WEEK 9: ERYTHROCYTE → Reference range: 26-34 pg (normal)

o <26 pg: decreased

ABNORMALITIES o >34 pg: increased
NORMAL ERYTHROCYTE
Hemoglobin
→ Formula: x 10
RBC count
SHAPE Biconcave shape (discocyte)
MEAN CELL/CORPUSCULAR HEMOGLOBIN
Color Light to red pink on wright’s stain CONCENTRATION (MCHC)
(salmon pink)
→ measures Hgb concentration in a single RBC; staining
Size 6-8 um in diameter (normocytic); capacity of RBC’s and amount of central pallor
approximately 7.2 (normal MCV) → Unit: g/dL
→ Reference range: 31-37 g/dL (normochromic)
Hemoglobin Correlates with pallor area/central o <31 g/dL: hypochromic
content pallor occupying 1/3 of the RBC o >37 g/dL: hyperchromic (de facto) 🡪 not
(normochromic – normal MCHC) reported
HemogloBin
In Vitro (slides) Flattened, round appearance with a → Formula : x 100
HematoCrit
central pallor

NO PRESENCE OF
INCLUSIONS

RBC INDICES/ INDEX

→ Measures parameters of a single RBC; useful in
the assessment of anemia
→ Measures the volume/ size of a
Mean
cell/corpuscular single RBC
volume (MCV)
→ Reported in femtoliters (fL)

Mean → Measures the weight/mass of

cell/corpuscular hemoglobin in a single RBC ABNORMAL ERYTHROCYTES
hemoglobin
(MCH) → Reported in picograms (pg) → Size – anisocytosis
→ Shape – poikilocytosis
Mean → measures Hgb concentration in → Color or hemoglobinization
cell/corpuscular a single RBC; staining capacity → Presence of inclusions
hemoglobin of RBC’s and amount of → Alteration in the distribution of cell on a blood smear –
concentration central pallor (g/dL) check in an area where cells do not overlap
(MCHC)
Variation in cell size
→ based on the standard deviation
of RBC volume/size and is → Normocyte: 6-8 um in diameter (MCV = 80-100fL)
Red cell routinely reported by → Macrocyte: >8 um in diameter (MCV = >100fL)
distribution automated blood cell analyzers o Result of a defect in either nuclear maturation
width (RDW)
or stimulated erythropoiesis; vitamin B12 or
→ Measures the degree of
folate (B9) deficiency 🡪 MEGALOBLASTIC
anisocytosis ANEMIA
→ MICROCYTE: <6um in diameter (MCV + <80fL)
MEAN CELL/CORPUSCULAR VOLUME (MCV)
o Decreased hgb synthesis (iron deficiency,
→ Average volume/size of a single RBC in a blood sample
impaired globulin synthesis, defect in heme
→ Unit: femtoliters (fL) synthesis)
→ Reference range: 80-100 fL (normocytic) → Anisocytosis: abnormal/increased variation in cell size
o Microcytic: <80 fL\ → Red Cell Distribution Width (RDW)
o Macrocytic: >100 fL o variation in red cell population size or diameter
Hematocrit (degree of anisocytosis)
Formula: x 10
RBC count o Helps to determine the cause of an anemia
MEAN CELL/CORPUSCULAR HEMOGLOBIN (MCH) o Normal range: 11.5 – 14.5%
→ Average weight/mass of hemoglobin per erythrocyte ▪ Increased: heterogenous cell size
→ Unit: picogram (pg) ▪ Decreased: homogenous cell size
(normal)
 membrane, ultimately resulting in reduced life span
leading to hemolysis
Variation in Hemoglobin Content → Abnormal lipid membrane concentration, osmotic
gradient imbalance, and hemoglobin concentration can
→ A normal erythrocyte has a moderately pinkish-red also destabilize the membrane
appearance (salmon pink) with a lighter-colored center o SPHEROCYTES
(central pallor) when stained with blood stains o ELLIPTOCYTES AND OVALOCYTES
→ Depth of staining serves as a rough guide to the amount o ECHINOCYTES/BURR CELLS CRENATED
of hemoglobin in red cells RBC
o Normochromic: central pallor/pallor area o PYKNOCYTES
occupies 1/3 of the cell o ACANTHOCYTES/ SPUR CELLS/ THORN
o Hypochromic: central pallor/pallor area is >1/3 CELLS
of cell; decreased hemoglobin concentration o STOMATOCYTES
o Hyperchromic: central pallor/pallor area is o TARGET CELLS/TARGET CELLS/
<1/3 of the cell ; increased hemoglobin MEXICAN HAT CELL
concentration
→ Anisochromia: variation in the normal coloration ; SPHEROCYTES
presence of both hypochromic and normochromic cells
(dimorphic anemia seen in sideroblastic anemia, iron → SMALL, ROUND, RBC with no central pallor
therapy for IDA, and transfusion (increased MCHC) ; may appear as artifacts if a slide is
→ Polychromatophilia or Polychromasia examined at the thin end of a normal blood smear
o blue-gray coloration indicates immature → Hereditary spherocytosis 🡪 Deficiency in either akyrin,
erythrocytes (reticulocytes); is a combination band 3, Spectrin and Protein 4.2
of the affinity of Hb for acid stains and the → Laboratory findings:
affinity of RNA for basic stains o MCHC >37g/dL ; can be microcytic RBCs
o Increased OFT
POLYCHROMASIA GRADING o Decreased surface area:volume ratio
→ CLINICAL SIGNIFICANCE:
Slight 1% o HEREDITARY SPHEROCYTOSIS
o Pre & Post splenectomy
1+ 3%
o HDN
2+ 5% o WAIHA, MAHA
o Severe burns or thermal injury
3+ 10% o Jaundice

