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

RBC inclusions

Platelet abnormalities and clumping

Peripheral Blood Morphology

Peripheral SmearsBarnes-Jewish Hospital

Daily total

Total CBCs 900-1100Peripheral smears*

Laboratory initiated 100-200Physician-initiated ~20

* Smears are saved for 30 days

Normal Peripheral Smear

Normal Peripheral Smear

“More information can be gained fromexamining the blood smear than

from any single hematologic procedure”

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)

Reticulocyte: Polychromasia

Reticulocyte Manual Count by Supravital Stain: Normal Count

Reticulocytes: Elevated Count

Erythrocyte Inclusions with Wright’s Stain

Inclusion Composition Appearance Condition

Basophilic Precipitated Evenly dispersed Lead poisoningstippling ribosomes fine or coarse granules thalassemia

other anemias

Howell-Jolly Nuclear Dense, round Post-splenectomybodies fragment blue granule

Pappenheimer Iron-containing Small blue granules Anemiasbodies granules in clusters

Organism Small blue inclusion MalariaBabesiosis

Basophilic Stippling

Howell-Jolly Body

Malaria

RBC Inclusions: Composite

Erythrocyte Distribution Abnormalities

Rouleaux formation Stacking of RBCs due to increased plasma proteins coating RBCs

Agglutination Antibody-mediated clumping;

temperature dependent

Rouleaux Formation

Agglutination Reaction

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

Hypochromic Microcytic RBC

Normal Hypochromic microcytic

Hypochromia without Anisocytosis: Thalassemia Trait

Severe Hypochromia: Iron Deficiency Anemia

Mixed Population: Treated Iron Deficiency Anemia

Microcytic Hypochromia: Alpha Thalassemia (-/--)

Microcytic Hypochromia: Beta Thalassemia Major

Microcytic Hypochromia: Beta Thalassemia Major

Macrocytic Anemia: Macro-Ovalocytes

Shape Abnormalities of Erythrocytes

Terminology Description Condition

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

Target Cells Diagnostic possibilities

• Liver disease

• Hemoglobinopathy

• Thalassemia

• Iron deficiency

• Post-splenectomy

• Lipid disorders

Echinocytes (Burr Cells)

Acanthocytes (Spur Cells)

Target Cells Spur Cells

Morphologic Changes in Liver Disease

Hepatorenal Syndrome: Burr + Spur Cells

Spherocytes

Spherocytes: Autoimmune Hemolytic Anemia

Spherocytes: Hereditary Spherocytosis

Schistocytes: Microangiopathic Hemolytic Anemia

Elliptocytes: Hereditary Elliptocytosis

Sickle Cell Anemia: Hgb SS

Hemoglobin SC Disease

Hemoglobin S-Beta Thalassemia

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Homozygous Hemoglobin C Disease (Hgb CC)

Teardrop Cells

Bite Cells

Heinz Bodies

Morphology of Leukocytes

Normal WBC populations• Neutrophils (Granulocytes)

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

Neutrophil

Eosinophil

Neutrophil Eosinophil

Monocytes

Monocytes

Small Lymphocyte

Small

Intermediate

Large

Lymphocytes

Basophils

Granulocyte Inclusions or VariantsTerminology Description Condition

Dohle bodies Pale blue areas in Infections, pregnancy, cancer neutrophil cytoplasm

Toxic Large purple granules InfectionGranulation 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

Dohle Bodies

Toxic Granulation

Toxic Granulation and Vacuole Formation

Hypersegmented Neutrophils

Auer Rod: Acute Myeloid Leukemia

Ehrlichia

Myeloid Leukemias and Leukemoid Reaction Bone marrow exam is almost always indicated

• Cytogenetic analysis

• Flow cytometry analysis

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Neutrophilia: Leukemoid Reaction

Neutrophilia: CML

Pelger-Huet Abnormality

Acute Myeloid Leukemia: M1Myeloblasts without Differentiation

Acute Myeloid Leukemia: M2Myeloblasts with Some Differentiation

Acute Myeloid Leukemia: M3 Promyelocytic Leukemia

Acute Myeloid Leukemia: M4 Myelomonocytic Leukemia

Acute Myeloid Leukemia: M5 Monocytic Leukemia

Acute Myeloid Leukemia: M6Erythroleukemia

Acute Myeloid Leukemia: M7Megakaryocytic Leukemia

Abnormalities of Lymphocytes

Variant Morphologic categories

Atypical lymphs Abundant cytoplasm, RBC “skirting”

Abnormal lymphs Nuclear abnormalities i.e. clefts, folds, notches

Plasmacytoid lymphs Abundant cytoplasm

Hairy cells Cytoplasmic projections

Sezary cells Deeply folded nucleus

Prolymphocyte Large lymph with prominent nucleolus

Atypical (Reactive) Lymphocytes

Atypical (Reactive) Lymphocytes

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Abnormal Lymphocytes

Plasmacytoid Lymphocytes

Plasma Cell: Plasma Cell Leukemia

Hairy Cell: Hairy Cell Leukemia

Sezary Cell

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Prolymphocytes

Chronic Lymphocytic Leukemia (CLL)

CLL: Smudge Cells

CLL: Balloon Cells

Acute Lymphocytic Leukemia: L1

Acute Lymphocytic Leukemia: L2

Acute Lymphocytic Leukemia: L3 (Burkitts)

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

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