VARIATION IN HEMOGLOBIN CONTENT
●
focuses on the content of concentration of
hemoglobin
NORMOCHROMIC CELL
● refers to erythrocytes with normal amounts of
hemoglobin.
● Possesses a central pallor which is about 1/3 of its
diameter.
○ Central pallor is the middle of RBC
HYPOCHROMIC CELL
● refers to erythrocytes with low hemoglobin
concentration wherein the central light area of the
cell is larger and paler than the normal
● MCH (mean corpuscular hemoglobin) and MCHC
(mean corpuscular hemoglobin concentration) are
decreased
○ Hypo = decreased
● Often associated with microcytosis → RBCs are
small
HYPERCHROMIC CELL
● red cells which have an increased hemoglobin (hb)
content and wherein the central light area is smaller
than the normal.
● The central pallor is missing
● Brighter central pallor
VARIATION IN STAINING PROPERTY
➔
➔
➔
Polychromasia
Hypochromasia
Hyperchromasia
POLYCHROMASIA
● Other name: Polychromatophilia or Diffuse
Basophilia
● A condition where red cells are stained with various
shades of blue with tinges of pink.
○ This is due to the combination of the affinity
of hb to acid stain and the affinity of RNA to
the basic dye.
○ Polychromasia has 2 to 3 colors → red, blue,
pink
● Slightly microcytic
● Indicates reticulocytosis
POLYCHROMASIA GRADING (reading done through
smears)
GRADE
POLYCHROMATOPHILIC
RBC PERCENTAGE
Slight
1%
1+
3%
2+
5%
3+
10%
4+
11%
HYPOCHROMASIA
● A condition where the red cells appear pale and the
central pallor is too large.
● Two possible causes:
○ Decreased hemoglobin concentration
○ Abnormal thinness of the cell seen in
conditions associated with:
■ Iron Deficiency Anemia (IDA) –
most common type of anemia
■ Sideroblastic anemia – indicates
blockage in the protoporphyrin
pathway
■ Thalassemia – a type of anemia
wherein there is a problem within
the alpha or the beta chain
● The grading is based on the size of the central pallor.
HYPOCHROMASIA GRADING
GRADE
DESCRIPTION
1+
Area of central pallor is ½ of cell diameter
2+
Area of central pallor is 2/3 of cell diameter
3+
Area of central pallor is ¾ of the cell diameter
4+
Thin rim of hemoglobin
HYPERCHROMASIA
● Conditions wherein the red cells are deeply stained
to abnormal thickness of cells.
● Seen in cases of:
○ Macrocytosis – greater size of the red blood
cells
○ Spherocytosis – abnormal shape of the
cells with the absence of central pallor.
○ Megaloblastic anemia – the red blood cells
are larger than 12 μm
VARIATION IN SIZE
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➔
Anisocytosis
Macrocyte
Microcyte
Megalocyte
ANISOCYTOSIS
● condition where in the red cells vary in size both
macrocytes and microcytes coexist on the same
smear.
● Normocyte (normocytic/normochromic) – 6-8 um in
diameter (normal) → normal size and normal
concentration
Associated disease:
● seen in normal condition
● acute post hemorrhagic anemia
● hemolytic anemia
● aplastic anemia – a problem in the bone marrow
wherein the production is few
○
associated with pancytopenia where all RBC,
WBC, and platelets production is few.
MACROCYTE
● larger than normal greater than 8 μm in size round in
shape (MCV > 100 FL)
○
MVC = mean corpuscular volume
○ Reference value of MCV = 80-100 FL
● Defect: Abnormal nuclear maturation but normal
cytoplasmic maturation
Associated disease:
● Non-Megaloblastic Anemia
● Myelodysplastic syndrome
● Chronic liver disease
● Bone marrow failure
●
Reticulocytosis
MICROCYTE
● cell which is less than 6 μm in size (MCV < 80 FL)
● Defect: Abnormal cytoplasmic maturation but normal
nuclear maturation
Associated disease:
● Iron deficiency Anemia
● Thalassemia
● Hemolytic anemia
● Hb E disease
● Inflammation
● Chronic post hemorrhagic anemia
● Sideroblastic Anemia
POIKILOCYTOSIS
● red cells exhibit variation in shape.
