Haematology basics

By Dr.R.GAJANTHAN.
RBC maturation
Erythroblast/pronormoblast[E1]
Normoblst[E2]-basophilic
Normoblast[E3]-basophilic
Normoblast[E4]-polychromatophilic
Normoblast[E5]-orthochromatophilic
polychromasia/reticulocyte
Mature RBC
WBC maturation
myeloblast
• Peripheral blood smear showing two normal
human myeloblasts.
• The size is medium (15 to 20 microns in
diameter), the nucleus is large and round with
finely granular chromatin, nucleoli are
present, granules are absent, and cytoplasm
is scanty.
promyelocyte
• Peripheral blood smear showing a normal human
promyelocyte.
• Promyelocytes are larger than myeloblasts and
myelocytes (>20 micron).
• The nucleus and nuclear chromatin and nucleoli
resemble myeloblasts but the cardinal feature is
the presence of many violet granules in the
cytoplasm with either a dense or coarse pattern
often obscuring other cell landmarks.
myelocyte
• Peripheral blood smear shows a normal
human myelocyte.
• As the myelocyte divides and matures, the
nucleus becomes smaller and irregularly
round, nuclear chromatin becomes coarse and
clumped, and nucleoli are sparse to absent.
• The nuclear to cytoplasmic ratio is reduced
compared to promyelocytes. Specific granules
are difficult to see on light microscopy.
metamyelocyte
• Peripheral blood smear shows a normal
human metamyelocyte.
• The cytoplasm resembles the mature
neutrophil and band forms; granules are
small, fine blue-black or grey, and dispersed
homogeneously throughout the cytoplasm.
• The nucleus is indented like a bean and the
nuclear chromatin is coarse, clumped, and
condensed peripherally.
Band form
• Peripheral blood smear shows a normal human
band form.
• The nucleus is nonsegmented and elongated
resembling a horseshoe shape; there are no
nuclear lobulations but a constriction is visible.
• The nuclear chromatin is aggregated into evenly
arranged clumps. The cytoplasm is like the
mature neutrophil with pink staining and fine
azure bluish granules.
Segmented form
Eosinophil
Basophil
Monocyte
PLT maturation
megakaryocyte
platelets
Lymphoid lineage
lymphoblast
lymphocyte
Plasma cell
Atypical lymphocyte
Haematological malignancies
 MULTIPLE MYELOMA
Plasma cell-Typical eccentric nucleus&basophilic
cytoplasm
Roulaeux formation
Ix-serum protein electrophoresis
-urine for Bence Jones protein
-skeletal survey
Type 2 RTA & type 1 CG
Complications-CRF;infection;anemia;vertebral #
Tx-CTD[ CPA, thalidomide & dexa] followed by
melphalan autograft.
 CML
• all stages of granulopoietic cells in blood film
Myeloblast
promyelocyte
metamyelocyte
band/segmented neutrophils
basophilia
• Mainly neutrophils & myelocytes
• Eosinophilia & basophilia may be seen
 3 phases of CML
1.chronic[<5% of blast]
2.accelerated[5-9%]
3.blast[>10%]
Ix-FBC;BP;BM aspirate;FISH[fluorescein-in-situ-
hybridization]
Confirmation by demonstrating philadelphia
chromosome[ so, no need for BM biopsy]
Tx-Imatinib is the first line treatment for the
chronic phase.
 Philadelphia chromosome
• Myeloid cells of CML are also characterized by
the Philadelphia chromosome (Ph1) on
karyotyping.
• This is a translocation of a portion of the q
arm of chromosome 22 to the q arm of
chromosome 9, designated t(9:22).
• Philadelphia chromosome is the smallest
chromosome.
 CLL
• Increase number of lymphocytes
• Characteristic smudge cells/smear cells[in CLL
lymphocytes are very readily damaged in the
preparation of smears]
• may be associated with haemolytic anaemia
polychromasia
redcell spherocytosis
strongly positive coomb’s test
• Immunophenotyping-CD19+; CD5+; CD23+
• B cell origin
• Monoclonal origin
• Tx-Chlorambucil
 AML
• mature forms less in amount
• AUER rods+
• promyelocytes with azurophilc grunules+
• Tx-daunorubicin[anthracycline]
cytarabine
 Acute Promyelocytic Leukemia
• Note the multiple Auer rods
 ALL
• high nuclear cytoplasmic ratio
• Rounded /cleft nuclei.
• Tx-vincristine, glucocorticoid , anthracycline,
asparaginase
• Need central nervous system directed therapy
also.
 hairy cell leukemia
Panel A: normal view of five hairy cells. The
cells have abundant, irregularly distributed
cytoplasm. The nuclei vary from round to oval
to slightly lobulated.
Panel B: same view but with the contrast
adjusted to show the irregular cytoplasmic
outlines, giving the cells their "hairy"
appearance (arrows).
 Hairy cells
• CD markers 22, 25 and 103
• Tx- cladribine
 Atypical lymphocytes
• Large cells[in contrast to blast cells,they have
abundant cytoplasm]
• Edges are often indented by adjacent redcells.
[peripheral scalloping]
• Causes-IMN
CMV infection
Toxoplasmosis
AIDS
Ix-Paul-Bunnell reaction[monospot test]
 Sézary cells
• Sézary syndrome is a rare, aggressive,
cutaneous T-cell lymphoma
• characterised by widespread erythroderma,
atypical peripheral lymphocytes (Sézary cells)
and lymphadenopathy.
Other haematological disorders
 Acanthocytosis/spur cells
• Causes
 Inhereted A/neuro A
1.Abetalipoproteinaemia
2.chorea-acanthocytosis syndrome
 Acquired A
1.Severe liver disease
2.Anorexia nervosa
3.Hypothyroidism
4.MDS
 Echinocyte / Burr cells
• Echinocytes are often confused with
acanthocytes.
• However, the projections of the red cell
membrane in echinocytes are smaller and
much more regular in shape and distribution
than in acanthocytes.
 Echinocytes DD
• Drugs-frusemide;doxarubicin
• Dehydration
• Uraemia
• PK deficiency
 Sickle cell anemia
• In the blood film – sickle cell
target cell
polychromasia
Howel jolly bodies.
• Glutamic acid is replaced by valine at 6th
codon of the β-chain.
• Diagnosis-Hb electrophoresis; HPLC; [Blood
picture]
 Sickle cell anaemia
• Target cell DD
1.s-sickle cell disease
2.l-Liver disease
3.i-IDA
4.t-Thalassaemia
 Howell-jolly body
• Howell-jolly body[nucleated RBC] DD
1.Post spenectomy
2.Sickle cell D[hyposplenism]
3.Other causes for hyposplenism[coeliac D; SLE;
leukaemia;amyloid]
 G6PD deficiency
• Bite cell
• Heinz body
• DD for heinz body[G6PD;post spenectomy;
CLCD; thalassaemia]
 G6PD deficiency
• Blister cell
 G6PD deficiency
• Ghost cells
• Summary-bite cells
blister cells
ghost cells
heinz body
 Basophilic stippling
• Occurs in lead poisoning
 represents causes

