peripheral blood smear examinationfamilymed.sbmu.ac.ir/uploads/hematology dr momtazmanesh.pdf ·...

Peripheral Blood Smear

Examination

Momtazmanesh MD.

Ped. Hematologist & Oncologist

Loghman General Hospital

1395

Peripheral

Blood Smear

• A peripheral blood smear is a snapshot of the cells that

are present in the blood at the time that the sample is

obtained.

Momtazmanesh M.D.

http://talented.mui.ac.ir/casediscussion/internal/How to Make Peripheral Blood Smear/I_SMR2L.BMP

When to Get Tested?

• When CBC results are abnormal. (flags)

• When a deficiency, disease, or disorder that can affect

blood cell production is suspected.

• As a quality control tool for the results of CBCs.

Momtazmanesh M.D.

http://talented.mui.ac.ir/casediscussion/internal/How to Make Peripheral Blood Smear/I_SMR3A.BMP

Blood Smear prepration and staining:

1-Within 3 hours

2-Tradition wedge smear

3-Romanowsky stain (usually

Wright's, Giemsa)

Momtazmanesh M.D.

Momtazm

anesh

M.D.

Making and Staining a Blood Smear

• Place a drop of blood approximately 4 mm in diameter on

the slide (near the end)

• Spread the drop by using another slide (called here the

“spreader”)

• placing the spreader at a 45° angle and BACKING into

the drop of blood.

PBS

• To make a short smear, hold the spreader at a steeper

angle, and to make a longer smear, hold it closer to the

drop.

• Prevent blood from reaching the extreme edges of the

slide.

• A smear with wavy lines or blanks spots should be

discarded, and a new smear made.

http://talented.mui.ac.ir/casediscussion/internal/How to Make Peripheral Blood Smear/I_SMR1.BMP

http://talented.mui.ac.ir/casediscussion/internal/How to Make Peripheral Blood Smear/I_SMR2A.BMP

http://talented.mui.ac.ir/casediscussion/internal/How to Make Peripheral Blood Smear/I_SMR2C.BMP

http://talented.mui.ac.ir/casediscussion/internal/How to Make Peripheral Blood Smear/I_SMR2L.BMP

Evaluation of Blood Cells

•Selection of a suitable area

•Traditional sequence:

White cells

Red cells

Platelets

Parasites

Momtazmanesh M.D.

Momtazmanesh M.D.

Evaluation of White Blood Cells

Total counts

Diff. counts

I:T ratio

Abnormal WBCs

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Pelger Huet

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Red Blood Cells

• Size

• Color

• Shape

• Arrangement

• Inclusions

• Young RBCs

Momtazmanesh M.D.

Hypochromia & microcytosis

• Iron deficiency anemia

• Thalassemia, α or β

• Sideroblastic anemia

• Chronic disease

• Infection

• Inflammation

• Cancer

• Lead toxicity

• Hemoglobin E trait

Macrocytosis

• Normal newborn

• Megaloblastic anemias

• Post-splenectomy

• Liver disease

• Hereditary aplastic anemia

• Hypothyroidism

Momtazmanesh M.D.

Target cells

• Thalassemic syndromes

• Hb C, SC, S-Thal, E, D

• Obstructive liver disease

• Postsplenectomy or hyposplenic states

• Severe iron deficiency

• LCAT (lecithin/cholesterol acyltransferase)

deficiency: (corneal opacifications, proteinuria,

target cells, moderately severe anemia)

• Abetalipoproteinemia

Momtazmanesh M.D.

Spherocytes

• Hereditary spherocytosis

• ABO incompatibility

• Autoimmune hemolytic anemia

• Burns

• Posttransfusion

• G-6-PD Deficiency

• Microangiopathic hemolytic anemia (MAHA)

• SS disease

• Hypersplenism

• Pyruvate kinase deficiency

• Water-dilution hemolysis

Momtazmanesh M.D.

Acanthocytes (spur cells)

• Liver disease

• DIC and other MAHA

• Postsplenectomy or hyposplenic state

• Vitamin E deficiency

• Hypothyroidism

• Abetalipoproteinemia: (fat malabsorption, retinitis

pigmentosa, neurologic abnormalities)

• Malabsorptive states

Momtazmanesh M.D.

Echinocytes (burr cells)

• Artifact

• Uremia

• Dehydration

• Liver disease

• Pyruvate kinase deficiency

• Peptic ulcer disease or gastric carcinoma

• Immediately after red cell transfusion

• Rare congenital anemias due to decreased

intracellular potassium

Momtazmanesh M.D.

Schistocytes • Helmet, triangular shapes, or small fragments

• DIC & MAHA (HUS, TTP)

• Severe hemolytic anemia (e.g., G6PD deficiency)

• Prosthetic cardiac valve, abnormal cardiac valve, cardiac

patch, coarctation of the aorta

• Connective tissue disorder (e.g., SLE)

• Kasabach–Merritt syndrome

• Purpura fulminans

• Renal vein thrombosis

• Homograft rejection

• Uremia, acute tubular necrosis, glomerulonephritis

• Malignant hypertension

Momtazmanesh M.D.

Elliptocytes

• Hereditary elliptocytosis

• Iron deficiency (increased with severity, hypochromic)

• SS disease & SA trait

• Thalassemia major

• Severe bacterial infection

• Leukoerythroblastic reaction


• Any anemia may occasionally present with up to 10%

elliptocytes

• Malaria

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Teardrop cells

• Newborn

• Thalassemia major

• Leukoerythroblastic reaction

• Myeloproliferative syndromes

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Stomatocytes

• Normal (in small numbers)

• Hereditary stomatocytosis

• Artifact

• Thalassemia

• Acute alcoholism

• Rh null disease (absence of Rh complex)

• Liver disease

• Malignancies

Blister cells

• G6PD deficiency (during hemolytic episode)

• SS disease

• Pulmonary emboli

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Basophilic stippling

• Hemolytic anemias (e.g., thalassemia trait)

• Iron-deficiency anemia

• Lead poisoning

Cabot’s Ring bodies

• Pernicious anemia

• Lead toxicity

Momtazmanesh M.D.

Howell–Jolly bodies

• Postsplenectomy or hyposplenia

• Newborn


• Dyserythropoietic anemias

• A variety of types of anemias (rarely iron-deficiency

anemia, hereditary spherocytosis)

Momtazmanesh M.D.

Heinz bodies

• G6PD Deficiency

• Normal in newborn

• Thalassemia (alpha)

• Asplenia

• Chronic liver disease

• Heinz body hemolytic anemia

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Nucleated red blood cells

• Not normal in the peripheral blood beyond the first week

of life

• Newborn (first 3–4 days)

• Intense bone marrow stimulation

• Hypoxia (especially postcardiac arrest)

• Acute bleeding

• Severe hemolytic anemia (e.g., thalassemia, SS

hemoglobinopathy)

• Congenital infections (e.g., sepsis, congenital syphilis,

CMV, rubella)

Momtazmanesh M.D.

Leukoerythroblastic reaction

• extramedullary hematopoiesis and bone marrow

replacement; most commonly:

• Leukemia

• Solid tumor

• Fungal and mycobacterial infection

Momtazmanesh M.D.

Platelet

Normal & Abnormal

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Bernard-Soulier Syn.

Grey Platelet Syndrome

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Bone Marrow Aspiration

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Normal Bone Marrow

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BMA in ITP

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Q

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myeloblast

Momtazmanesh M.D.

Bernard-Soulier Syn.

Momtazmanesh M.D.

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