● Severe anemia; certain shapes helpful diagnostically
● Problem with shape can be caused by problems with:
○ carbohydrates
○ lipids
○ protein
DISCOCYTES
prone
Cell description
in
bleeding
infection , anemia Clow platelets)
,
normal cell with a biconcave disc
shape with increased surface
volume surface
-
-
- -
-
Diseases Associated
●
●
●
Seen in normal condition
Acute post hemorrhagic
anemia
Aplastic anemia bone marrow
produce small amount of RBC
ACANTHOCYTES
Other name
●
●
Cell description
Spur cell
Thorn cell
small dense RBC with few
irregularly finger-liked spaced
projections of varying length; still
abnormalities
lipid
has central pallor
-
e
MEGALOCYTE
● large oval-shaped red cell which is 9-12 μm
● Defect: Abnormal nuclear maturation but normal
cytoplasmic maturation
○ Same defects with macrocyte
Associated disease:
● Megaloblastic anemias like pernicious anemia
● Anemia
● Vit. B12 deficiency anemia or Vit. B12 deficiency
● Diphyllobothrium latum infection (fish tapeworm)
abnormal membrane defect caused
--
Defect
by an increase in sphingomyelin
anddecrease in cholesterol
and
=
phospholipid.
● The problem is in the
lipids. (phospholipids)
● Cholesterol in the
membrane is excessive
-
PONS
-
Mainit
Diseases Associated
Hepatitis
VARIATION IN SHAPE
➔
➔
➔
➔
➔
➔
➔
➔
➔
➔
➔
➔
➔
➔
Poikilocytosis
Discocytes
Acanthocytes
Biscuit cell or Folded RBC
Burr cell
Blister cell or Bite cell
Echinocytes or Crenated cell
Codocytes
Teardrop cell or Dacrocyte
Elliptocytes
Spherocytes
Sickle cells or Drepanocytes
Schistocytes
Stomatocytes
-
Mala bsorp Ron
Excessive cholesterol
cirrhosis
-
jaundice
●
I
●
●
Neuroacanthocytosis
(abetalipoproteinemia,
McLeod syndrome)
Severe liver disease (spur
cell anemia)
Post splenectomy
Malabsorption state
●
Folded RBC
●
-
BISCUIT CELL
Other name
Cell description
Cell assumes a “pocket book roll”
appearance or biscuit shape
Defect
Cell membrane is folded
-
Diseases Associated
(hemoglobinophaties)
●
●
HbSC disease
(Hemoglobin Sickle-C
Disease)
HbCC disease
(Hemoglobin C Disease)
BURR CELL
SEC
Other name
●
●
●
Cell description
multiple small proj
-
spicules
.
But
Echinocytes
Sea-urchin cells
Crenated cells
cell with irregularly spaced blunt
processes, resembles crenated
RBC/sea-urchin cells; still has
central pallor
Other name
Leptocyte
-
membrane
PUta
D, 1 M
Diseases Associated
,
2●
↳●
5
4
●
●
3●
I
●
Cell description
Uremia
MAHA (Microangiopathic
Hemolytic Anemia)
Liver diseases
DIC (Disseminated
intravascular coagulation)
TTP (Thrombotic
Thrombocytopenic
Purpura) low platelets
PK (Pyruvate Kinase
Deficiency)
Cell w/ central area of hemoglobin
>
-
-
-
-
Defect
●
deficiency in cholesterol,
phospholipid in the
membrane
○ Excessive
cholesterol in the
membrane and
there is a
hemoglobin
imbalance.
deficiency in Lecithin
cholesterol acyl
transferase (LCAT)
Hold Hands wl
Bite cells
THriCL
Cell description
cell w/ eccentric vacuoles due to
the plucked-out Heinz body
Defect
G6P deficiency resulting to
accumulation of Heinz bodies →
there is a denaturation of the
hemoglobin
Diseases Associated
Target cell
Mexican hat or cells with
bull’s eye appearance
●
●
GataMan
●
●
surrounded by colorless area and a
peripheral ring; increase surface to
volume ratio (SAV – standard
average volume)
BLISTER CELL
Other name
hepatitis
cirrhosis
can also be seen when
the specimen is nearly dry
CODOCYTES
Abnormal lipid content of the
-
Defect
●
●
●
Diseases Associated
-
●
●
●
G6PD deficiency
(glucose-6-phosphate
dehydrogenase
deficiency)
HUS (Hemolytic Uremic
Syndrome)
MAHA
●
●
●
●
●
Thalassemia
Liver disease
Hemolytic anemia
HbSS and HbCC
LCAT deficiency
TEARDROP CELL
-
Other name
Cell description
●
Tennis
raquet
Dacrocyte → daCRYocyte
= crying cell
Cells appear in the shape of a
teardrop or pear with a single short
or long protrusion
● Protrusion is because of
the trauma or extension
from the spleen passage.
