CBC and

Peripheral Blood Smears

Morey A. Blinder, M.D.
Associate Professor of Medicine and Laboratory Medicine

Department of Internal Medicine

Divisions of Hematology and Laboratory Medicine

Objectives

Automated cell counting

Peripheral blood morphology

Coulter Principle

Red Cell Parameters

Red Cell Histogram and Count

Calculation of the RDW

RDW = Coefficient of variation of
red cell volume distribution
RDW =

S.D.
Mean

X 100

Normal range = 11.5% - 14.5%

Red Cell Distribution Width - RDW

Comparison of RDW in Iron Deficiency and

Anemia of Chronic Disease

CBC Report

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Automated Cell Counting: Deficiencies

Abnormalities and inclusions in WBC

RBC shape abnormalities

RBC inclusions

Platelet abnormalities and clumping

Peripheral Blood Morphology

Normal Peripheral Smear

Normal Peripheral Smear

More information can be gained from

examining the blood smear than
from any single hematologic procedure

Reticulocyte: Polychromasia

Reticulocyte Manual Count by Supravital

Stain: Normal Count

Reticulocytes: Elevated Count

Erythrocyte Inclusions with Wrights Stain

Inclusion

Composition

Appearance

Basophilic
stippling

Precipitated
ribosomes

Evenly dispersed
Lead poisoning
fine or coarse granules thalassemia
other anemias

Howell-Jolly
bodies

Nuclear
fragment

Dense, round
blue granule

Post-splenectomy

Pappenheimer Iron-containing
bodies
granules

Small blue granules

in clusters

Anemias

Organism

Small blue inclusion

Malaria
Babesiosis

Condition

Basophilic Stippling

Howell-Jolly Body

Malaria

RBC Inclusions: Composite

Erythrocyte Distribution Abnormalities

Rouleaux formation

Stacking of RBCs due to

increased plasma proteins
coating RBCs

Agglutination

Antibody-mediated
clumping;
temperature dependent

Rouleaux Formation

Agglutination Reaction

Variations in RBC Size and Shape

Anisocytosis

Variations in size (e.g. microcytes)

Poikilocytosis

Variations in shape (e.g. target

cells)

Hypochromia

Increased central pallor due to

decrease in hemoglobin

Hypochromic Microcytic RBC

Normal

Hypochromic microcytic

Hypochromia without Anisocytosis:

Thalassemia Trait

Severe Hypochromia: Iron Deficiency

Anemia

Mixed Population: Treated Iron

Deficiency Anemia

Microcytic Hypochromia: Alpha

Thalassemia (-/--)

Microcytic Hypochromia: Beta

Thalassemia Major

Microcytic Hypochromia: Beta

Thalassemia Major

Macrocytic Anemia: Macro-Ovalocytes

Shape Abnormalities of Erythrocytes

Terminology

Description

Condition

Target cells

Central hemoglobin; target-shaped

Liver disease; thalassemia:

Abnormal Hgb; iron deficiency

Echinocyte

Short spicules, equally-spaced

Uremia, hypokalemia, artifact

Acanthocyte

Spiculated, irregular

Liver disease (alcohol),

Post-splenectomy

Spherocyte

Spherical, no central pallor

HS, Immune hemolytic anemia

Schistocyte

Fragmented RBC, helmet cells

MAHA, burns

Ovalocyte

Oval/elliptical shaped

Hereditary elliptocytosis,
Megaloblastic anemia

Sickle cell

bipolar spiculated shape

banana shaped

Hgb S-containing
hemoglobinopathy

Teardrop cell

single elongated extremity

Myelophthistic changes

Bite cells

Irregular gap in membrane

G6PD deficiency

Target Cells

Diagnostic possibilities

Liver disease
Hemoglobinopathy
Thalassemia
Iron deficiency
Post-splenectomy
Lipid disorders

Echinocytes (Burr Cells)

Acanthocytes (Spur Cells)

Morphologic Changes in Liver Disease

Target Cells

Spur Cells

Hepatorenal Syndrome: Burr + Spur Cells

Spherocytes

Spherocytes: Autoimmune Hemolytic Anemia

Spherocytes: Hereditary Spherocytosis

Schistocytes: Microangiopathic Hemolytic Anemia

Elliptocytes: Hereditary Elliptocytosis

Sickle Cell Anemia: Hgb SS

Hemoglobin SC Disease

Hemoglobin S-Beta Thalassemia

Homozygous Hemoglobin C Disease

(Hgb CC)

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Teardrop Cells

Bite Cells

Heinz Bodies

Morphology of Leukocytes

Normal WBC populations

Neutrophils (Granulocytes)
Lymphocytes
Monocytes
Eosinophils
Basophils

Neutrophil

Eosinophil

Neutrophil

Eosinophil

Monocytes

Monocytes

Small Lymphocyte

Lymphocytes
Large

Small

Intermediate

Basophils

Granulocyte Inclusions or Variants

Terminology

Description

Condition

Dohle bodies

Pale blue areas in

neutrophil cytoplasm

Infections, pregnancy, cancer

Toxic
Granulation

Large purple granules

in neutrophil cytoplasm

Infection

Vacuoles

Transparent areas
in neutrophil cytoplasm

Infection, Toxin

Hypersegmented

6 nuclear lobes

Megaloblastic anemia

Auer rods

Reddish long needle-like

inclusions

Acute myeloid leukemia

Ehrlichia

Blue inclusions in
monocytes/neutrophils

Ehrlichia sp.

Dohle Bodies

Toxic Granulation

Toxic Granulation and Vacuole Formation

Hypersegmented Neutrophils

Auer Rod: Acute Myeloid Leukemia

Ehrlichia

Myeloid Leukemias and Leukemoid

Reaction

Bone marrow exam is almost always indicated

Cytogenetic analysis
Flow cytometry analysis

Neutrophilia: Leukemoid Reaction

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Neutrophilia: CML

Pelger-Huet Abnormality

Acute Myeloid Leukemia: M1

Myeloblasts without Differentiation

Acute Myeloid Leukemia: M2

Myeloblasts with Some Differentiation

Acute Myeloid Leukemia: M3

Promyelocytic Leukemia

Acute Myeloid Leukemia: M4

Myelomonocytic Leukemia

Acute Myeloid Leukemia: M5 Monocytic

Leukemia

Acute Myeloid Leukemia: M6

Erythroleukemia

Acute Myeloid Leukemia: M7

Megakaryocytic Leukemia

Abnormalities of Lymphocytes
Variant

Morphologic categories

Atypical lymphs

Abundant cytoplasm, RBC skirting

Abnormal lymphs

Nuclear abnormalities i.e. clefts, folds,

notches

Plasmacytoid lymphs

Abundant cytoplasm

Hairy cells

Cytoplasmic projections

Sezary cells

Deeply folded nucleus

Prolymphocyte

Large lymph with prominent nucleolus

Atypical (Reactive) Lymphocytes

Atypical (Reactive) Lymphocytes

Abnormal Lymphocytes

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Plasmacytoid Lymphocytes

Plasma Cell: Plasma Cell Leukemia

Hairy Cell: Hairy Cell Leukemia

Sezary Cell

Prolymphocytes

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Chronic Lymphocytic Leukemia (CLL)

CLL: Smudge Cells

CLL: Balloon Cells

Acute Lymphocytic Leukemia: L1

Acute Lymphocytic Leukemia: L2

Acute Lymphocytic Leukemia: L3 (Burkitts)