(A) basophilic stippling aggregated ribosomes thalassemia syndromes, iron

deficiency and lead
poisoning

(B) Howell-Jolly bodies nuclear remnants asplenia, pernicious anemia

and severe iron deficiency

(C) Cabot's ring bodies nuclear remnants lead toxicity, pernicious

anemia and hemolytic
anemias

(D) Heinz's bodies. denatured aggregated G6PD,thalassemia, asplenia

hemoglobin and chronic liver disease.
 Iron deficiency anaemia[IDA]
• Hypochromia
• Poikilocytes[variable shapes]
• Anisocytes[variable sizes]
• Pencil cell
• Hypochromic-more than 1/3 of the central
part of the RBC is pale
• Microcystic-smaller than mature lymphocytes
 Megaloblastic anaemia
• Hypersegmented nuclei of WBC[six or more
lobes]
 Macrocytic anaemia
• In B12 deficiency –oval shaped macrocytes &
hypersegmented neutrophil
• Ix-serum B12& folate level;Schilling test
• Tx-IOOOμg vit B12 IM injection
Pt on regular blood transfusion
 Thalassaemia
• Tests to confirm
1.Serum Hb electrophorosis
2.HPLC[high performance liquid
chromatography]
Microangiopathic haemolytic anaemia[MAHA]