4+ >11% Elliptocytes

VARIATION IN SHAPE → Have a cigar, elliptical, pencil, egg shape

→ Hemoglobin are concentrated at the two ends of
→ Poikilocytosis: variation in cell shape
the cell with normal pallor area
→ Greek origin is used to identify poikilocytes abnormal
shaped RBC’s
→ Hereditary elliptocytosis 🡪 due to deficiency in
→ CAUSED BY: either Spectrin and/or Protein 4.1
o Developmental macrocytosis → Clinical Findings:
o RBC Membrane abnormalities 🡪intrinsic o Hereditary elliptocytosis
defect o Iron deficiency anemia
o Abnormal hemoglobin content o Thalassemia major
o Trauma/Physical damage  extrinsic defect o Sickle cell anemia
o Pernicious anemia
POIKOLOCYTES CAUSED BY DEVELOPMENTAL
MACROCYTOSIS
o Myelofibrosis

Echinocytes/ Crenated RBC/ BURR cells

→ Macrocytes: large erythrocytes, mostly oval in shape
(MCV= >100 fL) → Echinocytes: evenly distributed blunt serrated
→ Seen in patients with Megaloblastic anemia edges/short projections
(macroovalocytes, oval macrocytes) → Burr cells; not evenly distributed blut serrated
edge/short projections
POIKILOCYTES CAUSED BY MEMBRANE
→ Causes:
ABNORMALITIES
o IN-VIVO: due to plasma abnormalities,
→ A deficiency or dysfunction in any one of these osmotic changes
o IN-VITRO: prolonged standing of blood
membrane proteins can weaken or destabilize the
o Can be an artifact
→ CLINICAL SIGNIFICANCE:
 o RENAL INSUFFICIENCY → Central area of hemoglobin surrounded by colorless
o LIVER DISEASE
o UREMIA ring and a peripheral ring of hemoglobin, resembles a
o PYRUVATE KINASE DEFICIENCY target

