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1. INTRODUCTION :
2. RED BLOOD CELL AND ITS DISORDER.
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ERYTHROCYTES AND RED BLOOD CELL ARE THE NON NUCLEATED FORMED ELEMENT IN THE BLOOD.

RED COLOR-DUE TO HEMOGLOBIN

SHAPE-BICONCAVE

SIZE-7.2

THICKNESS-2
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Sites of blood formation :
Adults………….. Bone Marrow •
(Flat bones)
Children …………. Bone Marrow •
(Flat & long bones)
Before Birth: …. Bone Marrow •
Liver & spleen,lymph nodes

Fetus 1st 4 months …Yalk Sac •

Control of Erythropoiesis
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Erythropoiesis is stimulated by erythropoietin
hormone

Stimulated by:
Hypoxia (low oxygen)
Anaemia ◦
Hemorrhage ◦
High altitude ◦
Lung disease ◦
Heart failure ◦
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Formation in the red

bone marrow
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Maturation Times
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Factors contributing to
normal maturation:

• Iron
• Folate
• Vitamin B12
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Reticulocytes
• Reticulocytes are immature red blood cells, typically
composing about 1% of the red blood cells in the human
body. In the process of erythropoiesis (red blood cell
formation), reticulocytes develop and mature in the bone
marrow and then circulate for about a day in the blood
stream before developing into mature red blood cells.
Like mature red blood cells, in mammals reticulocytes do
not have a cell nucleus. They are called reticulocytes
because of a reticular (mesh-like) network of ribosomal
RNA that becomes visible under a microscope with
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certain stains such as new methylene blue and
Romanowsky stain.
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of a
smear of human blood
from a patient
with

The reticulocytes are

the cells with the dark
blue dots and curved
linear structures
(reticulum) in the
cytoplasm.
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Reticulocyte counting
:
• A reticulocyte count is reported as the percentage of RBCs that are
reticulocytes.

• Each calculation depends on the counting procedure used.

• Standard Calculating Procedure

✓ # of reticulocytes counted
X 100 = % Retics
Total # RBCs counted

✓# of reticulocytesX 100 = % Retics

1000
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Why reticulocyte count ???
• The number of reticulocytes is a good indicator of bone
marrow activity because it represents recent production
and allows for the determination of reticulocyte count
and the reticulocyte production index.

• These values can be used to determine whether a

production problem is contributing to the anemia and
can also be used to monitor the progress of treatment
for anemia.
BRI - reticulocyte
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• The reticulocyte percentage depends on age.

• Newborns have a high reticulocyte count that decreases

2 after
weeks of age.
• Newborns2.5-6.5%

• In a healthy adult the retic count is usually stable.

• Adults0.5-1.5%
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Reticulocytes :

• The increased reticulocyte percentage can be caused by

…..
• Hemolytic anemias
• Hemorrhage
• Heavy smoking
• Living at high altitudes
• Treated folate, iron, B12 deficiency

• A decrease reticulocyte percentage can be caused by …..

• Aplastic anemia
• Bone marrow failure
• Untreated Vitamin B12 deficiency and Iron deficiency
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RBCS Abnormal Morphology

Peripheral Blood Morphology

 Content :Morphology
Abnormal Erythrocyte
Is found in pathological states that may be
abnormalities in
I. Red cell distribution.
II. Size a( nisocytosis
).
III. Hemoglobin content – Color Variation .
IV.Shape poikilocytosis
( ).
V. The presence of inclusion bodies in erythrocyte.
I. Erythrocyte Distribution Abnormalities
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Rouleauxformation
Stacking of RBCs due to increased
plasma
proteinscoating RBCs (resembling a stack of
coins)
Found in
• Hyperfibrinogenaemia
• Hyperglobulinaemia
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Agglutination
Antibody
-mediated Irregular clumping ,
temperature dependent

Found in
• Cold agglutinins
• Warm autoimmune hemolysis
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Rouloux Formation Agglutination

II. Variation In Erythrocyte Size (Anisocytosis)
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Anisocytosis
Variations in size (Microcyte and
Macrocyte)

Normocytic RBC’s
Normal size of RBC (8 μm) with
a range of 7 to 9 μm.
The nucleus of a small
lymphocyte (± 8 µm) is a useful
guide to the size of a red blood
cell).
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Microcytic
RBC cell smaller than the normal RBC ( <7 μm), and
is associated with a decrease in hemoglobin synthesis
Found in
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• Iron deficiency anemia.