• Fragmented RBC
• Causes for MAHA[TTP;DIC;HUS;HELLP]
• Mainstay of treatment for TTP-plasma
exchange
• Peripheral smears from two patients with
microangiopathic hemolytic anemia, showing
a number of red cell fragments (i.e.,
schistocytes), some of which take the form of
combat (red arrow), bicycle (thick black
arrow), or football (blue arrow) "helmets.
• Microspherocytes are also seen (thin black
arrows), along with a nucleated red cell (green
arrow).
• Peripheral blood smear from a patient with
the "Waring blender" syndrome due to
defective prosthetic heart valve.
• The smear shows marked red cell
fragmentation with multiple sharp edges and
small fragmented cells.
• Peripheral blood smear taken from a patient
with increased reticulocytes.
• Unlike mature red cells (thin black arrows),
which have central pallor and are the same
size as the nucleus of a small lymphocyte
(thick arrow), reticulocytes (blue arrows) are
larger, have a blue tint, and lack central pallor
because they are not biconcave discs.
(Wright-Giemsa stain).
 Spherocytes
• Absence of central pallor[RBC are no more in disc
shape]
• Osmotic fragility is increased .
• DD
1.Hereditary sperocytosis
2.AIHA
• To differentiate 1 &2 do DAT[direct agglutination
test]
note: cryo haemolysis specific for HS
 ELIPTOCYTOSIS
• 2 problems
1. Low grade haemolysis
2. cholelithiasis
Ppppppppppppp
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 Myelofibrosis
• Tear drop cell[DD-MF;thalassaemia]
• Also look for leucoerythroblastic picture &
giant degranulated plt
 Sideroblastic anaemia
• Refractory anaemia
• Causes for aquired SA
1.MD
2.Lead poisoning
3.Isoniazid
4.Alcohol
• Tx- withdraw the culprit drug/alcohol
Occasionally respond to pyridoxine
FA to treat accompanying folate def
 Sideroblastic anaemia
• Inherited SBA-↓MCV[mainly X linked]
• Acquired SBA-↑MCV
 SBA vs basophilic stippling
SBA basophilic stippling
 Leucoerythroblastic picture
• Both normoblasts & myelocytes are present
 Causes for LE picture
1. MF
2. MM
3. Metastatic Ca
4. Miliary TB
5. Marble bone disease/osteopetrosis
6. Metabolic disease[ Gaucher’s D]
7. Massive haemolysis
8. Megaloblastic anaemia [severe]
 Essential thrombocytosis
• Increased number of plt
• Giant plt
• Peripheral plt clumping may be seen
 Causes for thrombocytosis
• MPD-ET/PRV
• Inflammatory-RA/IBD
• Splenectomy
• Chronic infection-TB
• Tissue damage-MI/trauma
• IDA/tx for B12 def
 Giant platelets
• Inherited diseases
 Bernard-Soulier syndrome
gray platelet syndrome
May-Hegglin anomaly

