood Loss
Hemolytic Anemia
Aplastic Anemia
Myelopthistic Anemia
Stem Cell Related Anemia

Megaloblastic anemia

Anemia of liver disease

Chronic aplastic anemia
Anemia of Chronic Inflammation

Porphyria
Lead Poisoning
Iron Deficiency Anemia
Thalassemia
Sideroblastic Anemia

13
Lecture Notes in Seminar 1 Chester F. Ebersole

Red Cell Shape or Poikilocytosis – variation in shape

Red Cell Type Morphologic Defect or Associated
Appearance Change Conditions
__________( Erythrocyte Increased Severe liver
Spur Cells) with 3-12 ratio of disease
Thorn Cell irregular cholesterol to Pyruvate kinase
spikes that lecithin deficiency
vary, usually Splenectomy
dense and
lacking central Abetalipoproteine
pallor mia

Mcleod
Phenomenon
Vitamin E
deficiency
Hypothyroidism
__________/ Fragments of Extreme Disseminated
keratocyte/ RBCs varying fragmentation intravascular
Pyknocyte/ in size and produced by coagulation (DIC)
damage of
Helmet Cell shape and
RBCs by fibrin,
often display altered vessel Micro
pointed walls and angiopathic
extremities prosthetic hemolytic anemia
heart valves Physical Agents
Burns
Uremia
Renal Graft
Rejection
_________ RBC’s with Due to Disorders with
(Degmacyte) semicircular Splenic RBC inclusions
portion Pitting of
removed from Heinz
the cell Bodies
margin

*** Under
Schistocyte
Blister Cell Same as Bite Cell

__________ Short Evenly Depletion of Uremia /

( Burr Cells) Spaced 10-30 ATP Hemolytic Uremic
Spiculated/ scalloped Exposure to Syndrome
Prickled projections hypertonic Pyruvate Kinase
usually with solution Deficiency
central pallor Artefact in Cirrhosis
drying Hepatitis
Membrane Chronic renal
Defect disease

14
Lecture Notes in Seminar 1 Chester F. Ebersole

Red blood Lowest Hereditary

cells that are surface area spherocytosis
almost to volume Immune hemolytic
spherical in ratio anemia
shape with ( ↑ OFT) ABO/Rh
darker red Defective incompatibility
color and membrane
have no MCHC= (37) Micro
central pallor spherocytes may
be seen in severe
burned patients
__________ Central Excess
(Target Concentration surface Hemoglobinopathi
Cell) hemoglobin membrane to es
Or surrounded by volume ratio Thalassemia
Platycytes clear area and Post-splenectomy
peripheral rim Obstructive
*** of hemoglobin Liver
Leptocyte (bull’s eye) Disease
- thinner or Mexican
variant of hat cell
Codocyte May also form
bell or cup
shape
__________ Crescent Polymerizatio Sickle cell anemia
(Sickle Cell) shape cell n of de- (Hemoglobin SS
that lacks oxygenated or sometimes SC)
zone of hemoglobin
central pallor

May be
curved or S
shape

___________ 6-sided dark Hemoglobin CC

or Hexagonal disease
staining
projection
that
resembles
“Bar of
Gold”

__________ 1-2 like Hemoglobin SC

Finger disease
Washington projection
Monument
(Glove like
intracellular
Crystal)

15
Lecture Notes in Seminar 1 Chester F. Ebersole

__________ Elliptocyte Polymerization Hereditary

( Ovalocyte) Or cigar of oxygenated Elliptocytosis
shape RBC hemoglobin
Heredidary
Ovalocyte Ovalocytosis
Or Egg
Shape RBC Thalassemia
Major

Megaloblastic
Anemia

__________ Teardrop or Squeezing Myeloid

pear-shaped and metaplasia
with single fragmentatio Hypersplenism
elongated n during Pernicious anemia
point or tail splenic Thalassemia
passage

