Blood Lab First Week
This is a self propelled powerpoint study atlas of blood
cells encountered in examination of the peripheral blood
smear. It is a requirement of this course that you begin
review of these slides with the first day of class in order
to familiarize yourself with terms used in describing
peripheral blood morphology. Laboratory final exam
questions are derived directly from these slides. The
content of these slides may duplicate slides (1-37) listed
on the Hematopathology Website. You must familiarize
yourself with both sets of slides in order to have the best
learning opportunity.
Before Beginning This Slide
Review
• Please read the Laboratory information PDF
under Laboratory Resources file to learn about
– Preparation of a blood smear
– How to select an area of the blood smear for review
of morphology and how to perform a white blood cell
differential
– Platelet estimation
– RBC morphology descriptors
•
•
•
•
Anisocytosis
Poikilocytosis
Hypochromia
Polychromatophilia
Normal blood smear. Red blood cells display normal orange pink cytoplasm
with central pallor 1/3-1/2 the diameter of the red cell. There is mild variation in
size (anisocytosis) but no real variation in shape (poikilocytosis). To the left is a
lymphocyte. To the right is a typical neutrophil with the usual 3 segmentations of
Med. Utah pathology
the nucleus.
Normal blood: thin area
Ref 2
Normal peripheral blood smear. This field is good for exam of
cell morphology, although there are a few minor areas of
overlap of red cells. Note that most cells are well dispersed and
the normal red blood cell central pallor is noted throughout the
smear.
Thick area of smear: Red cells are artifactually stacked on one another and
do not uniformly show normal central pallor. White blood cells appear rolled
up and nucleus can not always be distinguished from cytoplasm. This is not a
good area to review of morphology
Ref 2
Lymphocyte
Tail edge, or feathered edge of smear. Not a good area to
review red cell morphology. However, some large cells such
as blasts may roll to the edge of the smear during preparation
and may be more readily found there on visual scanning of
the smear. Ref 2
Feathered edge or tail edge of smear. Again-this is not a good area to
review for morphology. It is an area to scan for larger cells such as
myeloblasts or more immature myeloid and lymphoid cells which are not
normally found in the peripheral blood. Above are mainly lymphocytes and
neutrophils Ref 2
Neutrophil Maturation Series
Note, neutrophils are the most predominant
white blood cell form in the peripheral blood
smear.
Occasional metamyelocytes and myelocytes
may be seen but their presence in peripheral
blood usually indicates infection, inflammation or
a primary bone marrow process.
The presence of progranulocytes or blast forms
in the peripheral blood always indicates a
serious disease process is present.
nucleoli
Myeloblast
Faint red
granules
Normal Myeloblast: Note the large slightly ovoid nucleus which is
eccentrically placed with a rim of blue cytoplasm. A small number of
red granules are sometimes seen. The nucleus finely granular and
stippled. There are generally 2-5 clear nucleoli that can be seen.
Ref 1
lmphocyte
Basophilic
normoblast
myeloblast
Normal Myeloblast. Several basophilic normoblasts are also in this field. Note
that their nuclei are much more condensed than the myeloblast and their
nuclei are smaller. Compare the mature small lymphocyte which also has a
U VA pathology
more condensed nucleus and no nucleoli.
Clumped
platelets
Promyelocyte. 12-25 µm; round or oval cell. Cytoplasm is more abundant than in the
myeloblast. Note the red- purple primary granules indicating this cell is of the myeloid
lineage. Also note the very large size of this cell and that its nucleus is greater than twice
the diameter of the red blood cell. Also present are open nucleoli, also indicative of the
immature stage of development of this myeloid precursor. Early chromatin clumping is
noted in the nucleus.
