1. ERYTHROPOIESIS Normal and abnormal Barrett W. Dick, M.D.
Director, Hematology Laboratories
Memorial Medical Center
Springfield. IL
Clinical Professor, Pathology and Medicine
Southern Illinois School of Medicine

2. RBC development Increasing cytoplasmic hemoglobin
Decreasing cytoplasmic RNA

3. POLYCHROMATOPHILIA VS. NORMAL
IMMATURE
MATURE
Immature red cells are bigger, bluer and have less central pallor than mature rbc.
NOTE: On the left is a diagrammatic representation of a young red cell, usually described as “polychromatophilic”. Note that it is larger and bluer than a mature red cell on the right. This is due to its RNA content.

4. Reticulocytes vs. Polychromasia

5. Reticulocytes vs. Polychromasia
Reticulocytes require special techniques for measurement
The two terms are not equivalent but frequently, but incorrectly, used as equivalent
Estimating polychromasia from a stained blood smear is not a substitute for performing a reticulocyte count. The correlation is poor.

6. Increased Polychromasia
Polychromatophilic Rbc

7. Blood Smear Examination
Too thick
Too thin
Area behind “feather edge”-
Just right.

8. Smear Examination
Thin Area
Feather Edge

9. Low Power Examination Of Blood Smear
Performed at 10X magnification
Evaluate quality of smear- appropriate thin area
Check for increased rouleaux formation
Scan for white cell distribution- even
With practice can estimate the white count and differential: at very least make sure they correlate with machine count and/or manual diff

10. Thin Area of Smear
10X mag

11. Ideal Area of Blood Smear
Red cells close, evenly spaced without significant overlapping
50X Oil

12. Increased Rouleaux Formation
Some degree of rouleaux formation is normal; this is increased

13. High Power Examination
Scan performed at no lower than 40X coverslipped smear or 50X oil
Estimate the differential and look for qualitative Wbc abnormalities
Rbc morphology
Platelet estimate
Perform a differential at 100X if specimen has been flagged as being abnormal- 200 cells.

14. Normal Rbc

15. Rbc variation Anisocytosis- Variation in size
Poikilocytosis- Variation in shape
Slight variation of size and shape is normal. When abnormalities are reported, what it should mean is that more than normal variation is present.

16. Normal Size Distribution
RBC 50
100
200
NOTE: This illustrates a normal red cell distribution with the horizontal scale representing cubic micra. The RDW is by convention a mathematical expression of the width of the curve near the base.

17. Red Cell Size
Red cell size can only be measured accurately using electronic instrumentation to measure the volume (MCV).
On blood smear examination, the size estimate is based on diameter, which is not very accurate and does not correlate well with the MCV
Small lymphocyte nuclei are a rough guide to normal Rbc diameter

18. Microcytic Rbc
7.5 mu
Avr.diameter of normal Rbc= 7.5 mu

19. Microcytic, Hypochromic Rbc

20. Microcytic Hypochromic Rbc
Hypochromia is the most frequently overcalled abnormality on blood smears, usually due to technical factors
When real, usually due to advanced iron deficiency
Men: Hgb<10g/dl
Women: Hgb<8g/dl
Rarely in our population- thalassemia major

21. Macrocytic Rbc
This smear also illustrates increased variation in size (anisocytosis) and increased variation in shape (poikilocytosis).

22. Abnormal red cell shapes- poikilocytosis

23. Elliptocytes (ovalocytes)
Elliptocytes are a common non-specific abnormality. Hereditary elliptocytosis is also relatively common and is usually not hemolytic. The hereditary form is more common in peoples of African origin

24. Burr Cells, Acanthocytes, Crenated Cells
Crenated Rbc
Terms that are frequently, but incorrectly, used interchangeably. When strictly defined the terms can have specific clinical correlations.

