BY
DR ABIODUN MARK AKANMODE.
Identify the components of the PBS
BLOOD SMEAR.
 The red blood cells here are normal, happy RBC's.
 They have a zone of central pallor about 1/3 the size of the RBC.
 The RBC's demonstrate minimal variation in size (anisocytosis) and
shape (poikilocytosis). A few small fuzzy blue platelets are seen.
 In the center of the field are band neutrophil on the left and
a segmented neutrophil on the right.
IDENTIFY THE CELLS ON THE PBS.
LYMPHOCYTE.
 A normal mature lymphocyte is seen on the left compared
to a segmented PMN on the right.
 An RBC is seen to be about 2/3 the size of a normal
lymphocyte.
IDENTIFY THE CELL?
MONOCYTE.
 Here is a monocyte. It is slightly larger than a lymphocyte and has a
folded nucleus.
 Monocytes can migrate out of the bloodstream and become tissue
macrophages under the influence of cytokines.
 Note the many small smudgy blue platelets between the RBC's.
IDENTIFY THE CELL?
EOSINOPHIL.
 In the center of the field is an eosinophil with a bilobed nucleus and
numerous reddish granules in the cytoplasm.
 Just underneath it is a small lymphocyte. Eosinophils can increase
with allergic reactions and with parasitic infestations.
IDENTIFY THE CELL.
BASOPHILS.
 There is a basophil in the center of the field which has a lobed nucleus
(like PMN's) and numerous coarse, dark blue granules in the
cytoplasm.
 They are infrequent in a normal peripheral blood smear, and their
significance is uncertain.
 A band neutrophil is seen on the left, and a large, activated
lymphocyte on the right.
IDENTIFY THE CELLS.
PMN.
 The RBC's in the background appear normal. The important finding
here is the presence of many PMN's.
 An elevated WBC count with mainly neutrophils suggests
inflammation or infection.
 A very high WBC count (>50,000) that is not a leukemia is known as a
"leukemoid reaction".
 This reaction can be distinguished from malignant WBC's by the
presence of large amounts of leukocyte alkaline phosphatase (LAP) in
the normal neutrophils.
WHAT IS THE PATHOLOGY HERE?
ROLEUX FORMATION.
 The RBC's here have stacked together in long chains. This
is known as "rouleaux formation" and it happens with
increased serum proteins, particularly fibrinogen and
globulins.
 Conditions which cause rouleaux formation
include infections, multiple myeloma, inflammatory and connective
tissue disorders, and cancers.
WHAT IS THE PATHOLOGY HERE?
IRON DEFFICIENCY ANEMIA.
 The RBC's here are smaller than normal and have an increased zone of
central pallor.
 This is indicative of a hypochromic (less hemoglobin in each RBC)
microcytic (smaller size of each RBC) anemia.
 There is also increased anisocytosis (variation in size) and
poikilocytosis (variation in shape).
WHAT IS THE PATHOLOGY HERE?
IRON DEFF ANEMIA.
 Here is data from a CBC in a person with iron deficiency anemia.
 Note the low hemoglobin (HGB).
 Microcytosis is indicated by the low MCV (mean corpuscular volume).
 Hypochromia correlates here with the low MCH (mean corpuscular
hemoglobin).
What is the pathology here?
Bite cells & Heinz bodies.
 Heinz bodies are formed via the oxidation of iron from ferrous to ferric
form leads to denatured hemoglobin precipitation and damage to RBC
membrane .
 When this damaged RBC makes their way into the spleen & the splenic
macrophages try to engulf them which are then seen as bite cells on a
peripheral blood smear.
WHAT IS THE PATHOLOGY HERE?
MEGALOBLASTIC ANEMIA (B12 DEFF)
 Here is a hypersegmented neutrophil that is present with
megaloblastic anemias.
 There are 8 lobes instead of the usual 3 or 4. Such anemias can be due
to folate or to B12 deficiency.
 The size of the RBC's is also increased (macrocytosis, which is hard to
appreciate in a blood smear).
WHAT IS THE PATHOLOGY HERE?
MEGALOBLASTIC ANEMIA.
 The CBC here shows a markedly increased MCV, typical for
megaloblastic anemia.
 The MCV can be mildly increased in persons recovering from blood
loss or hemolytic anemia, because the newly released RBC's, the
reticulocytes, are increased in size over normal RBC's, which decrease
in size slightly with aging.
IDENTIFY THE CELLS?
SHISTOCYTES.
 There are numerous fragmented RBC's seen here. Some of the irregular
shapes appear as "helmet" cells.
 Such fragmented RBC's are known as "schistocytes" and they are
indicative of a microangiopathic hemolytic anemia (MAHA) or other
cause for intravascular hemolysis.
