RBC’s Morphology - PowerPoint Presentation

Slide1

RBC’s Morphology

Practical Hematology Lab

- LAB 2 -Slide2

RBCS Abnormal MorphologyPeripheral Blood MorphologySlide3

Recording RBC Morphology

Scan area using ×100 (oil immersion).

Observe 10 fields.

Red cells are observed for

size

,

shape

,

hemoglobin content

, and the presence or absence of

inclusions.

Abnormal morphology: Red cell morphology is assessed according to See the following sample grading system. Note that red cell morphology must be scanned in a good counting area.

Two questions should be asked

Is the morphology seen in every field?

Is the morphology pathologic and not artificially induced? Slide4

Abnormal Erythrocyte Morphology

Is found in pathological states that may be abnormalities in Red cell distribution.

Size (anisocytosis).Hemoglobin content – Color Variation .

Shape (

poikilocytosis

).

The presence of inclusion bodies in erythrocyte.Slide5

Erythrocyte Distribution Abnormalities

Rouleaux

formation Stacking of RBCs due to increased plasma proteins coating RBCs (resembling a stack of coins)

Found in

Hyperfibrinogenaemia

HyperglobulinaemiaSlide6

AgglutinationAntibody-mediated Irregular clumping , temperature dependentFound inCold agglutininsWarm autoimmune hemolysisSlide7
Slide8

Rouloux FormationAgglutinationSlide9

Variation In Erythrocyte Size (

Anisocytosis)Anisocytosis

Variations in size (Microcyte and Macrocyte)

Normocytic RBC’s

Normal size of RBC (8

μm

) with a range of 7 to 9

μm

.

The nucleus of a small lymphocyte (± 8 µm) is a useful guide to the size of a red blood cell).Slide10

Microcytic

RBC cell smaller than the normal RBC ( <7 μm), and is associated with a decrease in hemoglobin synthesis

Found inIron deficiency anemia.Thalassaemia.

Sideroblastic

anemia.

Lead poisoning.

Anemia of chronic disease.Slide11

Macrocyte

RBC larger than the normal (<9 μm) and is the result of a defect in nuclear maturation or stimulated erythropoiesis. May be round or oval in shape, the diagnostic significance being different.

Found inFolate

and B12 deficiencies (oval)

Ethanol (round)

Liver disease (round)

Reticulocytosis

(round)Slide12

Example : Film Study

Most erythrocytes presented in the picture are microcytes (compare with the small lymphocyte). The degree of

hemoglobinization is sufficient. Normal platelets and single ovalocytes are present.

1.

M

icrocyte  

2.

N

ormocyteSlide13

Variation In Erythrocyte Color

A normal erythrocyte has a pinkish-red color with a slightly lighter-colored center (central pallor) when stained with a blood stain, such as Wright.

The color of the erythrocyte is representative of hemoglobin concentration in the cell.

Under normal conditions, when the color, central pallor, and hemoglobin are proportional, the erythrocyte is referred to as

Normochromic

.Slide14

Hypochromia

Increased central pallor and decreased hemoglobin concentration, the central pallor occupies more than the normal third of the red cell diameter.Found

in Iron deficiencyThalassaemia

any of the conditions

leading

to

MicrocytosisSlide15

Polychromasia

Red cells stain shades of blue-gray as a consequence of uptake of both eosin (by hemoglobin) and basic dyes (by residual ribosomal RNA). Often slightly larger than normal red cells and round in shape - round macrocytosis.

Found

in

Any situation

with

reticulocytosis

– for example bleeding, hemolysis or response to

heamatinic

factor

replacement

.Slide16

What Abnormal Results Mean

This test is used to diagnose the cause of anemia. The following are the types of anemia and their causes:Normocytic/ normochromic (NC/NC) anemia is caused by sudden blood loss, prosthetic heart valves, sepsis, tumor, long-term disease or aplastic anemia.

Microcytic/ hypochromic anemia is caused by iron deficiency, lead poisoning, or thalassemia.Microcytic/ normochromic anemia results from a deficiency of the hormone erythropoietin from kidney failure.Macrocytic /normochromic anemia results from chemotherapy, folate

deficiency, or vitamin B-12 deficiency.Slide17

Shape Abnormalities of Erythrocytes

Poikilocytosis is the general term for mature erythrocytes that have a shape other than the round, biconcave disk.