25. Burr Cells
Burr cells have rounded, blunt projections at the edges and have central pallor

26. Burr Cells
Uremia
Liver disease
Metabolic imbalance

27. Acanthocytes
Acanthocytes look like spherocytes with irregularly spaced, thin, spiny projections

28. Acanthocyte

29. Differential Dx for Acanthocytes
Liver Disease
Post-Splenectomy
aBeta lipoproteinemia

30. Crenated Red Cells
Crenated red cells have the appearance of sea urchin eggs: short, evenly-spaced, broad-based spikes projecting in three dimensions. They are seen in some severely ill patients with marked electrolyte abnormalities. In a reference laboratory setting, they are a frequent manifestation of a poorly preserved specimen..

31. Post-Splenectomy Howell-Jolly Bodies Acanthocytes Target Cells
Lymphocytosis

32. Post-Splenectomy
Howell-Jolly Body

33. Target Cells

34. Liver disease and/or hyperbilirubinemia Post-splenectomy
Target Cells
Liver disease and/or hyperbilirubinemia
Post-splenectomy
Hemoglobinopathies
Hemoglobin C syndromes:
AC, SC, C-thal
NOT thalassemia minor, <1% of cases

35. Spherocytes
The cells are small in diameter but not in volume. Because of their spherical shape they do not flatten on the slide.

36. Differential Dx- Spherocytes
Hereditary Spherocytosis
Autoimmune hemolysis
Alloimmune hemolysis-
Newborns with ABO incompatibility
Delayed transfusion reactions
Thermal injury- burn patients
Occasionally- non-specific with transfused red cells

37. Osmotic Fragility Test

38. Microspherocytes secondary to severe thermal injury

39. Tear Drop Cells
Common in disorders associated with marrow infiltration and splenomegaly

40. Coarse Basophilic Stippling
Coarse stippling is usually associated with some form of dyserythropoeisis.

41. Schistocytes- Rbc fragments, so-called “Microangiopathic Hemolytic Anemias”
TTP /HUS
Vasculitis
Partially thrombosed vessels including heart chambers
Sever cardiac valve abnormalities or malfunctioning prosthesis
DIC- rarely; most often associated with chronic DIC

42. Schistocytes

43. Schistocytes- Rbc fragments

44. Pocked (Pitted”) Red Cells
These cells look like spherocytes with bites in the edges, aka, “bite” cells. This is due to removal of denatured hemoglobin by the pitting function of the spleen

45. Heinz Body Hemolytic Anemias
Heinz Bodies are denatured hemoglobin usually due an oxidant. They are removed by the spleen causing deformed rbc- “pitted” rbc, aka “pocked” or “bite” cells
Hereditary
G6PD deficiency: hemolysis is usually drug induced or can be induced non-specifically by stress, such as infection
Unstable hemoglobins
Acquired: oxidant drug-induced without a hgb or enyzmatic abnormality

46. Common Hemoglobinopathies with Peripheral Blood Abnormalities
Thalassemia minor- microcytosis with mild or no anemia; worldwide in distribution
Hemoglobin AC- Target cells, sometimes spherocytes (few); from West Africa
Hemoglobin AE or EE- Microcytosis and target cells with minimal or no anemia: from SE Asia
Hemoglobin SS- Sickle cells with variable anemia
Hemoglobin SC- Target cells, spherocytes, sometimes sickle cells depending on the severity; may be asymptomatic

47. Thalassemia minor
Mild or no anemia with microcytosis. The prevalence of target cells in this disorder is markedly overstated in texts and in the literature

48. Sickle Cell Anemia

49. S-C Disease
SC crystals have a characteristic appearance with blunted, rhomboidal ends

50. Screening for Hemoglobinopathies
Thal minor CANNOT be diagnosed by Hgb electrophoresis in the overwhelming majority of patients; it is a diagnosis of exclusion: R/O iron deficiency
Hemoglobin electrophoresis is the procedure of choice for testing for other hemoglobin abnormalities; quick tests are not recommended

51. Hemoglobin electrophoresis
Screening for Hemoglobinopathies
Hemoglobin electrophoresis
A F S A2
D C
G E

52. Malaria

53. Malaria

54. Malaria

55. Platelet overlying a red cell
These are frequently mistaken for malaria parasites