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Peripheral Blood Smears

Peripheral Blood Smears. Department of Internal Medicine Divisions of Hematology and Laboratory Medicine. Complete Blood Count. Automated cell counting Peripheral blood morphology. Automated Cell Counting: Deficiencies. Abnormalities and inclusions in WBC RBC shape abnormalities

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Peripheral Blood Smears

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

  2. Complete Blood Count • Automated cell counting • Peripheral blood morphology

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

  4. Peripheral Blood Morphology

  5. Peripheral SmearsBarnes-Jewish Hospital Daily total Total CBCs 900-1100 Peripheral smears* Laboratory initiated 100-200 Physician-initiated ~20 * Smears are saved for 30 days

  6. Normal Peripheral Smear

  7. Normal Peripheral Smear “More information can be gained from examining the blood smear than from any single hematologic procedure”

  8. 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)

  9. Reticulocyte: Polychromasia

  10. Reticulocyte Manual Count by Supravital Stain: Normal Count

  11. Reticulocytes: Elevated Count

  12. Erythrocyte Inclusions with Wright’s Stain InclusionCompositionAppearance Condition Basophilic Precipitated Evenly dispersed Lead poisoning stippling ribosomes fine or coarse granules thalassemia other anemias Howell-Jolly Nuclear Dense, round Post-splenectomy bodies fragment blue granule Pappenheimer Iron-containing Small blue granules Anemias bodies granules in clusters Organism Small blue inclusion Malaria Babesiosis

  13. Basophilic Stippling

  14. Howell-Jolly Body

  15. Malaria

  16. RBC Inclusions: Composite

  17. Erythrocyte Distribution Abnormalities • Rouleaux formation Stacking of RBCs due to increased plasma proteins coating RBCs • Agglutination Antibody-mediated clumping; temperature dependent

  18. Rouleaux Formation

  19. Agglutination Reaction

  20. Variations in RBC Size and Shape • Anisocytosis Variations in size (e.g. microcytes) • Poikilocytosis Variations in shape (e.g. target cells) • Hypochromia Increased central pallor due to decrease in hemoglobin

  21. Hypochromic Microcytic RBC

  22. Normal Hypochromic microcytic

  23. Hypochromia without Anisocytosis: Thalassemia Trait

  24. Severe Hypochromia: Iron Deficiency Anemia

  25. Mixed Population: Treated Iron Deficiency Anemia

  26. Microcytic Hypochromia: Alpha Thalassemia (a-/--)

  27. Microcytic Hypochromia: Beta Thalassemia Major

  28. Microcytic Hypochromia: Beta Thalassemia Major

  29. Macrocytic Anemia: Macro-Ovalocytes

  30. Shape Abnormalities of Erythrocytes TerminologyDescriptionCondition Target cells Central hemoglobin; target-shaped Liver disease; thalassemia: Abnormal Hgb; iron deficiency Echinocyte Short spicules, equally-spaced Uremia, hypokalemia, artifact Acanthocyte Spiculated, irregular Liver disease (alcohol), Post-splenectomy Spherocyte Spherical, no central pallor HS, Immune hemolytic anemia Schistocyte Fragmented RBC, helmet cells MAHA, burns Ovalocyte Oval/elliptical shaped Hereditary elliptocytosis, Megaloblastic anemia Sickle cell bipolar spiculated shape Hgb S-containing “banana” shaped hemoglobinopathy Teardrop cell single elongated extremity Myelophthistic changes Bite cells Irregular gap in membrane G6PD deficiency

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

  32. Echinocytes (Burr Cells)

  33. Acanthocytes (Spur Cells)

  34. Morphologic Changes in Liver Disease Target Cells Spur Cells

  35. Hepatorenal Syndrome: Burr + Spur Cells

  36. Spherocytes

  37. Spherocytes: Autoimmune Hemolytic Anemia

  38. Spherocytes: Hereditary Spherocytosis

  39. Schistocytes: Microangiopathic Hemolytic Anemia

  40. Elliptocytes: Hereditary Elliptocytosis

  41. Sickle Cell Anemia: Hgb SS

  42. Hemoglobin SC Disease

  43. Hemoglobin S-Beta Thalassemia

  44. Homozygous Hemoglobin C Disease (Hgb CC)

  45. Teardrop Cells

  46. Bite Cells

  47. Heinz Bodies

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

  49. Neutrophil

  50. Eosinophil

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