Ref 1 ashimagebank-2005-101356
Myelocyte: Nucleus occupies around 50% of cell area. Cytoplasm is smooth light
blue-gray. Both azure primary granules and small number of specific granules are
present. Neutrophilic granules are beyond resolution of light microscope and appear
as lighter pinkish to tannish area often adjacent to nucleus (arrow). Ref U VA pathology
Metamyelocyte. Nucleus: an indented oval, resembling kidney or
bean; clumped chromatin; nucleoli absent
Cytoplasm is completely filled with specific neutrophilic color (pink)
granules. A few primary (azure) granules may be present
Ref 2
Myeloid band form. 10-l5 µm. The nuclear chromatin has completely indented to
form a C shape. Bands may also be occasionally coiled. Note the pink/purple
granules dispersed throughout the cytoplasm, characteristic of the granulocytic
lineage. The band is differentiated from a metamyelocyte by its thinner, longer
nucleus with parallel sides and from the segmented form by having no filamentous
indentation between nuclear lobes
Ref 1
Myeloid band forms. Note that one band form is beginning the
process of nuclear segmentation
Ref 1
ashimagebank2005-101349
.
Platelets
Segmented neutrophil on right. Band form on left. Note the well dispersed fine
pink to purple granules in the cytoplasm characteristic of the granulocytic
series. 2 to 5 nuclear lobes are connected by fine filament
Ref 1
Barr body
Normal neutrophil. In normal females 2-3% of neutrophils have an
appendage of condensed chromatin called a Barr body
Ref 1
Large lymph
Small lymphocyte
Small lymphocytes have very dense, clumped chromatin in an ovoid
or notched nucleus. Occasional larger lymphocytes may also be
found in the peripheral blood.
Ref 1
Atypical lymphocytes. These cells have very scant granules, if any, and abundant
cytoplasm that is often draped around neighboring red blood cells on the smear. The
nucleus is dense with the appearance of having been colored with a wide crayon. The
nuceloli are not large and open as would be seen in a lymphoblast. These cells are
characteristically seen in viral infections, particularly infectious mononucleosis. Ref 1
Atypical lymphocytes in infectious mononucleosis, also known as
Downey cells
Ref: U VA
Pathology
Monocyte: 12-20µm Often horse shoe, kidney or clover shaped nucleus that is
lacey and less dense than a lymphocyte.
Cytoplasm is usually abundant, pale gray-blue. A few coarse
azure granules may be present; tiny azure dust-like granules may be present.
May have cytoplasmic vacuoles which are seen as clear, colorless vacuoles in
the Wright Giemsa stain.
U VA Pathology
Monocyte with vacuoles present.
U VA
pathology
ashimagebank2005-101369
Compare: Upper panel meta myelocyte.
Lower panel is a monocyte. Note the fine
azurophilic granules in the cytoplasm of the
metamyelocyte and the denser nucleus.
The monocyte has more clear grey blue
cytoplasm and a more lacey nucleus
Mature Eosinophil: 2 to 3
nuclear lobes, bright
orange/pink cytoplasm due
to large, acidophilic
granules.
Ref 1
Mature basophil: 2 to 3 nuclear lobes, dark
blue-purple cytoplasm due to large basophilic granules. These
granules are rich in serotonin, histamine, and leukotrienes
Med Utah Pathology
Eosinophil
Lymphocyte
Abnormalities in Neutrophils
Unrelated to Malignancy
• Hypersegmentation
• Pelger Huet anomaly
• Leukemoid reaction
Hypersegmented Neutrophil (Poly)- A neutrophil is considered hyersegmented if it
has greater than or equal to 5 lobes. Characteristic of megaloblastic anemia, e.g.
B12 or folate deficiency.
University of Utah Pathology
Ref 1
Leukemoid reaction. A response in the peripheral white blood count in which the white
blood count has increased beyond 30,000 or when there is a pronounced shift to
immaturity, usually in response to infection. Note toxic granulations and vacuolization in
neutrophils. Note presence of myelocyte indicating release of young cells under conditions
of stress into the peripheral blood. Rarely a promyleocyte will be seen. The finding of
blasts in the peripheral blood is always worrisome for leukemia or a bone marrow process.
Upper right hypersegmented granulocyte (poly) and small lymphoctye lower
left. Also note that the red blood cells in this smear are macrocytic with some
cells approaching the size of the nucleus of the small lymphocyte.
