Abnormal Erythrocytes

Dr Jamil Mourad

Hypochromia
Corresponds to a very thin rim of Hgb and a larger center pale area.
These red cells are often microcytic and are seen in iron deficiency,

thalassemias
sideroblastic anemia

Microcytosis
<6 micrometers in diameter
These cells are usually hypochromic and have prominent central pallor. Differential diagnosis includes

iron deficiency anemia

anemia of chronic disease thalassemias sideroblastic anemia

Macrocytosis
>9 micrometers in diameter
Differential diagnosis includes liver disease alcoholism aplastic anemia myelodysplasia

Megaloblastic anemias (B12 and folate deficiencies) have macro-ovalocytes (large oval cells). Reticulocytes are large immature red cells with polychromatophilia.

Schistocytes
fragmented cells
Schistocytes are caused by mechanical disruption of cells in the microvasculature by fibrin strands or by mechanical prosthetic heart valves.

Differential diagnosis includes

TTP/HUS (Thrombotic Thrombocytopenic Purpura - Hemolytic Uremic Syndrome) DIC HELLP Syndrome ( H- hemolysis EL- elevated liver enzymes (liver function) LP- low platelets counts ) malignant hypertension

Acanthocytes
speculated cells with irregular projections of varying length
These are often seen with liver disease.

Crenated/Burr Cells
cells with short, evenly spaced cytoplasmic projections
Crenated cells may be an artifact of slide preparation or found in

renal failure
uremia

Heinz bodies:
inclusions seen only on staining with violet crystal
Heinz bodies represent denatured Hgb found in glucose-6-phosphate dehydrogenase after oxidative stress

Bite Cells
cells with a smooth semicircle extracted
Bite Cells are due to: spleen phagocytes that have removed Heinz bodies consisting of denatured Hgb. They are found in

hemolytic anemia due to glucose-6phosphate dehydrogenase deficiency.

Spherocytes
round, dense cells with an absent central pallor
Spherocytes are seen in immune hemolytic anemia hereditary spherocytosis.

Sickle Cells
sickle-shaped cells
Sickle cells are due to polymerization of Hgb S This occurs from the substitution of a valine for glutamic acid as the sixth amino acid of the beta globin chain,

which produces a hemoglobin tetramer (alpha2/beta S2) that is poorly soluble when deoxygenated.
They are found in sickle cell disease

Target Cells
cells with extra hemoglobin in the center surrounded by a rim of pallor; bulls eye appearance
Target cells are due to an increase in the ratio of cell membrane surface area to Hgb volume within the cell.

They have a central spot of Hgb surrounded by a ring of pallor from the redundancy in the cell membrane.
They are found in liver disease,

post splenectomy,
in hemoglobinopathies.

Teardrop cells/dacryocytes
teardrop-shaped cells
These are found in myelofibrosis myelophthisic states of bone marrow

Ovalocytes/ Elliptocytes/ Cigar cells

elliptical cells
Ovalocytes are due to abnormal membrane cytoskeleton found in hereditary elliptocytoisis.

Polychromatophilia
blue hue of cytoplasm
This is due to the presence of RNA and ribosomes in reticulocytes.

Howell-Jolly bodies
small, single, purple cytoplasmic inclusions
These represent nuclear remnant DNA and are found after Splenectomy with functional asplenism

Basophilic Stippling
Dark-purple inclusions, usually multiple
Basophilic stippling arises from precipitated RNA found in lead poisoning thalassemia

Nucleated red cells:

These are not normally found in the peripheral blood.
They appear in hypoxemia myelofibrosis

Other myelophthisic conditions

sever hemolysis

Parasites
A variety of parasites, including malaria, trepanozoma, and babesiosis, may be seen with red blood cells

Rouleaux
red cell aggregates resembling a stack of coins
Rouleaux is due to the loss of normal electrostatic charge-repelling red cells due to coating with abnormal paraprotein, Which is present in multiple myeloma.