Evaluation of the Peripheral Blood Smear

Ahmed Shorafa, MD5/4/2015

Normal blood smearRBCs

Normal blood smearWBC

BAND SEGMENTED

LYMPHOCYTEBASOPHIL

EOSINOPHIL

MONOCYTE

Band neutrophil

Diameter:12-16 Cytoplasm : pink Granules Nucleus:

dark purple blue dense chromatin

Band neutrophil

Segmented neutrophil

Diameter: 12-16 Cytoplasm : pink Granules Nucleus:

dark purple blue dense chromatin

2-5 lobes

Segmented neutrophil

Eosinophil

Diameter: 14-16 Cytoplasm : full of granules Granules: large refractile, orange-red Nucleus: blue dense chromatin 2 lobes like a pair of glass

Eosinophil

Basophil

Diameter: 14-16 Cytoplasm : pink Granules: dark blue –black

obscure nucleus Nucleus: blue

Basophil

Lymphocyte

Diameter: small 7-9 large 12-16 Cytoplasm: medium blue Granules: small agranular large a few

primary granules Nucleus: dark blue \round dense chromatin

Lymphocyte

Monocyte

Diameter: 14-20 Cytoplasm : grey blue Granules: dust-like lilac color

granules Nucleus: blue large irregularly shaped and

folded

Monocyte

Normal human promyelocyteLarger than myeloblasts and myelocytes (>20 micron). The nucleus and nuclear chromatin and nucleoli resemble myeloblasts but the cardinal feature is the presence of many violet granules in the cytoplasm with either a dense or coarse pattern often obscuring other cell landmarks.

Normal human myeloblasts. The size is medium (15 to 20 microns in diameter), the nucleus is large and round with finely granular chromatin, nucleoli are present, granules are absent, and cytoplasm is scanty.

The lymphocyte is a small cell with a heavily stained condensed nucleus and a small rim of blue cytoplasm. The monocyte has an irregular nucleus with grayish, blue cytoplasm that has few granules. The metamyelocyte has a kidney bean-shaped nucleus with a granulated cytoplasm.

Reticulocytes are larger, have a blue tint, and lack central pallor because they are not biconcave discs

Supravital stain shows blue-stained residual reticulin (ribosomal RNA) in reticulocytes

• Small, dark, dense hyperchromic red cells • Without central pallor • HS or AIHA

Small microspherocytes (red arrows)Larger spherocytes (black arrow)Reticulocytes (blue arrows)

• Leukcoerythroblastic blood smear • Nucleated RBC and immature WBC. • Myelofibrosis and metastatic cancer

Iron deficiency anemia

Iron deficiency anemia

Megaloblastic blood picture

Marked macroovalocytosisB12 deficiency

• Myeloblasts• Large cells with high NC ratio • Nucleoli• Auer rod in the cytoplasm

• Chronic lymphocytic leukemia• Almost mature appearing lymphocytes• Sparse cytoplasm• Round to slightly oval nuclei• No evident nucleoli. • Damaged lymphocytes ("smudge cells")

• CML• Basophilia and granulocytosis

with neutrophils and immature granulocytes

Chronic myelogenous leukemiaThree normal-appearing basophils. These cells differ from a neutrophil by the presence of coarse, dark blue-black granules.

Hairy cell leukemia. A: abundant, irregularly distributed cytoplasm. The nuclei vary from round to oval to slightly lobulated. B: same view with contrast adjusted to show the irregular cytoplasmic outlines, giving "hairy" appearance (arrows).

Schistocytes• Form of helmets (red arrow)• Microspherocytes (thin black arrows)• Nucleated red cell (green arrow)

Schistocytes

• Fragmented red blood cells• Shaped like helmets,

triangles. • Microangiopathic

hemolytic process

Pseudothrombocytopenia• Platelet Clumping • In vitro phenomenon• Drawing blood in a citrate tube rather than

an EDTA tube eliminates this phenomen

Pseudothrombocytopenia

•Sickle cell anemia• Multiple spindly sickle cells (blue arrows)• Nucleated red blood cell in the upper left• Howell-Jolly body (black arrow), nuclear fragment normally removed by

the spleen. • Target cells (red arrow)

bite-like deformity Heinz bodies

G-6-PD deficiency

• Sézary cells• Lymphocytes with frequently convoluted

nuclei

Sezary cells in mycosis fungoides

Multiple MyelomaRouleaux formationGiving the appearance of stacked coins.

