EVALUATION OF RED CELL MORPHOLOGY AND SUMMARY OF PLATELET

AND WBC MORPHOLOGY

ANISOCYTOSIS AND POIKILOCYTOSIS
 Anisocytosis implies a variation in size. Poikilocytosis implies a variation in shape seen in well-stained,
well-dispersed smear.
 It is recommended that a simple statement (“aniso and poik observed”) be adopted
when applicable and that the quantitation or use of qualitative adjectives be reserved only for the more
important assessment of the actual number and types of morphologic abnormal cells.
 What is paramount in smear examination is the type of cells seen.
 The qualitative genre applies the adjective “slight” “moderate” or “marked” to the words “aniso” and
“poik”

THE NORMAL RED BLOOD CELL

 On a Wright-stained blood smear, the mature RBC has a reddish orange appearance; it has an average
range of 6.0 to 8.0µm and an average volume of 90µm3

SIZE VARIATIONS
Macrocytes
Physiologic Mechanism
 Macrocytes are cells with a diameter of approximately 9µm or larger, having a mean cell volume (MCV)
of greater than 100µm3.
 Macrocytes may arrive in the peripheral circulation by several mechanisms. Three of the most distinct
are (1) impaired deoxyribonucleic acid (DNA) synthesis (2) accelerated erythropoiesis yielding a
reticulocytosis which in the Wright-stained smear is manifested as polychromatophilic macrocytes; (3)
increased membrane cholesterol and lecithin, although this mechanism may not be reflective of a true
macrocytosis (obstructive liver disease)
Peripheral Blood Findings
 Macrocytes should be evaluated for shape (oval versus round), color red versus blue), presence or
absence of pallor, and the presence or absence of inclusions.
 Common clinical conditions include the megaloblastic anemias vitamin B 12 or folate deficiency and
myelodysplasia. Liver disease, postsplenectomy, or hyposplenic conditions. Chemotherapy drugs
interfere with folate metabolism or DNA synthesis.

Microcytes
Physiologic Mechanism
 It’s a small cell having a diameter of less than 7µm and an MCV of less than 80µm 3.
 Any defect that results in impaired hemoglobin synthesis causes a microcytic hypochromic blood
picture. When developing erythroid cells are deprived of any of the essentials in hemoglobin synthesis,
the result is increased cellular divisions and, consequently, a smaller cell in the peripheral blood.
 Microcytosis develops from:
(1) ineffective iron utilization, absorption, or release
(2) decreased or defective globin synthesis.
Peripheral Blood findings
 Only three clinical conditions produce a microcytosis: iron- deficiency anemia, thalassemia syndromes
and anemia of chronic disease.

COLOR VARIATIONS
Hypochromasia
Physiologic Mechanism
 Any RBC having a central area of pallor of greater the 3µm is said be hypochromic.

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 There is a direct relationship between the amount of hemoglobin produced in the RBC and the
appearance of the RBC when properly stained.
 Most assess hypochromia based on the mean cell hemoglobin concentration (MCHC) which measures
hemoglobin content in a given volume of cells (100ml).
 Not all hypochromic cells are microcytic.
Peripheral Blood Findings
 The most common and severe hypochromia is found in patients with iron deficiency anemia. Red cells
exhibit an inordinately thin band of hemoglobin.
 The sideroblastic anemia shows a dimorphic blood picture. Some hypochromic cells may be seen in lead
poisoning.
Polychromasia
Physiologic Mechanism
 RBCs are delivered to the peripheral circulation prematurely. Red cells showing polychromatophilia are
gray-blue and are usually larger than normal red cells. The basophilia of the RBC is the result of the
residual ribonucleic acid (RNA)

SHAPE VARIATIONS
Target Cells (Codocytes)
 Target cells appear in the peripheral blood as a result of increase in RBC surface membrane. Their true
circulation form is a bell-shaped cell. They appear as “targets” and are always hypochromic.
 The mechanisms related to excess membrane cholesterol and phospholipids and decreased cellular
hemoglobin well documented in patients with liver disease. Osmotic fragility is also decreased.
Peripheral Blood Findings
 Common clinical finding in any of the conditions in which hemoglobin synthesis is abnormal.

Spherocytes
Physiologic Mechanism
 Spherocytes have the lowest surface area-to-volume ratio.
 They are smaller in diameter than normal red cells, and their hemoglobin content is relatively
concentrated, because these cells have no visible central pallor.
 Their shape change is irreversible. There are several mechanisms for the production of spherocytes, each
sharing the mutual defect of loss of membrane. In the normal aging process of RBCs, spherotypes are
produced as a final stage before senescent RBCs are detained in the spleen and trapped by the
reticuloendothelial system (RES). Coating of the red cells with antibodies and effect of the complement
activation will produce spherocytes as the RBC membrane loses cholesterol and, consequently, surface
area owing to splenic sequestration.
 Spherocytes have 35 times the ability of normal cells to metabolize glucose; these cells can handle their
increased sodium content as they travel trough plasma, by producing enough energy to pump sodium
from the cell.
Peripheral Blood Findings
 Seen in immune hemolytic anemias, hemoglobinopathies, hereditary spherocytosis and in severe burns.