PYKNOCYTES → Due to increased membrane surface after loading of

the membrane with cholesterol and phospholipids
→ Are distorted, contracted erythrocytes that are similar to (phosphatidylcholine)
burr cells → In some instances, such as abnormal hemoglobins, the
defect is related to a maldistribution of hemoglobin
→ May be seen in small number during the first 2 to 3
→ LEPTOCYTE: THINNER VARIANT OF A TARGET
months of life as infantile pyknocytes
CELL
→ Clinical Significance:
→ CLINICAL SIGNIFICANCE:
o Acute, severe hemolytic anemia o Hemoglobinopathies (Hb C disease, S-C and S-S
o Glucose-6-phosphate dehydrogenase (G6PD) disease, sickle cell thalassemia, and thalassemia)
deficiency o Hemolytic anemias
o Hereditary lipoprotein deficiency o Hepatic disease with or without jaundice
ACANTHOCYTES/ SPUR CELLS/ THORN CELLS o Iron deficiency anemia
o Post-Splenectomy
→ Contains uneven spaced, pointed projections without
central pallor POIKILOCYES CAUSED BY TRAUMA OR
→ Fewer projections than echinocytes PHYSICAL DAMAGE
→ Due to the changes in the ration of plasma lipids;
decreased plasma and RBC membrane lipids (lecithin → RBC may fragment and lyse when subjected to
and sphingomyelin excessive physical trauma in cardiovascular system
(CVS)
→ CLINICAL SIGNIFICANCE: o SCHISTOCYTE/SCHIZOCYTES
o ABETALIPOPROTENEMIA o KERATOCYTES/HELMET CELLS/HORN
o Alcoholic cirrhosis w/ HA CELLS
o Malabsorption states o BLISTER CELL
o Post splenectomy o KNIZOCYTE
o Hepatitis of newborn o MICROSPHEROCYTES/
o Pyruvate kinase deficiency PYROPOIKILOCYTES
o Lipid metabolism disorders o DACRYOCYTE
o SEMILUNAR BODIES
o McLeod phenotype 🡪 absence of Kx gene;
absence of Kell antigens SCHISTOCYTE/SCHIZOCYTE/FRAGMENTED RBC
STOMATOCYTES → Characterized by cleaved, fragmented RBC
→ Are fragments of erythrocytes that are small and
→ Characterized by elongated or slit like pallor area
irregularly shaped; these cells are produced as the
instead of circular pallor (mouth like central pallor)
result of the breaking apart of an erythrocyte, the
→ Can appear as an artifact in blood film
schistocyte is about half the size of a normal
→ Overhydrated stomatocytosis: increased membrane erythrocyte and may have a deeper red appearance
permeability to sodium and potassium leading to water → Includes helmet, triangular, variety of small, irregular
influx shapes with few pointed extremities
→ Dehydrated stomatocytosis: increased membrane → FRAGMENTATION IS CAUSED BY:
permeability to potassium leading to loss of water from o Altered vessel walls
cell
o Presence of fibrin (CLOTS)
→ Can be seen with puddled hemoglobin at the periphery o Prosthetic heart valves
of cells with spicules o Renal transplant rejections
→ CLINICAL SIGNIFICANCE
→ CLINICAL SIGNIFICANCE
o RH NULL DISEASE
o Severe burns
o Acute alcoholism, alcoholic cirrhosis
o Glomerulonephritis
