RBC MORPHOLOGY Aug.

2011

0 Anemia- defined as a reduction in the total quantity

of red cells or hemoglobin (Hb) in the circulation.

0 RBC provide a mode of transport of Hb to deliver

oxygen to the tissues and carbon dioxide from the tissues.

ERYTHROCYTE MATURATION 1. Proerythroblast (14-19 m): Nucleus is large with fine chromatin and nucleoli; cytoplasm is scant and basophilic. 2. Basophilic erythroblast (12-17 m): Slightly smaller nucleus with slight chromatin condensation; increased cytoplasm and intensely blue (RNA abundance); no granules and no nucleoli present. 3. Polychromatophilic erythroblast (12-15 m): Moderately condensed chromatin; lighter, grayish cytoplasm. The color of the cytoplasm is due to coloring by both acidic and basic components of the stain. Basophilia is from staining of ribosomes and acidophilia from hemoglobin. The nucleus is condensed and intensely basophilic with coarse heterochromatin granules giving a characteristic checkerboard appearance. 4. Orthochromatophilic erythroblast (8-12 m): Dark, opaque nucleus; gray-red cytoplasm (trace blue). The nucleus has become pyknotic and there is abundant acidophilic hemoglobin. 5. Reticulocyte (7-10 m)Nucleus has been extruded; cytoplasm is reddish-pale blue. RNA is still present. 6. Erythrocyte (7-8 m): No nucleus; orange-red cytoplasm; RNA is lost

0 RBC morphology- determined through peripheral blood smear ( in the thin

part, at feathery edge )

0 Why at the feathery edge of the smear? 1. Distribution- cells not in this edge are stacked (patong-patong) 2. Cell contents (nucleus, cytoplasm) are clearly seen 3. passage of light through thin part morphology can be determined 4. WBC are numerous at the THICK part because they are bigger .

Indications for requesting for RBC morphology: 1. For diagnosis of malaria hospitals have specific tests for malaria but still use the smear to confirm 2. To detect anemia- any defect in RBC will produce anemia 3. To confirm sickle cell anemia; to concretize the diagnosis of the type of anemia Other specimens tested for RBC/for diagnosis of anemia: 1. Bone marrow aspirate 2. Urine- identification of hematuria in patients w/ renal problems, doc looks for dysmorphic RBCs

Anemia -Pallor: pale conjunctiva, decreased capillary refill (at nail beds), pale skin (if person is dark-skin, check the mucosa)
0 *CBC only used for RBC count (amount/quantity), not the form of RBCs

DEFINITION OF TERMS
0 CRENATION- the RBC are with shrunken or irregular

borders,tiny smooth projection(ruffles) in their membrane. This results from loss of intracorpuscular water through osmosis and not a significant diagnostic indicator of any disease state can be drugs, dehydration, etc.

0 ACANTHOCYTES-similar to crenated RBC; however the

projections are irregularly spaced and at the apex of the projections are sharp points. Seen in px with metabolic dysfunction (dec. lipoprotein absorption in GIT )

0 BURR CELLS similar to elongated crenated rbc and often assume irregular shapes such as that of

quarter moon. Seen in px with bleeding gastric ulcers and renal insufficiency.

0 TARGET CELLS dark-staining periphery and darker central area with a lighting between the 2

dark areas.Seen in px with hemoglobinopathies such as thalassemia and liver disease.

0 PYKNOCYTES observed during the 1st trimester of life in the newborns.Have similar appearance to

spherocytes with small spinal projections.Seen in px with G-6-PD dificiency.

0 SICKLE CELL mature RBCs that have become crescent-shaped.

0 ELLIPTOCYTES are mature RBCs that assume an elliptical or oval shape. Seen in px with hereditary elliptocytosis, some forms of anemia. Believed to be a defect in the integrity of corpuscular membrane.

0 SCHISTOCYTES fragments of RBC still in the peripheral circulation. Formed in the spleen and intravascular fibrin clot. Indication of hemolysis.

0 SPHEROCYTES smaller than normocytes and contains abnormally large amount of Hb. Seen in px with hereditary spherocytosis.

0 MICROCYTES smaller RBC in diameter. 0 ( 6.0 um or less)

0 MACROCYTES ave. diameter of 9.0 um in diameter or greater.

0 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 a band neutrophil on the left and a segmented neutrophil on the right.

0 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).

0 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. Such long chains of RBC's sediment more readily. This is the mechanism for the sedimentation rate, which increases non-specifically with inflammation and increased "acute phase" serum proteins.

0 The most common cause for a hypochromic microcytic

anemia is iron deficiency. The most common nutritional deficiency is lack of dietary iron. Thus, iron deficiency anemia is common. Persons most at risk are children and women in reproductive years (from menstrual blood loss and from pregnancy).

0 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).

0 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)

Spherocytes

0 This peripheral blood smear demonstrates many larger bluish

reticulocytes as well as smaller RBC's lacking central pallor-spherocytes. This patient had an autoimmune hemolytic anemia. Antibody coated the RBC's, and portions of the RBC's were removed, decreasing cell size. Many RBC's were removed entirely, resulting in anemia and a bone marrow response with increased erythropoiesis and elevated reticulocyte count (20%). The patient developed an indirect hyperbilirubinemia as well.

Tear drop cells

0 This peripheral blood smear demonstrates tear drop cells.

These characteristically shaped RBC's can be seen in patients with myelofibrosis and those who underwent radiation

0 The RBC in the center of the field contains several Howell-

Jolly bodies, or inclusions of nuclear chromatin remnants. There is also a nucleated RBC just beneath this RBC. Abnormal and aged RBC's are typically removed by the spleen. The appearance of increased poikilocytosis, anisocytosis, and RBC inclusions suggests that a spleen is not present.

Spherocytes
No central pallor

0 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.

0 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. Such stippling may also appear with severe anemia, such as a megaloblastic anemia.

Poikilocytosis

0 This peripheral blood smear demonstrates marked

poikilocytosis (abnormally shaped RBC's) as well as some anisocytosis (variation in RBC size), though many are small (microcytes). This patient had beta-thalassemia, a hereditary disorder of beta globin chain synthesis that leads to ineffective erythropoiesis and a microcytic anemia. Some of the RBC's resemble jigsaw puzzle pieces.

0 This is sickle cell anemia in sickle cell crisis. The abnormal

hemoglobin SS is prone to crystallization when oxygen tension is low, and the RBC's change shape to long, thin sickle forms that sludge in capillaries, further decreasing blood flow and oxygen tension. Persons with sickle cell trait (Hemoglobin AS) are much less likely to have this happen.

HbC

HbSC

0 In the center of the field is a rectangular RBC that is

indicative of Hemoglobin SC disease. Both hemoglobin S and hemoglobin C are present. 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.

0 Malaria is a parasitic disease caused by the genus

Plasmodium, of which there are four species that affect man. Shown here are "ring forms" of Plasmodium vivax in red blood cells. This disorder can produce hemolysis and anemia.