● Has wand-like projection.
-
-
-
-
CRENATED CELL
Other name
●
●
Echinocytes
Sea-urchin Cells
Defect
●
ATP deficiency due to
prolonged storage of
anticoagulated blood
ATP deficiency causes
premature destruction of
RBCs.
Pathologically; due to
abnormal lipid content of
the membrane
Defect
abnormal maturation squeezing
--
ande
fragmentation during splenic
passage I trauma
-
pathologic (wrong w/ATP)
non-pathologic (old blood)
1.
●
-
-
BUG
,
CHeS
Diseases Associated
(usually artifactual if
not pathogenic)
●
●
●
-
Uremia
bleeding ulcers
gastric carcinoma
Diseases Associated
HMM
●
●
●
HA (Hemolytic Anemia)
MA (Megaloblastic
Anemia)
MMM (Myelofibrosis with
Myeloid Metaplasia)
ELLIPTOCYTES
SICKLE CELLS
menisocyte
Other name
●
Ovalocytes
Cell description
Oval or elliptical (cigar to egg,
screen names of RBC pencil or sausage-shaped)
●Hb appears to be
Pencil form
-Rod
concentrated at the two
ends of the cell leaving a
agar sunsage
normal central area of
-Egy-Rod
pallor.
● -Lifespan is shortened
Other name
●
Cell description
●
Major problem-skeletal protein
OF
RBCS
-
Me HeHelte
,
SPHEROCYTES -ball
Cell description
-
●
●
●
shaped
healthy person – shouldn’t
be plenty
Megaloblastic anemia
IOW Hy bC
Hypochromic anemia C
Hereditary ovalocytosis cacquired3
cell
.
=
-
-
polymerization
oF A S
Diseases Associated
Crescent shape cell due to
abnormal aggregation of HbS
which ⑧
gives a tendency for the cell
to assume a sickle shape.
-
-
●
●
Sickle cell anemia
Sickle cell trait
●
Schizocyte /Helmet cell
SCHISTOCYTES
-
-
.
-
Defect
●
small round dense cell which lacks
the central pallor area usually
size= 6 2-7 0
microcytic and sphere shape
think 2 2-3 4
● Cells become
smaller and
denser with increased
Hb
small RBL
content and become less
deformable with age.
● The MCH is greater than
> 37 %
MCH
37% and osmotic fragility
↑ osmotic
increased as well.
● There are also
fragility
microspherocytes (size is
< 4 μm.) -> thermal injury
microsphericyte
Shortened survival time because
=Yum
they can be sequestered in the
spleen and destroyed
.
-
-
Abnormal membrane due to
defective spectrin define in band
protein 4.1
elliptihape
Diseases Associated
-
-
-
Defect
Sickle cells are thin and
elongated with pointed
ends and are well filled
with hemoglobin.
● They may be curved or
straight or have S, V or L
shaped.
● 0No central pallor
● He
Cell shape is due to cell
membrane alteration due
or amino acid alteration.
-
-
-
Drepanocytes
Fragmentocyte
Other name
.
-
Cell description
-
irregularly, contracted cell;
fragmented cell
-
=
Cell fragmentation due to trauma
--
Defect
caused by physical and mechanical
agents.
-
-
Defect
●
●
●
CHEl
Diseases Associated
●
●
●
●
Primary: Spectrin
Deficiency
Secondary: defective
interaction of spectrin wl
other skeletal proteins
Spectrin makes the
biconcave shape of the
RBC.
Hereditary spherocytosis
(HS)
Chronic Lymphocytic
Leukemia
Extensive burns (along
with schistocytes)
Immune hemolytic anemia
due to ABO
incompatibility.
-
-
-
Diseases Associated
Are
na
Mainit
HatDoy
●
●
MAHA
○ TTP
○ DIC
○ HUS
Uremia
●
Mouth cells
na
-
STOMATOCYTES
Other name
1y dro cyte
Cell description
characterized by an elongated or
slitlike area of central pallor
Defect
Caused by osmotic changes due to
cation imbalance (Na,K)
Diseases Associated
He-
He , HeR
●
●
●
●
Alcoholic cirrhosis
Hereditary stomatocytosis
Hepatobiliary disease
Rh null syndrome - The
Rh deficiency syndrome,
also known as Rh-null
syndrome, is a blood
disorder where people
have red blood cells
(RBCs) lacking all Rh
Antigens
PATHOLOGICAL CHANGES IN RBC
throughout cytoplasm
Composition of
inclusion
Precipitated RNA
Diseases Associated
●
●
●
●
●
HemenMathy
[
Lead poisoning
Thalassemia
Hemoglobinopathies
Megaloblastic anemia
Myelodysplastic syndrome
HOWELL-JOLLY BODIES
● 0.5-1 μm in size
●
●
●
●
●
Normocytes are normal in terms of size and shape.