Ovalocytes/elliptocytes
Physiologic Mechanism
 It can appear normochromic or hypochromic, normocytic or macrocytic.
 Hemoglobin seems to have a bipolar arrangement in these cells, and they seem to have a reduction in
membrane cholesterol
 Ovalocytes are egg-shaped. Elliptocytes, on the other hand, are pencil-shaped and invariably not
hypochromic.
Peripheral Blood Findings
May be found in patients with megaloblastic anemias. May be seen in sickle-cell
anemia, myelodysplasia and thalassemia major.

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Stomatocytes
Physiologic Mechanism
 Normal –sized cell that, in wet preparation, appears bowl-shaped.slitlike area of central pallor.
 Mechanism in vivo is yet to be clarified. Stomatocytes are known to have an increased permeability to
sodium; consequently, their osmotic fragility is increased.
Peripheral Blood Findings
 Stomatocytes are more often artifactual than a true manifestation of a particular pathophysiologic process
found in a patient with hereditary spherocytosis.
Sickle Cells (Drepanocytes)
Physiologic Mechanism
 Sickle cells are red cells that have been transformed by hemoglobin polymerization into rigid, inflexible
cells with at least one pointed projection.
 Patients are homozygous or heterozygous for hemoglobin S.
Conditions of low oxygen tension (in vivo or in vitro) cause the abnormal hemoglobin to polymerize,
forming tubules that line up in bundles to deform the cell.
 Most sickle cells poses the ability to revert to the discocyte shape when oxygenated, but appropriately
10 percent of these cells are incapable of reverting to their
normal shape. They appear as crescent-shaped cells with long projections. In Wright-Geimsa stain are
oat cells or boat-shaped.
Peripheral Blood Findings
 Sicke cells are naturally seen in patients homozygous for hemoglobin S. and are rarely seen in the
heterozygous states. Several other hemoglobinopathies may exhibit sickling.

Acanthocytes
Physiologic Mechanism
 Cell of normal or slightly reduced size possessing 3 to 12 blunt-ended spicules of uneven lengths
distributed along the periphery of the cell membrane.
 Acanthocytes contain an excess of cholesterol and have an increased cholesterol-to-phospholipid ratio.
Their surface area is increased. Inherited condition in which numerous acanthocytes are seen in
congenital abetalipoproteinemia.
 The RBC responds to this excess cholesterol in one of two ways, depending on the balance of other
lipids in the membrane: it will become either a target cell or an acanthocyte.
Peripheral Blood Findings
 Seen in congenital abetalipoproteinemia . Severe liver disease hypothyroidism and vitamin E deficiency
splenectomized patients.

The Fragmented Cells (Burr Cells Helmet Cells, Schistocytes)

Physiologic Mechanism
 Fragmentation may be defined as loss from the cell of a piece of membrane which may or may not
contain hemoglobin. Not all membrane alterations occur pathologically. Certain triggering events in
disease invariably lead to fragmentation.
 Two mechanisms for fragmentation are recognized: first, alteration of normal fluid circulation occurs.
Second, intrinsic defects of the RBC make it less deformable and therefore more likely to be fragmented.
Peripheral Blood Findings
1. Burr cells (echinocytes) are red cells with approximately 10 – 30 spicules evenly placed over the
surface. May be observed as an artifact, but can also occur in small numbers in uremia, heart disease,
stomach cancer, bleeding peptic ulcer, immediately following an injection of heparin patients with
untreated hypothyroidism.
2. Helmet cells recognized by their distinctive projections –usually two surrounding an empty area of
the RBC membrane that looks as if it has been bitten off, (Heinz bodies) Fragmentation occurs by
the pitting mechanism of the spleen.
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 3. Schistocytes represent the extreme form of RBC fragmentation. Whole pieces of RBC membrane
seem to be missing and very bizarre RBCs are apparent. DIC, heart valve surgery, hemolytic uremic
syndrome, thrombotic thrombocytopenic purpura severe burns.

Teardrop Cells
Physiologic Mechanism
 Teardrop cells appear as pear-shaped red cells.
 As cells containing large inclusions attempt to pass through the microcirculation, the portion of the cells
containing the inclusion gets pinched, leaving a tailed end, as it continues its journey.

Peripheral Blood Finding

 Seen especially in myelofibrosis with myeloid metaplasia.