• Thalassaemia.
• Sideroblastic anemia.
• Lead poisoning.
• Anemia of chronic disease.
Macrocyte
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RBC larger than the normal
<9 μm)( and is the result of a
defect in nuclear maturation or stimulated erythropoiesis.
May be round or oval in shape, the diagnostic significance
being different.

Found in
• Folat and B12deficiencies (oval)
• eEthanol (round)
• Liver disease (round)
• Reticulocytosis
(round
)
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III. Variation In Erythrocyte Color
• A normal erythrocyte has a pinkish-red color with a
slightly lighter-colored center (central pallor) when
stained with a blood stain, such as Wright.

• The color of the erythrocyte is representative of

hemoglobin concentration in the cell.

• Under normal conditions, when the color, central

pallor, and hemoglobin are proportional, the
erythrocyte is referred to as Normochromic.
 Hypochromia Content :
• Increased central pallor and decreased hemoglobin
concentration, the central pallor occupies more
than the normal third of the red cell diameter.
Found in
• Iron deficiency
• Thalassaemia
• any of the conditions leading
to Microcytosis
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Polychromasia
• Red cells stain shades of blue-gray as a consequence of
uptake of both eosin (by hemoglobin) and basic dyes
(by residual ribosomal RNA). Often slightly larger
than normal red cells and round in shape - round
macrocytosis.

Found in
Any situation with reticulocytosis
– for example bleeding,
hemolysis or response to
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heamatinic factor
replacement.
 IV. Shape Abnormalities of Erythrocytes
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• Poikilocytosis
is the general term for mature
erythrocytes that have a shape other than the round,
biconcave disk.
• Poikilocytes
can be seen in many shapes.(e.g.
Acanthocyte
, Spherocytosis,
…)
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Shape Abnormalities of Erythrocytes
Terminology Description Condition
Target Cells Central Hemoglobin; target Liver Disease; Thalassaemia,
shaped Abnormal Hb; Iron Deficiency
Echinocyte Short specula's, equally- Uremia, Hypokalemia, Artifact
spaced
Acanthocyte Speculated, Irregular Liver disease (Alcohol),
Postspleenoctomy. Spherocyte Spherical, no central pallor HS, immune
Hemolytic anemia
Shistocyte Fragmented RBC, Helmet MAHA, burns
cells
Ovalocyte Oval / Elliptical shaped Hereditary elliptocytosis,
Megaloblastic
anemia.
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Sickle Cell Bipolarspeculated shape “ Hb S-containing
banana” shaped hemoglobinopathy
Teardrop cellSingle elongated extremity Myelophthisticchanges Bite cells
Irregular gap in membrane G6PD deficiency
Target cell Content :
Red cell with a“target” or bull’s-eye appearance. The cell
appears with a central bull
’s eye that is surrounded by a
clear ring and then an outer red ring
.
Found in
• Obstructive liver disease
• Severe iron deficiency
• Thalassaemia
• Post splenectomy
• Lipid disorders
• Haemoglobinopathies(S and C)
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Spherocytosis
Red cells are more spherical. Lack the central area of
pallor on a stained blood film.
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Found in
• Hereditary spherocytosis
• Immune haemolytic anemia
• Zieve's syndrome
• Microangiopathic haemolytic
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Stomatocyte
Red cells with a central linear slit or stoma. Seen as
mouthshaped form in peripheral smear.
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Found in
• Alcohol excess
• Alcoholic liver disease
• Hereditary stomatocytosis
Ovalocyte Content :
An elongated oval cell. They are a result of a
membrane defect.
Found in
• Thalassaemiamajor.
• Hereditaryovalocytosis
.
• Sickle cell anemia
Elliptocyte Content :
The red cells are oval or elliptical in shape.
Long
axis is twice the short axis.

Found in
• Hereditaryelliptocytosis
• Megaloblasticanemia
• Iron deficiency
• Thalassaemia
• Myelofibrosis
 Schistocyte Content :
Red cell fragments that are
irregular in shape and size. They
are usually half the size of the
normal RBC; therefore, they
have a deeper red color.

Found in
• DIC
• Micro angiopathic haemolytic
anemia
• Mechanical haemolytic anemia
Blister cell: pre
keratocyte
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Haveaccentrichallow area. Resemble a women's handbag
and may be called
pocket-bookcell.