o Glutathione deficiency
o MAHA
o Hereditary spherocytosis
o TTP
o Infectious mononucleosis
o DIC
o Lead poisoning
o Malignancies KERATOCYTES/ HELMET CELLS
o Thalassemia minor
o Transiently accompanying hemolytic anemia → Type of schistocyte with one or more hornlike
projections, hollow interior portion of cell; resembling
TARGET CELLS/CODOCYTE/MEXICAN HAT CELL helmet or horn
 → Are usually the larger scooped out part of the cell that
remains after the rupturing of a blister cell and are
formed as a result of the physical process of
fragmentation
→ Formed in the spleen and intravascular fibrin clots
BLISTER CELL
→ RBC containing one or more vacuoles that resemble a
blister on the skin
→ Has a significantly thinned area at the periphery or
outer border of the cell membrane
→ The vacuoles may rupture. If rupturing does occur,
distorted cells (keratocytes) and cell fragments
(schistocytes) are produced
→ CLINICAL SIGNIFICANCE:
o Pulmonary emboli in sickle cell anemia
o Microangiopathic hemolytic anemia
o Heinz body hemolytic anemia
KNIZOCYTE
→ Resemble a pinched bottle ; can be trianglular in
shape
→ This abnormality is associated with hemolytic
anemias, including hereditary spherocytosis
→ RBC has 2 pallor area
MICROSCPHEROCYTES/PYROPOIKILOCYTES
→ Disk shaped cells with smaller volume
→ Due to thermal damage to cell membrane protein
spectrin, no pallor area
→ LABORATORY
o 203 um in diameter
o MCV = <60fL
→ CLINICAL SIGNIFICANCE:
o Severe burns
o Hereditary pyropoikilocytosis 🡪 Fragmented
cells increases when heated in vitro at 45C
(normal fragmentation: 49C)
DACRYOCYTE
POIKILOCYTES CAUSED BY ABNORMAL
HEMOGLOBIN CONTENT
→ SICKLE CELLS/DREPANOCYTES/MENISOCYTES
→ HEMOGLOBIN CC CRYSTALS
→ HEMOGLOBIN SC CRYSTALS
SICKLE CELLS/ DREPANOCYTES/MENISOCYTES
→ Long rod, crescent shaped, with thin and elongated with
pointed ends; holly-leaf like app
→ Contains polymers of abnormal hemoglobin
→ Fully hemoglobinized, no pallor area
→ Polymerization of Hb S is influenced by lowered
oxygen levels and decreased blood pH as well as influx
of sodium ions and increased intracellular calcium
→ Can be due to amino acid substitution resulting to cell
membrane alterations
→ CLINICAL SIGNIFICANCE
o SICKLE CELL ANEMIA/ Hgb S
o Hgb SC disorder
o Hgb C-Harlem disorder
o Hgb S-Memphis disorder
HEMOGLOBIN CC CRYSTALS
→ Homogeneous: hexagonal with blunt ends ;
BAR OF GOLD APPEARANCE
→ Leaves the hemoglobin free and colorless
→ Cell membrane is not usually visible
→ Confirmed with hemoglobin electrophoresis
→ CLINICAL SIGNIFICANCE:
o HGB CC DISEASE
HEMOGLOBIN SC CRYSTALS
→ Dark-hued crystals of condensed hemoglobin
→ Crystals appear straight with parallel sides and one
blunt, point, protruding end, fingerlike
→ WASHINGTON’S MONUMENT APPEARANCE
→ Confirmed by hemoglobin electrophoresis
→ CLINICAL SIGNIFICANCE: HGB SC DISEASE