Poikilocytes can be seen in many shapes.(e.g. Acanthocyte, Spherocytosis,…)Slide18

Shape Abnormalities of Erythrocytes

TerminologyDescriptionConditionTarget CellsCentral Hemoglobin; target shaped

Liver Disease; Thalassaemia, Abnormal Hb; Iron DeficiencyEchinocyte

Short specula's, equally-spaced

Uremia, Hypokalemia,

Artifact

Acanthocyte

Speculated, Irregular

Liver disease (Alcohol), Post-

spleenoctomy

.

Spherocyte

Spherical, no central pallor

HS, immune Hemolytic

anemia

Shistocyte

Fragmented RBC, Helmet cells

MAHA, burns

Ovalocyte

Oval / Elliptical shaped

Hereditary elliptocytosis, Megaloblastic anemia.

Sickle Cell

Bipolar

speculated shape “ banana” shaped

Hb S-containing

hemoglobinopathy

Teardrop cell

Single elongated extremity

Myelophthistic

changes

Bite

cells

Irregular gap in membrane

G6PD deficiencySlide19

Red cell with a “target” or bull’s-eye appearance. The cell appears with a central bull’s eye that is surrounded by a clear ring and then an outer red ring.

Found inObstructive liver diseaseSevere iron deficiencyThalassaemiaPost splenectomyLipid disordersHaemoglobinopathies (S and C)

Target cellSlide20

Red cells are more spherical. Lack the central area of pallor on a stained blood film.

Found inHereditary spherocytosis Immune haemolytic anemia Zieve's syndromeMicroangiopathic haemolytic

SpherocytosisSlide21

Red cells with a central linear slit or stoma. Seen as mouth-shaped form in peripheral smear

.Found inAlcohol excessAlcoholic liver disease Hereditary stomatocytosis

StomatocyteSlide22

Ovalocyte

An elongated oval cell. They are a result of a membrane defect.Found

inThalassaemia major.

Hereditary

ovalocytosis

.

Sickle cell anemiaSlide23

Elliptocyte

The red cells are oval or elliptical in shape. Long axis is twice the short axis.

Found inHereditary

elliptocytosis

Megaloblastic

anemia

Iron deficiency

Thalassaemia

MyelofibrosisSlide24

Red cell fragments that are irregular in shape and size. They are usually half the size of the normal RBC; therefore, they have a deeper red color.

Found inDIC Micro angiopathic haemolytic anemiaMechanical haemolytic anemia

SchistocyteSlide25

Have accentric hallow area. Resemble a women's handbag and may be called

pocket-book cell.Found inMicroangiopathic hemolytic anemia

Blister cell: pre

keratocyteSlide26

Part of the cell fuses back leaving two or three

horn-like projections. The keratocyte is a fragile cell and remains in circulation for only a few hours.Found inUraemiaSevere burnsEDTA artifactLiver disease

Also called helmet cells

Keratocytes

(horn cell)Slide27

Degmacyte "bite cell"

An abnormally shaped red blood cell with one or more semicircular portions removed from the cell margin. These "bites" result from the removal of denatured hemoglobin by macrophages in the spleen.

Found

In

G-6-PD deficiency, in which uncontrolled oxidative stress causes hemoglobin to denature and form Heinz bodies, is a common disorder that leads to the formation of bite

cells.Slide28

Sickle shaped red cells.

Found in Hb-S disease and trait

Sickle

CellsSlide29

Red cell with 30 or more, short blunt projections which are regularly distributed on their surface

Found in Usually artifactual— the result of slow drying under humid conditions.Sometimes are non - artifactual, indicating uremia or pyruvate kinase deficiency.Hemolytic anemiaUremia.Megaloblastic anemia Cells retain the central pallor.

Echinocyte

“Burr” (crenation ) cell:Slide30

Echinocytes

(Burr Cells)Slide31

Red blood cells with irregularly spaced projections, these projections very in width but usually contain a rounded end

Found inLiver disease Post splenectomyAnorexia nervosa and starvation

Acanthocytosis

(Spur Cells):Slide32

Acanthocytes (Spur Cells)Slide33

Resembles a tear and usually smaller than the normal RBC.