VARIATIONS IN RED CELL DISTRIBUTION

Agglutination
 Cold antibody syndromes such as cold hemagglutination disease and paroxysmal cold hemoglobinuria.
Warming the sample helps to break up the agglutination.
Rouleaux
 Rouleaux formation is the result of elevated globulins or fibrinogen in the plasma. Appearance of a stack
of coins.
 The use of a saline dilution of the plasma will disperse rouleaux.
 Rouleaux formation correlates well with a high erythrocyte sedimentation rate and occurs as a direct
result of protein disposition or adsorption to the erythrocyte membrane.
 Multiple myeloma, Walden-ströms macroglobulinemia, chronic inflammatory disorders and some
lymphomas.

RED CELL INCLUSIONS

Howell-Jolly Bodies
 Howell-Jolly bodies are nuclear remnants containing DNA. 1 to 2 µm in size and may appear singly or
doubly in an accentric position on the periphery of the cell membrane.
 Under ordinary circumstances the spleen effectively pits these nondeformable bodies from the cell may
be seen following splenectomy and in thalassemic syndromes, hemolytic anemias megaloblastic anemias
and functional hyposplenia.

Basophilic Stippling
 Red cells that contain ribosomes can potentially form stippled cells; it is believed that the preparation for
microscope examination. Coarse, diffuse or punctuate basophilic stippling may occur and consist of
ribonucleoprotein and mitochondia remnants.

Sideroblastic Granules/Pappenheimer Bodies

 Sideroblastic granules are small, irregular magenta inclusions seen along the periphery of RBCs. They
usually appear in clusters, as if they have been gently place upon the red membrane.
 Presence is evidence for the presence of iron. Prussian blue stain is the confirmatory test.
 Granules consist of non-heme iron caused by an excess of available iron throughout the body.
 They are known as “Pappenheimer bodies in a Wright-stained smear and “siderotic granules” in a
Prussian blue-stained smear.
 They are found in sideroblastic anemias, hemochromatosis, and hemosiderosis.

Heinz Bodies
 Heinz bodies are formed as result of denatured or precipitated hemoglobin.

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 They are large (0.2 to 2µm) inclusions that are rigid and severely distort the cell membrane seen in
thalassemia (G6PD) deficiency and any unstable hemoglobin syndromes.

Cabot’s Rings
 Appear in a “figure-eight” conformation like the beads of a necklace are rare but may be found in
megaloblastic anemias.

PLATELET MORPHOLOGY
General Comments
 Normal platelet is approximately 2 to 4 µm. In rare instances one may see megakaryocytic fragments in
the peripheral circulation.
 A thorough examination of platelet morphology will provide important information regarding the
patient’s hemostatic capability.
 Large platelets may occur in any disorder associated with increased platelet turnover as may occur with
idiopathic thrombocytopenic purpura (ITP) or bleeding disorders.

WHITE BLOOD CELL MORPHOLOGY

 WBCs (leukocytes) may exhibit several morphologic changes with neutrophils as the cell type primarily
affected.
 Severe infections, inflammatory conditions, or other leukemoid reactions may be accompanied by toxic
granulation, toxic vacuolization or the presence of Döhle bodies.
 Toxic granulation and Döhle bodies are generally considered nonspecific reactive changes, whereas
vacuolization strongly indicates a serious bacterial infection.
 Toxic granulation describes medium to large granules that are evenly scattered throughout the cytoplasm
of segmented polymorphonuclear neutrophil leukocytes (PMNs). Although nonspecific they may occur
in patients with severe bacterial infections, toxemia of pregnancy, or vasculitis or in patients receiving
chemotherapy.
 Toxic vacuolization refers to the round, clear unstained areas that are dispersed randomly throughout
the cytoplasm of neutrophils in patients with overwhelming infections.
 Döhle bodies are oval, blue, single or multiple inclusions originating in RNA, and are 1 to 3 µm in
diameter. Döhle bodies may be seen in peripheral patients with severe burns, in pregnant women, and in
patients receiving chemotoxic drugs.
 “Shift to the left” implies a release of younger granulocytes, specifically bands and metamyelocytes from
the marrow storage pool.
 Leukocytosis or neutrophilia is useful in discriminating among bacterial, viral or fungal conditions. A
shift to the left is seen in the peripheral blood. Fungal infections may also be associated with neutrophilia
and an increased WBC count, but a monocytosis is more commonly observed. Viral infections
lymphocytosis.
 Leukemoid reactions are characterized by a peripheral neutrophilia that may resemble an emerging
leukemia. WBC count is between 50,000and 100,000 cells/µl.
 However, a high blast count is not part of the WBC differential picture which can be helpful in
eliminating leukemia as part of the differential diagnosis.
 Acute infections chronic infections such as TB and chronic osteomyelitis as well as severe metabolic
inflammatory and neoplastic processes have all been associated with leukemoid reactions.
 Physiologic leukocytosis is defined as an increased WBC count without a shift to the left or any
associated morphologic changes previously described as granulocytes.
 This transient condition may be associated with such stimuli as exercise, intense emotional stress or the
administrative of epinephrine or glucocorticoids.