→ Tear drop, pear drop shaped with blunt pointed ERYTHROCYTE INCLUSIONS
projection
→ Due to squeezing of red cells through small openings → DEVELOPMENTAL ORGANELLES
or splenic sinuses and remains behind o Howell-Jolly bodies
→ CLINICAL SIGNIFICANCE o Basophilic stippling/Punctuate basophilia
o Myeloid metaplasia o Pappenheimer bodies
o Primary myelofibrosis o Ringed sideroblast
o Myelopthisic anemia o Diffuse basophilia 🡪 Reticulocytes in Supravital
o Pernicious anemia stains
o Beta thalassemia o Cabot rings
o Tuberculosis → ABNORMAL HEMOGLOBIN PRECIPITATION
o Heinz body formation o Heinz bodies
o Hemoglobin H inclusions
SEMILUNAR BODIES → PROTOZOAN PARASITES
o Plasmodium species
→ Half moon cell, half crescent cell
o Babesia microti
→ Large, pale pink staining ghost of red cell o Leishmania species
→ Causing overt hemolysis
→ ASSOCIATED WITH MALARIA DEVELOPMENTAL BODIES

HOWELL-JOLLY BODIES
→ Small, 1-2 um in size; nuclear fragments of DNA
→ Normally pitted by splenic macrophages and are not
seen in normal RBCs
→ Develop in periods of accelerated or abnormal
erythropoiesis because the spleen cant keep up with
pitting of the remnants
→ Reddish blue; Dark blue-purple with Wright’s
stain
→ Positive in Feulgen reaction (DNA stain)
→ CLINICAL SIGNIFICANCE
o POST SPLENECTOMY
o CONGENITAL ABSENCE OF SPLEEN
o SPLENIC ATROPHY
o SICKLE ATROPHY
o SICKLE CELL ANEMIA
o ALCOHOLISM
o MEGALOBLASTIC ANEMIA
BASOPHILIC STIPPLING/PUNCTUATE BASOPHILIA
→ Multiple, tiny, fine or coarse rRNA inclusions
(precipitated RNA)
→ rRNA inclusions aggregates in drying & staining
→ Hemoglobin appears homogeneous
→ Blueberry gel appearance
→ Dark blue to purple with Wright’s stain
→ CLINICAL SIGNIFICANCE:
o Megaloblastic anemia
o Alcoholism
o Thalassemia
o Lead & arsenic toxicity
o Pyrimidine-5’-nucleotidase
Deficiency
PAPPENHEIMER BODIES/SIDEROTIC GRANULES
→ Aggregates of mitochondria, ribosomes, and IRON
PARTICLES
→ Appears in the periphery of the erythrocytes
→ Small, irregular, light blue to purple staining IRON
GRANULES with Wright’s stain
→ SIDEROTIC GRANULES: iron (ferritin) aggregates
→ Pers Prussian blue  iron stain
→ Siderocyte: RBC with siderotic granules
→ Sideroblast: Normoblast with siderotic granules
→ CLINICAL SIGNIFICANCE:
o Sideroblastic anemia
o Hemoglobinopathies
o Thalassemias
o Megaloblastic anemia
o Myelodysplastic syndromes
o Hyposplenism
o Post-splenectomy
RINGED SIDEROBLAST
→ Numerous siderotic granules found within mitochondria
and form a ring around the nucleus
→ CLINICAL SIGNIFICANCE : SIDEROBLASTIC
ANEMIA
CABOT RINGS
→ The ring like structure, circular and may form
figure or eight, incomplete rings
→ Represent remnants of microtubules from the
mitotic spindles
→ Stain reddish violet in Wright’s stain
→ Associated with Howell jolly bodies in the same
RBC
→ CLINICAL SIGNIFICANCE”:
o MEGALOBLASTIC ANEMIA
o MYLODYSPLASTIC SYNDROMES
DIFFUSE BASOPHILIA
→ Young cells with no nucleus but contains RNA
remnants
→ Wrght’s stain: bluish tinge throughout cytoplasm; also
called polychromasia/ polychromatophilia
→ Supravital stain:
o New Methylene blue 🡪 CLSI
m=recommended
o Brilliant Cresyl Blue
o Crystal violet 🡪 for Heinz bodies
preparations
→ CLINICAL SIGNIFICANCE: (INCREASED
RETICULOCYTES)
o Increased RBC production
o Increased EPO stimulation of the marrow
ABNORMAL HEMOGLOBIN PRECIPITATION
HEINZ BODIES
→ Precipitated/denatured globin due to destruction of
Hgb
→ 0.2 to 2.0 um in size, that can be seen with a stain
such as crystal violet or brilliant cresyl blue
→ Pitted golf ball appearance
→ BITE CELL/DEGMACYTE  RBC with pitted
Heinz bodies
→ NOT VISIBLE ON WRIGHT’S STAIN
HEMOGLOBIN H INCLUSIONS
→ Small, dark blue or greenish granules ; Precipitated
beta-globin chains of hemoglobin
→ Failure of synthesizing three alpha globin chains (Hgb
H disease)
→ Results to unstable, easily oxidized and easily
precipitated hemoglobin
→ Can be mistake as reticulocytes
o Retics: granulofilamentous pattern
o Hb H inclusions: single body
→ Seen after 4 drops of blood incubated with 0.5ml 1%
→ BCB for 20 minutes at 37C
→ CLINICAL SIGNIFICANCE:
o HEMOGLOBIN H DISEASE
 o In-vitro 🡪 thick moist blood film under coverslip
o Can be an artifact (thicker parts) ; True rouleaux
formation (pathologic rouleaux) is determine in the thin
parts of blood films
o CLINICAL SIGNIFICANCE
▪ Hyperproteinemia
▪ Plasma cell dyscrasias
● Multiple dyscrasias
● Waldenstrom’s Macroglobunemia
▪ Increased fibrinogen
(Hyperfibrinogenemia)