 This finding is typical for disseminated intravascular coagulopathy
(DIC).
WHAT IS GOING ON HERE?
SPHEROCYTES.
 The size of many of these RBC's is quite small, with lack of the central
zone of pallor.
 These RBC's are spherocytes. In hereditary spherocytosis, there is a
lack of spectrin, a key RBC cytoskeletal membrane protein.
 This produces membrane instability that forces the cell to the smallest
volume--a sphere.
 In the laboratory, this is shown by increased osmotic fragility. The
spherocytes do not survive as long as normal RBC's.
WHAT IS THE PATHOLOGY HERE?
BASOPHILLIC STIPLING.
 The nucleated RBC in the center contains basophilic
stippling of the cytoplasm.
 This suggests a toxic injury to the bone marrow, such as
with lead poisoning.
WHAT IS THE PATHOLOGY HERE?
SICKLE CELL ANEMIA.
 Example of sickled erythrocytes in a patient with Hgb SS
who presented with severe abdominal pain in sickle crisis.
 The sickled cells are prone to stick together, plugging
smaller vessels and leading to decreased blood flow with
ischemia.
IDENTIFY THE CELLS HERE?
TARGET CELLS.
 This patient has hemoglobin SC disease, with hemoglobin
S and hemoglobin C both present.
 With SC disease, the RBC's may sickle, but not as
commonly as with Hemoglobin SS disease.
 The hemoglobin C leads to the formation of "target"
cells--RBC's that have a central reddish dot.
POLYCYTHEMIA.
 This usually denotes a very high red blood cell count with a
corresponding high hemoglobin count.
 Polycythemia is of 2 types:
-Relative polycythemia.
-Absolute polycythemia.
WBC.
WHAT IS THE PATHOLOGY HERE?
ATYPICAL LYMPHOCYTES.
 The WBC's seen here are "atypical" lymphocytes.
 They are atypical because they are larger (more cytoplasm)
and have nucleoli in their nuclei.
 The cytoplasm tends to be indented by surrounding RBC's.
Such atypical lymphocytes are often associated with
infectious mononucleosis.
WHAT IS THE PATHOLOGY HERE?
ALL (ACUTE LYMPHOBLASTIC
LEUKAMIA)
 The WBC's seen here are lymphocytes, but they are blasts--
very immature cells with larger nuclei that contain
nucleoli.
 Such lymphocytes are indicative of acute lymphocytic
leukemia (ALL).
 ALL is more common in children than adults. Many cases
of ALL in children respond well to treatment, and many are
curable.
WHAT IS THE PATHOLOGY HERE?
CHRONIC LYMPHOBLASTIC
LEUKAMIA(CLL)
 These mature lymphocytes are increased markedly in
number.
 They are indicative of chronic lymphocytic leukemia, a
disease most often seen in older adults.
 This disease responds poorly to treatment, but it is
indolent.
SMUDGE CELLS IN CLL.
WHAT IS THE PATHOLOGY HERE?
Auer rods in AML
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AML
 Here are very large, immature myeloblasts with many
nucleoli.
 A distinctive feature of these blasts is a linear red "Auer
rod" composed of crystallized granules.
 These findings are typical for acute myelogenous leukemia
(AML) that is most prevalent in young adults.
WHAT IS THE PATHOLOGY HERE?
CML.
 This condition is one of the myeloproliferative states and is
known as chronic myelogenous leukemia (CML) that is
most prevalent in middle-aged adults.
 A useful test to help distinguish this disease is the
leukocyte alkaline phosphatase (LAP) score, which should
be low with CML and high with a leukemoid reaction.
What is the pathology here?
HAIRY CELL LEUKEMIA
 Hairy cell leukemia is an uncommon hematological
malignancy characterized by an accumulation of abnormal B
lymphocytes.
 Hairy cells are abnormal white blood cells with hair-like projections
of cytoplasm; they can be seen by examining a blood smear or bone
marrow biopsy specimen.
 The blood film examination is done by staining the blood cells
with Wright's stain and looking at them under a microscope. Hairy
cells are visible in this test in about 85% of cases.
IDENTIFY THE CELL HERE?
Reed-Sternberg cells.
 Note the large cells with large, pale nuclei containing large
purple nucleoli at the arrowheads.
 These are Reed-Sternberg cells that are indicative of
Hodgkin's disease.
 There are four main subtypes of classic Hodgkin
lymphoma with CD15+ Reed-Sternberg cells and variants:
lymphocyte rich, nodular sclerosis, mixed cellularity, and
lymphocyte depletion.
Muchas gracias ..Al Final.