2. Peripheral Blood Smears Department of Internal Medicine Divisions of Hematology and Laboratory Medicine

3. Complete Blood Count Automated cell counting Peripheral blood morphology

4. Automated Cell Counting: Deficiencies Abnormalities and inclusions in WBC RBC shape abnormalities RBC inclusions Platelet abnormalities and clumping

5. Peripheral Blood Morphology

6. Peripheral Smears Barnes-Jewish Hospital Daily total Total CBCs900-1100 Peripheral smears* Laboratory initiated100-200 Physician-initiated ~20 * Smears are saved for 30 days

7. Normal Peripheral Smear

8. “More information can be gained from examining the blood smear than from any single hematologic procedure”

9. Clinical Indications for Examination of a Blood Smear Anemia, unexplained jaundice or both Features of thrombocytopenia or neutropenia Features suggestive of possible lymphoproliferative disorder Feature suggestive of a myeloproliferative disorder Suspicion of DIC Acute or recent onset renal failure Suspicion of a bacterial or parasitic disease that can be diagnosed on a smear Features of a non-hematopoietic cancer (weight loss, bone pain) General ill health (malaise, fever)

10. Reticulocyte: Polychromasia

11. Reticulocyte Manual Count by Supravital Stain: Normal Count

12. Reticulocytes: Elevated Count

13. Erythrocyte Inclusions with Wright’s Stain InclusionCompositionAppearance Condition Basophilic PrecipitatedEvenly dispersedLead poisoning stipplingribosomesfine or coarse granulesthalassemia other anemias Howell-Jolly Nuclear Dense, round Post-splenectomy bodiesfragmentblue granule PappenheimerIron-containingSmall blue granulesAnemias bodiesgranulesin clusters OrganismSmall blue inclusionMalaria Babesiosis

14. Basophilic Stippling

15. Howell-Jolly Body

16. Malaria

17. RBC Inclusions: Composite

18. Erythrocyte Distribution Abnormalities Rouleaux formationStacking of RBCs due to increased plasma proteins coating RBCs AgglutinationAntibody-mediated clumping; temperature dependent

19. Rouleaux Formation

20. Agglutination Reaction

21. Variations in RBC Size and Shape AnisocytosisVariations in size (e.g. microcytes) PoikilocytosisVariations in shape (e.g. target cells) HypochromiaIncreased central pallor due to decrease in hemoglobin

22. Hypochromic Microcytic RBC

23. Normal Hypochromic microcytic

24. Hypochromia without Anisocytosis: Thalassemia Trait

25. Severe Hypochromia: Iron Deficiency Anemia

26. Mixed Population: Treated Iron Deficiency Anemia

27. Microcytic Hypochromia: Alpha Thalassemia (  -/--)

28. Microcytic Hypochromia: Beta Thalassemia Major

30. Macrocytic Anemia: Macro-Ovalocytes

31. Shape Abnormalities of Erythrocytes TerminologyDescriptionCondition Target cellsCentral hemoglobin; target-shapedLiver disease; thalassemia: Abnormal Hgb; iron deficiency EchinocyteShort spicules, equally-spacedUremia, hypokalemia, artifact AcanthocyteSpiculated, irregularLiver disease (alcohol), Post-splenectomy SpherocyteSpherical, no central pallorHS, Immune hemolytic anemia SchistocyteFragmented RBC, helmet cells MAHA, burns OvalocyteOval/elliptical shapedHereditary elliptocytosis, Megaloblastic anemia Sickle cellbipolar spiculated shapeHgb S-containing “banana” shapedhemoglobinopathy Teardrop cellsingle elongated extremityMyelophthistic changes Bite cellsIrregular gap in membrane G6PD deficiency

32. Target Cells Diagnostic possibilities Liver disease Hemoglobinopathy Thalassemia Iron deficiency Post-splenectomy Lipid disorders