Ref 1
Pelger Huet anomaly (bilobed nucleus) seen in the nucleus of these mature
granulocytes. A benign inherited dominant disorder of nuclear segmentation.
Pseudo-pelger cells are seen as an acquired phenomenon with leukemia or
myelodysplasia Ref 1
Dohle body: aggregates of rough endoplasmic
reticulum seen with infection. They are a faint bluish
accumulation of material seen in the periphery of
the granulocyte.
Ref 1
Dohle body
Ref 1
Platelets
Platelet on top of red blood cell
Normal platelets-note that normal platelets have redpurple granules present
Lichtman’s Atlas of
Hematology
Large granular
lymphocyte
Agranular
platelet
Normal
platelet
Abnormalities in platelets
Large platelet or
macrothrombocyte
Ref 2
Grey platelets, as in Grey Platelet Syndrome:
Note decreased granules and larger than
normal size platelets seen in this congenital
disorder of platelet function and number
Ref 2
Giant platelet
Normal platelets
Giant platelet. Note size compared to red blood cell and
more normal platelets
Ref 1 ashimagebank2004-101140
Red Blood Cell Morphology
• Anisocytosis
• Poikilocytosis
• Red blood cell morphology changes due to
changes in hemoglobin content
• Characteristic red blood cell shape
changes
• Red blood cell inclusions
Poikilocytosis: variation in shape-pencil forms, fragmented cell
and tear drop noted
Hypochromia: central pallor is greater than 1/3 diameter of red
blood cell
Ref 1
Marked (4+) Poikilocytosis: variation in shape of red blood cells
Williams Hematology,
7th ed, 2006
Polychromatophilia or polychromasia: a bluish color of RBCs suggesting reticulocytosis,
the presence of many young RBCs. Often seen in hemolytic anemias and acute sudden
blood loss and are a sign of a normally functioning bone marrow
Ref 1 ashimagebank2004-101122
Reticulocytes: Reticulocytes are suspected in the peripheral blood smear
by the presence of polychromatophilia in the red blood cells. A special
Ref 1
stain methylene blue or brilliant cresyl blue is required to identify them
ashimagebank2005-101299
Orthochromatic normoblast
Leukoerythroblastic blood smear: Note many immature red
blood cell precursors normally found in marrow. This could be
as a result of a severe hemolysis as seen in hemolytic disease
of the newborn
Ref 1
Lymphocyte
Hypochromic microcytic red blood cells. Note the red blood cells are much smaller in
diameter than the small lymphocytes on the smear. The central pallor is greater than 1/3 the
red cell diameter. This indicates a disorder of heme synthesis, e.g. iron deficiency
Med
Utah Pathology
Monocyte
Lymphocyte
Hypochromia: Note increased central pallor of red
blood cells, greater than 1/3 the diameter of the red
blood cell. Microcytosis: Red blood cell is less than
2/3 the diameter of the small lymphocyte. This picture
is consistent with iron deficiency
Ref 2
Macrocytes. Unfortunately there is no lymphocyte to compare size
with in this view. Also note the poikilocytosis (variation in shape)
with tear drop forms, microspherocytes and ovalocytes present.
Anisocytosis is also evident on this smear with varying size of cells.
Elliptocytes: a disorder of red blood cell
membrane
Ref 1
ashimagebank2004-101268
Spherocytes noted at arrows. Note the cells have loss of central pallor. This is
not due to viewing a poorly dispersed section of the smear as many red blood
cells demonstrate normal central pallor. A spherocyte represents the minimal
amount of red blood cell membrane that can incorporate the contents of the
cell. This is seen autoimmune hemolysis and in hereditary spherocytosis
Ref 1 ashimagebank-2001-100214
Spherocytosis: The uniformity of the spherocytes in this smear is consistent with
hereditary spherocytosis. In HS the deficiency is usually of ankyrin which
destabilizes the red cell membrane so that it fragments, thus losing surface area and
changing from a discocyte to a spherocyte.