• Acquired disease
ITP
 May–Hegglin anomaly(MHA)
• Also known as Dohle leukocyte inclusions
with giant platelets and
macrothrombocytopenia with leukocyte
inclusions
• is a rare genetic disorder of the
blood platelets that causes them to be
abnormally large.
 Rouleaux formation
• Conditions which cause rouleaux formation include
infections, multiple myeloma, inflammatory and
connective tissue disorders, and cancers. It also occurs
in diabetes mellitus and is one of the causative factors
for microvascular occlusion in diabetic retinopathy.
• Acute phase proteins, particularly fibrinogen, interact
with sialic acid on the surface of RBCs to facilitate the
formation of rouleaux. An increase in the ratio of RBCs
to plasma volume, as seen in the setting of anaemia
and hypovolemia, increases rouleaux formation and
accelerates sedimentation. Rouleaux formation is
retarded by albumin proteins.
 RBC AGGLUTINATION
• Red blood cell agglutination indicates clumping of RBC’s
due to cold agglutinins which are most commonly IgM
antibodies.
• These antibodies cross-link red cells, which causes
overlapping (arrow) and loss of central pallor.
• The agglutination leads to reduction in red cell count,
elevation in MCH and MCV as measured by automated
instruments.
• Only a handful of conditions are known to cause
production of agglutinins including typically Myoplasma
infection (and a few other infections-IMN,CMV), B-cell
lymphoproliferative disorders, and plasma cell dyscrasias.
I
 LE cell
• The pink blobs are denatured nuclei. Here are
two, with one seen being phagocytozed in the
center by a PMN.
• This test is not nearly as sensitive as the ANA
which has supplanted the LE cell test.
Therefore, NEVER order an LE cell test.
• Occurs in
SLE
Active chronic hepatitis
 Dimorphic blood picture
• Causes
1.Mixed deficiency anaemia[B12+Fe]
2.Partially treated iron deficiency
3.Sideroblastic anaemia
4.Post transfusion
 Stomatocytes[mouth like pale area]
• hereditary stomatocytosis
• lead poisoning
• thalassemia trait.
leucopenia
• 2-3x larger than a mature RBC
• Low nuclear to cytoplasmic ratio (more cytoplasm
than nucleus)
• Nucleus is mature with 2 lobes connected by thin
chromatin filament
• Nucleoli are absent
• In some cases, hypergranulation, hypogranulation or
abnormal granules can be seen
• Pseudo Pelger-Huet neutrophils are a form of
dysplastic neutrophils
Associated with:
• Myelodysplastic Syndrome (MDS)
• Pelger Huet Anamoly (if they are true pelger
huet cells)
Large granular lymphocytic leukemia
• Large Granular Lymphocyte in Large granular
lymphocytic leukemia[ LGL]
 Chediak-Higashi syndrome
• Peripheral blood smear from a patient with
Chediak-Higashi syndrome shows giant granules
in the cytoplasm of both a neutrophil and a band
form.
• These granules are formed by the inappropriate
fusion of lysosomes and endosomes.
• AR
• Occulocutaneous albinism
• Pyogenic infection
 Note
• Large granules in the lymphocytes
-LGL
• Large granules in the neutrophil
-CHS
Main 3 toxic changes in Neutrophil
• Left panel: Peripheral blood smear shows
neutrophils with toxic granulations, which are
dark coarse granules. A Döhle body is also
seen (arrow). Right panel: A neutrophil with
toxic granulations, vacuoles (another toxic
change), and a Döhle body (arrow). These
abnormalities are characteristic of toxic
systemic illnesses.
• Azurophilic cytoplasmic inclusions (Alder-
Reilly granules) in neutrophil of a patient with
mucopolysaccharidosis.
Left
• The peripheral blood smear on the left is from a five-month-old boy
with eosinophilia of unknown cause.
• Eosinophil granules are normal in number and size; nuclei are
slightly hyperlobulated (ie, more than the usual two lobes).
• Eosinophilia gradually regressed, with no residual organ dysfuction.
Right
• The peripheral blood smear on the right is from a 50-year-old male
with hypereosinophilic syndrome and a three year history of
eosinophilia, bone marrow failure and multiple end-organ
involvement.
• The eosinophils show marked hypogranulation.
• Peripheral smear from a patient with
homozygous hemoglobin C disease, showing
the presence of hemoglobin crystals (blue
