DR.RATHER WASEEM YOUSUF

MVSC VETY CLINICAL MEDICINE

RBC & WBC ABNORMALITIES AND

THEIR INTERPRETATION

HEMATOLOGY

Study of blood and blood forming tissues

Key components of hematologic system are:BloodBlood forming tissues

Bone marrow Spleen Lymph system

WHAT DOES BLOOD DOES Transportation

Oxygen

Nutrients Hormones Waste Products

Regulation Fluid, electrolyte Acid-Base balance

Protection Coagulation Fight Infections

Components of BloodPlasma

55%Blood Cells

45%Three types

Erythrocytes/RBCs

Leukocytes/WBCs

Thrombocytes/Platelets

Erythrocytes/Red Blood Cells

Composed of hemoglobinErythropoiesis

= RBC production Stimulated by hypoxia Controlled by erythropoietin

Hormone synthesized in kidneyHemolysis

= destruction of RBCsReleases bilirubin into blood stream

Leukocytes/White Blood Cells

5 typesBasophilsEosinophilsNeutrophilsMonocytesLymphocytes

Types and Functions of Leukocytes

GranulocytesNeutrophilEosinophilBasophilAgranulocytesLymphocyteMonocyte

Phagocytosis, early phase of inflammation

Phagocytosis, parasitic infections

Inflammatory response, allergic response

Cellular, humoral immune response

Phagocytosis; cellular immune response

TYPE CELL FUNCTION

Abnormalities of RBCs

Abnormal erythrocyte morphology is found in pathological states that may be :

- abnormalities in size (anisocytosis).

- In shape (poikilocytosis). - In hemoglobin content. - presence of inclusion

bodies

1-Variation in erythrocyte size (anisocytosis)

1-Microcytosis:Morphology: Decrease in the red cell size. Red cells are

smaller than normal.

Found in:- Iron deficiency anemia..- Lead poisoning.- Anemia of chronic disease.

1-Variation in erythrocyte size (anisocytosis)

1-Microcytosis:Morphology:- Decrease in the red

cell size. Red cells are smaller than normal.

Found in:- Iron deficiency anemia..- Lead poisoning.- Anemia of chronic disease

1-Variation in erythrocyte size (anisocytosis)

2-Macrocytosis: Morphology:

Increase in the size of a red cell. Red cells are larger than normal. May be round or oval in shape, the diagnostic significance being different.

Found in:- Foloate and B12 deficiencies (oval)- Ethanol (round)- Liver disease (round)- Reticulocytosis (round)

II-Variation in hemoglobin content

1-Hypochromasia:Morphology:

Increase in the red cells' central pallor which occupies more than the normal third of the red cell diameter.

Found in: - Iron deficiency- Thalassaemia any of the conditions leading to Microcytosis

II-Variation in hemoglobin content

2- Polychromasia: Morphology:

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 haemostatic factor replacement.

Anemia Classifications

Microcytic, hypochromic

Microcytic, normochromic

Normocytic, normochromic

Macrocytic, normochromic

NORMOCYTIC, NORMOCHROMIC ANEMIA

MCV normalMCHC normalExamples:

acute blood lossaplastic anemiamost leukemia'sbone marrow infiltration

MICROCYTIC, HYPOCHROMIC ANEMIA

MCV decreased MCHC decreasedExamples:

iron deficiencythalassemialead poisoninganemia of chronic disease

MICROCYTIC, NORMOCHROMIC ANEMIA

MCV decreasedMCHC normalExamples:

mid-stage iron deficiencythalassemia

MACROCYTIC, NORMOCHROMIC ANEMIA

MCV increasedMCHC normalExamples:

folate deficiencyvitamin B12 deficiencypernicious anemia

III- Variation of red cells shape (Poikilocytosis)

RBCs may have different shapes:

1- Spherocytosis: Morphology:

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

Found in:

- Hereditary spherocytosis- Immune haemolytic anemia- Zieve's syndrome- Microangiopathic haemolytic anemia

III- Variation of red cells shape (Poikilocytosis)

2-Target Cells:Morphology:Red cells have an area of

increased staining which appears in the area of central pallor.