___________ Normal sized Known to Hereditary

cell with slit have stomatocytosis
like area or increased Rh null disease
mouth like in permeability Alcoholism
center to sodium Liver Disease

The Red Cell Morphology Grading Chart

Morphology Grade As
Polychromatophilia 1+ = 1 to 5 / field
Helmet Cell 2+ = 6 to 10 / field
Teardrop RBC 3+ = > 10/field
Acanthocyte
Schistocyte
Spherocyte
Poikilocytosis 1+ = 3 to 10 / field
Ovalocytes 2+ = 11 to 20/ field
Burr Cells 3+ = > 20 / fields
Bizarre Shaped RBC
Elliptocytes
Stomatocyte
Rouleaux 1+ = aggregates of 3 to 4 RBCs
2+ = aggregates of 5 to 10 RBCs
3+ = numerous aggregate with few RBCs
Sickle Cell Report as positive only
Basophillic Stippling
Pappenheimer bodies
Howell Jolly Bodies

16
Lecture Notes in Seminar 1 Chester F. Ebersole

Red Cell Inclusions

Red Cell Type Morphologic Defect or Change Associated
Appearance Conditions
Coarse round Nuclear Megaloblastic
densely remnants anemia
stained purple containing Accelerated
1-2 um condensed DNA erythropiesis
granules Post splenectomy
eccentrically Sickle Cell Anemia
located on
periphery of
membrane
May be single
or double

Rings, loops or Remnants of Dyserythropoiesis

figure of eight; microtubules of Thalassemia
dark blue to mitotic spindle Post Splenectomy
purple Megaloblastic
May resemble Anemia
beads

Round dark Represents COARSE: Lead

blue granules impaired poisoning
uniformly erythropoiesis or Pyrimidine-5-
distributed, aggregation of nucleotidase
MULTIPLE, RNA(ribosomes) deficiency
PUNCTUATE FINE : Young RBC
BASOPHILIA

Deep purple Represent Hereditary defects

irregular precipitated, in hexose
shaped denatured monophosphate
inclusions 2 to hemoglobin due shunt
3 um to oxidative G6PD deficiency
Found on RBC injury ( 5 or more per
inner surface cell)
of membrane Unstable
hemoglobins
Small 2 to 3 Unused iron Sideroblastic
um irregular deposites anemia
basophilic Defective
inclusions that erythropoiesis
aggregate in Hemochromatosis
small clusters
near periphery
with Wright’s
stain due to
associated
protein

17
Lecture Notes in Seminar 1 Chester F. Ebersole

Nucleated RBC Excessive iron Sideroblastic

that contains overload in anemia
nonheme iron mitochondria of
particles normoblasts
arranged in Due to defective
ring form heme synthesis
Multiple evenly Due to Hemoglobin H
dispersed accumulation of disease
granules haemoglobin β
described as chains
“golf balls” or
“raspberries”

Inclusion Composition Wright Supravital Prussian Blue

Howell Jolly + + -
Bodies
Basophillic Stippling + + -
Pappenheimer + + +
Body
Cabot Ring + + -
Heinz Body - + -
Hemoglobin H - + -

QUIZ 2 Up to Here
READ PREVIOUS NOTES ASSOCIATED WITH THE ASSIGNED TOPICS

Advance Reading ( Use your notes and book)

Outline
A. Anemia
 General Characteristics
 MUST KNOW FOR:
1. Acute Blood Loss
2. Hemolytic Anemia ( Intravascular and Extravascular)
3. Membrane Defect Anemia
4. Iron Associated Anemia ( IDA, ACD and Sideroblastic Anemia)
5. Hemoglobinopathy and Thalassemia
6. Megaloblastic Anemia
7. Fanconi ANemia and Diamondblack Fan
8. CDA type II
SUMMARY OF THINGS YOU NEED TO STUDY

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Lecture Notes in Seminar 1 Chester F. Ebersole

PREPARE FOR PRE TASK NEXT WEEK

FOLLOWED BY RATIONALE
POST TASK QUIZ

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