Essenntial thrombocythemia

Myelofibrosis

Leukoerythroblastic blood smearTeardrops

Red cell fragments (Schistocytes), some of which take the form of helmets (red arrow)Microspherocytes (thin black arrows)Nucleated red cell (green arrow)

DIC

t

Target cells

Hereditary elliptocytosis

Hereditary Stomatocytosis

Multiple myeloma

Basophilic stipplingFine or coarse purplish blue dots dispersed through the red cell Very nonspecific feature occurring in thalassemia, lead poisoning, and dyserythropoiesis in general

Basophilic stippling in several red cells from a patient with lead poisoning. The granules represent ribosomal precipitates. A similar picture can be seen in a number of other conditions including thalassemia, megaloblastic anemia, sickle cell anemia, and sideroblastic anemia.

Red cell agglutination.Irregular aggregates of red cellsMycoplasma pneumoniae infection.Infectious mononucleosisChronic cold hemagglutinin disease

Dِhle’s body. Pale blue-gray amorphous inclusion near the cell membrane of a neutrophil. Can result from infection and inflammation

Pelger-Huët anomaly inherited, but similar Pelger neutrophils are seen in myelodysplastic syndromes,

Pelger-Huet anomaly

Toxic granulationHeavy staining of azurophilic granules of neutrophils. When accompanied by neutrophil vacuolation, it is often indicative of infectionCan also result from inflammation, tissue damage, and pregnancy

Hypersegmented neutrophil More than five nuclear segments or lobesMegaloblastic anemia Also said to be present if there are increased numbers of neutrophils with five lobes or if the median lobe count is increased

Normal-sized platelet

Giant platelets As large as or larger than normal red cellsIndicate increased platelet turnover or an inherited or acquired defect in thrombopoiesis

Malaria Intraerythrocytic ring forms (trophozoites)

Babesia microti

Several erythrocytes contain multiple parasites, including a diagnostic tetrad form (arrow)

Follicular lymphomaCells with a "notched nucleus" (centrocytes)Nuclei are partially or completely divided by a cleft (arrows). The chromatin stains intensely These cells have also been called "buttock" cells.

Essential thrombocythemia increased platelet number and clumps of large, abnormal platelets.

Target cellshave an area of central density surrounded by a halo of pallor (arrows). Liver disease and certain hemoglobinopathies

Splenic B-cell lymphoma circulating villous lymphocytes

Echinocytes, also known as burr cells. Echinocytes are often confused with acanthocytes. However, the projections of the red cell membrane in echinocytes are smaller and much more regular in shape and distribution than in acanthocytes

Acanthocytes (spur cells). These cells have prominent irregular protrusions scattered over the surface in an asymmetrical pattern. They are often confused with echinocytes in which the protrusions are smaller and more regular

Neutrophils with toxic granulations, which are dark coarse granules. A Döhle body is also seen (arrow). Right panel: A neutrophil with toxic granulations, vacuoles (another toxic change), and a Döhle body (arrow). Characteristic of toxic systemic illnesses.

Severe intravascular hemolysis due to sepsis with Clostridium perfringens. Neutrophils show toxic changes, including toxic granulation and vacuoles. There is an increased number of spherocytes (blue arrows) and polychromatophilic red cells (ie, reticulocytes, red arrow). The major finding on this slide is the large number of red blood cell ghosts (black arrows), due to the intravascular lysis of red cells from the phospholipase and other lytic enzymes elaborated by the Clostridial organisms.

Howell-Jolly bodies in two red cells (black arrows), nuclear remnants that are normally removed by the spleen. Thus, they are seen in patients who have undergone splenectomy (as in this case) or have functional asplenia (eg, sickle disease disease). Target cells are also seen (blue arrows), another consequence of splenectomy.

The peripheral blood smear on the left is from a 5-month-old boy with eosinophilia of unknown cause. Eosinophil granules are normal in number and size; nuclei are slightly hyperlobulated (ie, more than the usual two lobes). Eosinophilia gradually regressed, with no residual organ dysfuction. The peripheral blood smear on the right is from a 50-year-old male with hypereosinophilic syndrome and a three year history of eosinophilia, bone marrow failure and multiple end-organ involvement. The eosinophils show marked hypogranulation.

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