Williams Hematology,
7th edition, 2006
Target Cells
Target cells. Target red blood cells occur when there is an excess of
red blood cell membrane compared to hemoglobin content. Target
cells are seen in thalassemia where there is a decrease in
hemoglobin synthesis and liver disease in which there is an excess
of membrane synthesized.
Ref 1
Basophilic stippling: pathologic precipitation of
ribosomes. This is a sign of disordered heme
synthesis in erythrocytes. One example is
lead intoxication.
Nucleated red blood cell. Howell Jolly bodies present (arrows). The presence of nucleated red
blood cells always indicates a disease process present such as early release of the RBCs from
the marrow due to brisk hemolytic anemia or to a bone marrow process pushing early RBC
forms out of the marrow prematurely for example. Howell Jolly bodies indicate absence of
spleen.
Tear drop cells: these stretched and deformed cells are seen
in thalassemia and myelophthisic and myelofibrotic disorders
Ref 3
Schistocytes: Fragmented red blood cells. In this case
from mechanical valve hemolysis
Ref Williams Hematology 7th ed
2006
Schistocytes: Note the variably misshapen red blood
cells with randomly torn circumference. In this case
the underlying disorder was disseminated
intravascular coagulation
Ref Williams Hematology
7th edition 2006
Hemoglobin C disease: target cells and a “box car” cell
showing condensed hemoglobin
Nucleated red
blood cell
Sickle Cells:
Ref Williams Hematology
7th ed, 2006
Basophilic stippling: pathologic precipitation of
ribosomes. This is a sign of disordered heme
synthesis in erythrocytes. One example of a
cause is lead intoxication.
Ref 3
Rouleaux formation: stacking of red blood cells as a result of
protein coating. Seen in hypergammaglobulinemic states
Ref 1
Red blood cell agglutination as seen in cold
agglutinins disease where agglutinating RBC
antibodies (often IgM antibodies) bind to RBCs
and cause agglutination
Ref 1
lymphocytes
Chronic lymphocytic leukemia. Numerous smudge cells noted by arrows.
Smudge cellno cytoplasm
present and
nucleus
appears to be
disintegrating
Leukemic blasts, in this case lymphoblasts, as recognized by scant blue cytoplasm
surrounding the nucleus with no granules noted. Open nuceoli are present indicating
an immature cell. Also note that the nucleus of these blasts are more than twice the
diameter of a red blood cell. These features distinguish these cells from normal
mature peripheral blood lymphocytes.
Additional Good Sources to Review
Peripheral Blood Cell Morphology
• http://www.meded.virginia.edu/courses/path/innes/nh/morphology.cfm
• http://library.med.utah.edu/WebPath/HEMEHTML/HEME
IDX.html#2
• http://www.wadsworth.org/chemheme/heme/microscope/
celllist.htm
• Williams Hematology Atlas
http://online.statref.com.proxy.lib.umich.edu/Document/D
ocument.aspx?FxID=167&DocId=1&SessionId=B27731
VURZQOKNVV
Slide References
• Ref 1- Williams Textbook of Hematology Atlas
• Ref 2-ASH slide bank
• Ref 3- U Va Pathology
©2007 University of Virginia
Charles E. Hess, M.D.
Lindsey Krstic, B.A.
• Ref 4- University of Utah Pathology
http://library.med.utah.edu/WebPath/HEMEHTML/HEMEIDX.html#2
• Ref 5http://images.google.com/imgres?imgurl=http://www.wadsworth.org/chemheme/heme/
microscope/pix/metamyelocyte_nw.jpg&imgrefurl=http://www.wadsworth.org/chemhe
me/heme/microscope/metamyelocyte.htm&h=305&w=400&sz=14&hl=en&start=1&u
m=1&tbnid=npegNYdkPtJRM:&tbnh=95&tbnw=124&prev=/images%3Fq%3Dwadsworth%2Bcenter%2B
metamyelocyte%26svnum%3D10%26um%3D1%26hl%3Den%26sa%3DG