Found inBone marrow fibrosisMegaloblastic anemiaIron deficiencyThalassaemia

Dacryocytes

(

Teardrop

)Slide34

Envelope Form Cell

Found inThalassaemia

Sickle cell anemiaSlide35

Erythrocyte Inclusions with Wright’s Stain

InclusionCompositionAppearanceConditionBasophilic stipplingPrecipitated ribosomesEvenly dispersed fine or coarse granules

- Lead poisoningThalassaemia , other anemia.Howell-Jolly bodies

DNA in origin

Nuclear Fragment

Dense,

round blue granule

Post

– Splenectomy

Pappenheimer bodies

Iron-containing granules

Small blue granules in clusters

Anemia's

Heinz

bodies

Denatured

Hemoglobin

Round blue precipitates

G6PD

Cabot Rings

Remnants of Nuclear membrane

Reddish

-blue thread like rings

Severe

anemia, Lead poisoning.

Organism

Small blue inclusion

Malaria

BabesiosisSlide36

Small round cytoplasmic red cell inclusion with same staining characteristics as nuclei

Found inPost splenectomyMegaloblastic anemia

Howell-Jolly BodiesSlide37

These are iron containing granules in red blood cells that are seen because the iron is aggregated with mitochondria and ribosomes. They appear as faint violet or magenta specks, often in small clusters, due to staining of the associated protein.

They are associated with severe anemias and thalassemias. Pappenheimer bodies can be increased in hemolytic anemia, infections and post-splenectomy.

Siderotic

Granules (

Pappenheimer

Bodies)Slide38

Considerable numbers of small basophilic inclusions in red cells.

Found inThalassaemiaMegaloblastic anemiaHemolytic anemia Liver diseaseHeavy metal poisoning.

Basophilic stipplingSlide39

Represent denatured hemoglobin (methemoglobin

- Fe+++) within a cell. With a supravital stain like crystal violet, Heinz bodies appear as round blue precipitates. Presence of Heinz bodies indicates red cell injury and is usually associated with G6PD-deficiency.

Heinz BodiesSlide40

Heinz Body Preparation. RBC are incubated supravitally in new Methylene blue to identify precipitates of oxidatively denatured hemoglobin.Slide41

Reddish-blue threadlike rings in RBCs of severe anemia's. These are remnants of the nuclear membrane or remnants of microtubules and appear as a ring or figure 8 pattern.

Very rare finding in patients with Megaloblastic anemia. severe anemia's.lead poisoning.Dyserythropoiesis.

Cabot Rings

A - Cabot ring

B - Howell-Jolly bodySlide42

Two organisms are have a tendency to

invade the RBCs. All 4 species of the malaria parasite will invade RBCs. We will see the Plasmodium of different species in RBCs. Theileria microti (Bebesia microti)

Parasites of Red CellSlide43

MalariaSlide44

RBCs Abnormal

morphology

Depiction of red blood cell morphologies that may appear on a peripheral smear, showing: basophilic stippling, Howell-Jolly bodies, Cabot's ring bodies

Heinz's bodies. Slide45

Red Blood Cell Morphology

A normal

red blood cell should be approximately the same size as a normal lymphocyte nucleus or 2 normal sized red blood cells should fit side by side across a normal sized poly (not a

hypersegmented

poly).

Grade

Degree of abnormality

NO.

of Field/ Oil imm.

1+

1-6 per oil imm. field

2+

7-10 per OIF

3+

11-20 per OIF

4+

> 20 per OIFSlide46

Reporting results

Where possible use macrocytic and microcytic, rather than simply

anisocytosis

alone, when describing red cell morphology.

 Use specific cell morphology when possible, rather than simply reporting

poikilocytosis

.

 When red cells are normocytic, normochromic, report out as NORMAL. When abnormal morphology has been noted, DO NOT indicate normal on the report form.

EXAMPLE: 7-10 microcytic RBC's/OIF is reported out as: 2+

microcytosis

or Moderate

microcytosis

.Slide47

Determine A Quantitative Scale

1Slide48

Grading Inclusions

2Slide49

Blood Film In Some CasesSlide50

Normal Peripheral SmearSlide51

Autoimmune Hemolytic Anemia

SpherocytesSlide52

Hereditary Spherocytosis

SpherocytesSlide53

Hereditary pyropoikilocytosisSlide54

Microangiopathic

Hemolytic AnemiaSchistocytesSlide55

Sickle Cell Anemia

Hb SSSlide56

Idiopathic myelofibrosisDacryocytesSlide57

Iron Deficiency Anemia

Severe HypochromiaSlide58

Treated Iron Deficiency Anemia

Mixed Population: Slide59

Alpha

Thalassaemia (a-/--)Microcytic HypochromiaSlide60

Target Cells

Spur CellsMorphologic Changes in Liver DiseaseSlide61

Hepatorenal

SyndromeBurr + Spur Cells