arrows) within erythrocytes.
• This phenomenon is most commonly seen
when a wet preparation of red cells is allowed
to partially dehydrate. Target cells (black
arrow) are also present.
 Anaplasmosis
• A 51-year-old man with no significant past medical history
presented with a five-day history of fever, malaise, and
diffuse myalgias with no recollection of a tick bite.
• He was found to have thrombocytopenia, elevated
transaminase levels, and renal insufficiency. Examination of
the peripheral smear suggested the diagnosis of
anaplasmosis.
• He was started on a course of doxycycline with eventual
complete resolution of symptoms.
• The peripheral smear (1000x, "feather edge") shows
morulae of anaplasmosis in the patient's granulocytes.
• Photomicrographs B and C were taken from the extreme
feather edge, and show exploded neutrophils containing
well-delineated morulae.
BONE MARROW
• big arrow-bone trabeculae
• arrowhead -fat cells
• long thin arrow -hematopoietic elements
• The ratio of hematopoietic elements versus fat cells
depends on the age and activity of bone marrow in
response to various physiologic stimuli.
• Marrow cellularity is roughly inversely proportion to the
age.
• Thus, newborns have almost 100% cellular bone marrow
whereas older individuals in their eighth or ninth decades
have 20-30% cellularity.
• This marrow is from an 54-year-old individual.
A rough guide to cellularity by age
0-3 months: 100%
3 months – 10 years: 80%
20 years: 65%
30 years: 50%
40 years: 45%
50 years: 40%
60 years: 35%
70 years and over: about 30%
 Aplastic anaemia
• Markedly hypocellular marrow, due to
replacement of hemopoietic marrow by
adipous tissue (not fibrosis or neoplastic cells).
 Myelofibrosis
• the bone marrow becomes fibrotic
• normal hematopoiesis can no longer occur
• extramedullary hematopoiesis (myeloid
metaplasia) occurs in the liver and spleen.
 Follicular lymphoma
• Reactive lymphocytes alongside the
trabeculae
• Normal trilineage maturation
 Megaloblast
• The megaloblast is an abnormal immature red cell precursor and is
the equivalent of the normoblast in normal red cell production.
• (The general term 'erythroblast' covers both normoblasts and
megaloblasts).
• The megaloblast is characterized by (a) its larger size and (b) the
fine reticular nuclear structure in comparison with the nuclear
structure of a normoblast at the same stage of cytoplamic
haemoglobinization.
• Normoblast nuclei have a very coarse reticular structure .
• This type of abnormal erythropoiesis is usually caused by a
deficiency of vitamin B12 or folic acid.
• Purple arrow - haemoglobinization just starting
• Red arrow - haemoglobinization almost complete but nucleus is
still finely reticular, instead of being darkly staining and amorphous;
this is also referred to as nucleocytoplasmic dissociation.
 Hemophagocytic
lymphohistiocytosis (HLH)
• also known as haemophagocytic
lymphohistiocytosis ,and hemophagocytic or
haemophagocytic syndrome
• is an uncommon hematologic disorder
• showing red blood cells within macrophages.
Patient with anaemia
• The marrow aspirate shows very much
diminished erythropoeisis, and the giant
proerythroblast characteristic of parvovirus
infection.
 Gaucher's disease
• Gaucher's disease is called a "lipid storage
disease" where abnormal amounts of lipids
called "glycosphingolipids" are stored in
special cells called reticuloendothelial cells.
• Classically, the nucleus is pushed off to the
side and the remainder of the cell is filled with
abnormal lipids.
• Bone marrow aspirate showing a number of
large macrophages laden with cerebrosides
(Gaucher cells, arrows) in a patient with
Gaucher disease and concomitant multiple
myeloma.
• The cytoplasm has a pattern which has been
likened to wrinkled silk or crumpled
newspaper.
LYMPHNODES
 Benign reactive lymphnode
• Normal architecture is maintained
 Follicular lymphoma
• No capsule
 Hodgkin lymphoma
• Reed-sternberg cell[LN biopsy]
• B-cell origin
• Always from LN
• LNE-axial;contiguous spread;alcohol induced
pain.
• B sym-wt loss>10%;fever;night sweat
• Curable in majority
Thank you
Good luck