○ Normal shape is a biconcave.
Problems or variations in size are called Anisocytosis.
Poikilocytosis is the irregularities in shape caused by
problems with the CLP (carbohydrates, lipids, protein)
content of the RBC.
Low hemoglobin content can be termed as
hypochromic cells.
VARIATION DUE TO THE PRESENCE OF
INCLUSION BODIES
➔
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Diffuse basophilia
Basophilic stippling
Howell - Jolly body
Heinz body
Pappenheimer bodies
Cabot ring
Hemoglobin H inclusions
Supravital stain
Dark blue-purple dense, round
granule; usually one per cell;
occasionally multiple
-
Wright stain
Dark blue-purple dense, round
granule; usually one per cell;
occasionally multiple
Composition of
inclusion
DNA (nuclear fragment)
Diseases Associated
●
●
●
HY
IMS Kaya sit s
ay
●
●
●
H0I
Hyposplenism
Postsplenectomy
Megaloblastic anemia –
highlight of this condition
Hemolytic anemia
Thalassemia
Myelodysplastic
Syndrome
HEINZ BODIES seen in periphery
,
● Inclusions can be seen up to 6 and is 0.3-2 μm in size
irregular refrac s
DIFFUSE BASOPHILIA
Supravital stain
Supravital stain
Wright stain
Dark blue granules and filaments in
cytoplasm
-
Bluish tinge throughout cytoplasm
-
Composition of
inclusion
Diseases Associated
RNA
NMB , BCB
,
PAR
Round, dark blue-purple granule
attached to inner RBC membrane
Wright stain
Not visible
Composition of
inclusion
Denatured hemoglobin
Diseases Associated
●
●
Hemolytic anemia
After treatment for iron,
vitamin B12, or folate
deficiency
●
Ag
A●
●
Glucose-6-phosphate
dehydrogenase deficiency
Unstable hemoglobins Beta thalassemia
Oxidant drugs/chemicals
PAPPENHEIMER BODIES
BASOPHILIC STIPPLING
● Blueberry bagel appearance
Supravital stain
induced
anemic
Supravital stain
Irregular clusters of small, light to
dark blue granules often near
periphery of the cell
Dark blue-purple, fine or coarse
punctate granules distributed
throughout cytoplasm
Wright stain
Irregular clusters of small, light to
dark blue granules often near
periphery of the cell
Dark blue-purple, fine or coarse
punctate granules distributed
Composition of
inclusion
-
-
Wright stain
big
Iron
-stained al iron stain
-dark blue / volet
-cause
by the accumulation
=
Perl's
Prussian
mitochondrion
of
ribosomes
iron
Blue
Diseases Associated
Hy
pms
SA
-
HoT
●
●
●
●
●
●
●
Sideroblastic anemia
Hemoglobinopathies
Thalassemias
Megaloblastic anemia
Myelodysplastic syndrome
Hyposplenism
Post-splenectomy
CABOT RING
Supravital stain
Rings or figure-eights
Wright stain
Blue rings or figure-eights
Composition of
inclusion
Remnant of mitotic spindle
Diseases Associated
●
●
●
HEMOGLOBIN H INCLUSIONS
Megaloblastic anemia
Myelodysplastic syndrome
Lead poisoning
problem
=
Supravital stain
Fine, evenly dispersed, dark blue
granules; imparts “golf ball”
appearance to RBCs
Wright stain
Not visible
Composition of
inclusion
Precipitate of b-globin chains of
hemoglobin
Diseases Associated
●
●
●
●
●
●
ie
shortage Produc
Hb H disease
MISCELLANEOUS VARIATIONS
Rouleaux formation – stacks of coins
○ Due to increase of proteins or the smear was
done improperly
Partially hemolyzed RBC
○ Due to your extraction
Acid stain of erythrocytes – red cell is colored RED
Alkaline stain of erythrocytes – If buffer solution is too
alkaline, red cell are colored dirty gray
Design Formation of RBC – caused by fat or oil on the
slide ahead of the spreader during the smear
preparation.
○ Avoid using slides repeatedly.