33. Echinocytes (Burr Cells)

34. Acanthocytes (Spur Cells)

35. Target Cells Spur Cells Morphologic Changes in Liver Disease

36. Hepatorenal Syndrome: Burr + Spur Cells

37. Spherocytes

38. Spherocytes: Autoimmune Hemolytic Anemia

39. Spherocytes: Hereditary Spherocytosis

40. Schistocytes: Microangiopathic Hemolytic Anemia

41. Elliptocytes: Hereditary Elliptocytosis

42. Sickle Cell Anemia: Hgb SS

43. Hemoglobin SC Disease

44. Hemoglobin S-Beta Thalassemia

45. Homozygous Hemoglobin C Disease (Hgb CC)

46. Teardrop Cells

47. Bite Cells

48. Heinz Bodies

49. Morphology of Leukocytes Normal WBC populations Neutrophils (Granulocytes) Lymphocytes Monocytes Eosinophils Basophils

50. Neutrophil

51. Eosinophil

52. Neutrophil Eosinophil

53. Monocytes

55. Small Lymphocyte

56. Small Intermediate Large Lymphocytes

57. Basophils

58. Granulocyte Inclusions or Variants Terminology Description Condition Dohle bodies Pale blue areas in Infections, pregnancy, cancer neutrophil cytoplasm Toxic Large purple granules Infection Granulation in neutrophil cytoplasm Vacuoles Transparent areas Infection, Toxin in neutrophil cytoplasm Hypersegmented ≥ 6 nuclear lobes Megaloblastic anemia Auer rods Reddish long needle-like Acute myeloid leukemia inclusions Ehrlichia Blue inclusions in Ehrlichia sp. monocytes/neutrophils

59. Dohle Bodies

60. Toxic Granulation

61. Toxic Granulation and Vacuole Formation

62. Hypersegmented Neutrophils

63. Auer Rod: Acute Myeloid Leukemia

64. Ehrlichia

65. Myeloid Leukemias and Leukemoid Reaction Bone marrow exam is almost always indicated Cytogenetic analysis Flow cytometry analysis

66. Neutrophilia: Leukemoid Reaction

67. Neutrophilia: CML

68. Pelger-Huet Abnormality

69. Acute Myeloid Leukemia: M1 Myeloblasts without Differentiation

70. Acute Myeloid Leukemia: M2 Myeloblasts with Some Differentiation

71. Acute Myeloid Leukemia: M3 Promyelocytic Leukemia

72. Acute Myeloid Leukemia: M4 Myelomonocytic Leukemia

73. Acute Myeloid Leukemia: M5 Monocytic Leukemia

74. Acute Myeloid Leukemia: M6 Erythroleukemia

75. Acute Myeloid Leukemia: M7 Megakaryocytic Leukemia

76. Abnormalities of Lymphocytes VariantMorphologic categories Atypical lymphsAbundant cytoplasm, RBC “skirting” Abnormal lymphsNuclear abnormalities i.e. clefts, folds, notches Plasmacytoid lymphsAbundant cytoplasm Hairy cellsCytoplasmic projections Sezary cellsDeeply folded nucleus ProlymphocyteLarge lymph with prominent nucleolus

77. Atypical (Reactive) Lymphocytes

79. Abnormal Lymphocytes

80. Plasmacytoid Lymphocytes

81. Plasma Cell: Plasma Cell Leukemia

82. Hairy Cell: Hairy Cell Leukemia

83. Sezary Cell

84. Prolymphocytes

85. Chronic Lymphocytic Leukemia (CLL)

86. CLL: Smudge Cells

87. CLL: Balloon Cells

88. Acute Lymphocytic Leukemia: L1

89. Acute Lymphocytic Leukemia: L2

90. Acute Lymphocytic Leukemia: L3 (Burkitts)

91. Blood smears - The future Long-term storage - digital imaging of abnormal smears Increased education (Featured in journals) Image-recognition technology Tele-hematology for remote interpretation or second opinions

92. Spend time with your family and friends Enjoy activities outside of the hospital Exercise or participate in sports