ABNORMAL ERYTHROCYTE DISTRIBUTION

→ AGGLUTINATION
o Erythrocytes are exposed to antibodies
o Autoagglutination: red cells agglutination in his own
serum/plasma with no known agglutinins
o Cold agglutinin disease (CAD)
▪ RBCs agglutinates <25 C: specimen should be
warmed before testing to correct the false
decrease of hematocrit and false increase of
MCHC
▪ Associated with IgM antibodies and
complement proteins
o CLINICAL SIGNIFICANCE:
▪ Primary Atypical pneumonia (PAP) 
▪ Mycoplasma pneumoniae infection
▪ Staphylococcal infections
▪ Tyrpanosomiasis
▪ Cold agglutinin disease

PROTOZOAN PARASITES BLOOD SMEAR GRADING OF POIKIOLCYTES,

INCLUSION, AND ROULEAUX
→ Plasmodium species
o Causative agent of Malaria ; Vector:
Anopheles mosquito
o Rings, trophozoite, schizonts, gametocytes
o Includes: Plasmodium vivax, P. falciparum, P.
malariae, P. ovale, and P. knowlesi
→ Babesiosis
o Causative agent is called Babesia microti
(Maltese-cross appearance)
→ Leishmania species 🡪 hemoflagellates ; found in
mononuclear cells

ABNORMAL ERYTHROCYTE DISTRIBUTION

→ ROULEAUX FORMATION
o Appears short or long stacks of coins (stacking of RBC)
o In-vivo 🡪 Due to abnormal or increased plasma
proteins (decreases zeta potential) ; associated with
increased ESR
 NORMAL ERYTHROCYTE POLYCHROMATOPHILIA MICROCYTIC HYPOCHROMIC RBC

MACROCYTES/MACROCYTIC RBC ANISOCYTOSIS DIMORPHIC

ECHINOCYTES/ CRENATED RBC/ BURR

SHOERICYTES ELLIPTOCYTES
CELLS

ACANTHOCYTES/ SPUR CELLS/ THORN

PYKNOCYTES ARTIFACT
CELLS
 TARGET CELLS/ CODOCYTE/ SCHISTOCYTE/SCHIZOCYTE/
STOMACTOCYTES
MEXICAN HAT CE FRAGMENTED RBC

KERATOCYTES/ HELMET CELLS BLISTER CELL KNIZOCYTE

MICROSPHEROCYTES/
DACROCYTE SEMILUNAR BODIES
PYROPOIKILOCYTES
SICKEL CELLS/ DREPANOCYTES/
HEMOGLOBIN CC CRYSTALS HEMOGLOBIN SC CRYSTAL
MENISOCYTES

BASOPHILIC STIPPLING/ OAOOERNHEIMER BODIES/

HOWELL-JOLLY BODIES
PUNCTUATE BASOPHILIA SIDEROTIC GRANULES

RINGED SIDEROBLAST CABOT RINGS DIFFUSE BASOPHILIA

HEINZ BODIES HEMOGLOBIN H INCLUSIONS HEINZ BODIES

PROTOZOAN PARASITES