Found in
Microangiopathic
hemolytic anemia
Keratocytes(horn cell)
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Part of the cell fuses back leaving two or three-like
horn
projections. Thekeratocyteis a fragile cell and remains in
circulation for only a few hours.
Found in
• Uraemia
• Severe burns
• EDTA artifact
• Liver disease
Also called helmet cells
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Degmacyte "bite cell"
• An abnormally shaped red blood cell with one or more
semicircular portions removed from the cell margin.
• These "bites" result from the removal of denatured
hemoglobin by macrophages in the spleen.
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Found In
• G-6-PD deficiency, in which
uncontrolled oxidative stress
causes hemoglobin to
denature and form Heinz
 that leads to the formation of
bite cells.
Sickle Cells Content :
Sickle shaped red cells.

Found in
Hb-S disease and trait
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Echinocyte “Burr” (crenation ) cell:
Red cell with 30 or more, short blunt projections
which are regularly distributed on their surface Found
in
Usually artifactual— the result of slow drying under
humid conditions.
Sometimes are non - artifactual, indicating uremia
or pyruvate kinase deficiency. • Hemolytic anemia
• Uremia.
• Megaloblastic anemia
Cells retain the central pallor.
Echinocytes (Burr Cells)
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 Acanthocytosis
(Spur Cells
):
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Red blood cells with irregularly spaced
projections, these projections very in width but
usually contain a rounded end

Found in
• Liver disease
• Postsplenectomy
• Anorexia nervosa and starvation
Acanthocytes
Content(Spur
: Cells)
Dacryocytes(Teardrop)
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Resembles a tear and usually smaller than the
normal RBC.
Found in
• Bone marrow fibrosis
• Megaloblasticanemia
• Iron deficiency
• Thalassaemia
Envelope Form Cell :
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Found in
• Thalassaemia
• Sickle cell anemia
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V. Erythrocyte Inclusions with Wright’s Stain
Inclusion Composition Appearance Condition
Basophilicstippling Precipitated Evenly dispersed - Lead poisoning
ribosomes fine or coarse Thalassaemia ,
granules other anemia.
Howell-Jollybodies DNA in origin Dense, round blue Post – Splenectomy
Nuclear Fragment granule

Pappenheimer Iron-containing Small blue granules Anemia's bodies

granules in clusters

Heinz bodies Denatured Round blue G6PD

Hemoglobin precipitates
Cabot Rings Remnants of Reddish-blue thread Severe anemia, Nuclear
membrane like rings Lead poisoning.
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Organism Small blue inclusion Malaria
Babesiosis
Howell-Jolly Bodies
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Small round cytoplasmic red cell inclusion
with same staining characteristics as nuclei

Found in
• Post splenectomy
• Megaloblasticanemia
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Siderotic Granules (Pappenheimer Bodies)
These are iron containing granules in red blood cells that
are seen because the iron is aggregated with
mitochondria and ribosomes. They appear as faint violet
or magenta specks, often in small clusters, due to
staining of the associated protein.
They are associated with severe anemias and
thalassemias. Pappenheimer bodies can be increased
in hemolytic anemia, infections and post-splenectomy.
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Basophilic stippling
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Considerable numbers of small basophilic
inclusions in red cells.

Found in
• Thalassaemia
• Megaloblasticanemia
• Hemolytic anemia
• Liver disease
• Heavy metal poisoning.
 Heinz Bodies
Content :
Represent denatured hemoglobin methemoglobin
( - Fe+++)
within a cell.
With asupravitalstain like crystal violet, Heinz bodies
appear as round blue precipitates.
Presence of Heinz bodies indicates red cell injury and is
usually associated with 6PD
G-deficiency.
Cabot Rings Content :
Reddish
-blue threadlike rings in RBCs of severe anemia's.
These are remnants of the nuclear membrane or remnants
of microtubules and appear as a ring or
8pattern.
figure

Very rare finding in patients with

• Megaloblastic
anemia.
• severe anemia's.
• lead poisoning.
• Dyserythropoiesis
.

A- Cabot ring
B - Howell
-Jolly body
Parasites of Red Cell
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Two organisms are have a tendency to invade the RBCs.
1. All 4 species of the malaria parasite will invade RBCs.
We will see the Plasmodium of different species in
RBCs.
2. Theileria microti (Bebesia microti)
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Malaria :
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RED BLOOD CELL MORPHOLOGY
A normal red blood cell should be
approximately the same size as a normal
lymphocyte nucleus or 2 normal sized red blood
cells should fit side by side across a normal sized
poly (not a hypersegmented poly).

NO. of Field/ Oil imm. Grade Degree of abnormality

1-6 per oil imm. field 1+
7-10 per OIF 2+ 11-20 per OIF 3+ > 20 per
OIF 4+
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