Found in:-Obstructive liver disease

-Severe iron deficiency- Thalassaemia- Haemoglobinopathies - Post splenectomy

III- Variation of red cells shape (Poikilocytosis)

3- Ovalocytes:Morphology:

oval shape red blood cell

Found in:

- Thalassaemia major.- Hereditary ovalocytosis. - Sickle cell anemia

III- Variation of red cells shape (Poikilocytosis)

4- Elliptocytosis:Morphology:

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

Found in: - Hereditary elliptocytosis

- Megaloblastic anemia- Iron deficiency - Thalassaemia- Myelofibrosis

III- Variation of red cells shape (Poikilocytosis)

5- Tear Drop Cells:Morphology:

Red cells shaped like a tear drop or pear

Found in:

- Bone marrow fibrosis- Megaloblastic anemia- Iron deficiency- Thalassaemia

III- Variation of red cells shape (Poikilocytosis)

6- Blister cell:Morphology: Have accentric hallow

area.Found in: Microangiopathic

hemolytic anemia

III- Variation of red cells shape (Poikilocytosis)

7- Schistocytosis:Morphology: Fragmentation of

the red cells. Found in:

- DIC - Micro angiopathic haemolytic anemia- Mechanical haemolytic anemia

III- Variation of red cells shape (Poikilocytosis)

8- Stomatocytosis:Morphology:

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

Found in:- Alcohol excess- Alcoholic liver disease- Hereditary stomatocytosis- Hereditary spherocytosis

III- Variation of red cells shape (Poikilocytosis)

9- Burr (crenation ) cell:

Morphology:Red cell with uniformly

spaced, pointed projections on their surface.

Found in:- hemolytic anemia

- Uremia.- Megaloblastic anemia

III- Variation of red cells shape (Poikilocytosis)

10- Keratocytes (horn cell):

Morphology: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 in:- Uraemia- Severe burns- EDTA artifact- Liver disease

III- Variation of red cells shape (Poikilocytosis)

11- Acanthocytosis:Morphology:

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

Found in:- Liver disease - Post splenectomy- Anorexia nervosa and starvation

III- Variation of red cells shape (Poikilocytosis)

12- Sickle Cells:Morphology: Sickle shaped red

cells Found in: Hb-S disease

III- Variation of red cells shape (Poikilocytosis)

13- Rouleaux Formation:

Morphology:

Stacks of RBC's resembling a stack of coins.

Found in:

-Hyperfibrinogenaemia

-Hyperglobulinaemia

III- Variation of red cells shape (Poikilocytosis)

14- Red cell-agglutination:

Morphology: Irregular clumps of red

cellsFound in:

- Cold agglutinins- Warm autoimmune hemolysis

III- Variation of red cells shape (Poikilocytosis)

15- Nucleated red blood cells.

These red blood cells are released from the bone marrow early into the blood stream, due to the need for oxygen. Normal red blood cells do not contain a nucleus on a peripheral smear.

IV -Erythrocyte inclusion bodies 1- Howell-Jolly Bodies:Morphology:

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

Found in:- Post splenectomy- Megaloblastic anemia

IV -Erythrocyte inclusion bodies

2- Siderotic Granules (Pappenheimer Bodies)

RBCs which contain no hemoglobin iron granules. They appear as dense blue, irregular granules which are unevenly distributed in Wright stained RBCs. Pappenheimer bodies can be increased in hemolytic anemia, infections and post-splenectomy.

IV -Erythrocyte inclusion bodies

3- Basophilic stippling: Morphology:

Considerable numbers of small basophilic inclusions in red cells.

Found in:

- Thalassaemia- Megaloblastic anemia- Hemolytic anemia - Liver disease- Heavy metal poisoning.

IV -Erythrocyte inclusion bodies

4- Heinz Bodies: 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.

IV -Erythrocyte inclusion bodies

5- Cabot Rings: Reddish-blue threadlike rings

in RBCs of severe anemia's. These are remnants of the nuclear membrane and appear as a ring or figure 8 pattern. Very rare finding in patients with Megaloblastic anemia, severe anemia's, lead poisoning, and dyserythropoiesis.

IV -Erythrocyte inclusion bodies

6- Parasites of Red Cell:

are protozoan parasites which occur in many species of birds and are the cause of avian malaria. Transmitted by mosquitoes, infection with Plasmodium can be a cause of hemolytic anemia

Erythrocyte inclusion bodies

Depiction of red blood cell morphologies that may appear on a peripheral smear, showing:

(A)Basophilicstippling

(B) Howell-Jolly bodies

(C)Cabot'sringbodies(D) Heinz's bodies.

Leukocytes (White Blood Cells)

The leukocytes, or white blood cells, constitute only 1% of the total blood volume.

They originate in the bone marrow and circulate throughout the lymphoid tissues of the body.

There they function in the inflammatory and immune processes.

They include: the granulocytes

Neutrophils – 55-65% Eosinophils – 1-4% Basophils – 0-1%

the lymphocytes – 20-40% the monocytes – 3-8%

Differential CountNeutrophil

50 – 75 %

Eosinophil

0 – 3 %

Basophil

0 – 1 %

Lymphocyte

20 – 40 %

Monocyte

2 – 6 %

Abnormalities of WBCs(quantative)

Leucocytosis – substantial increase in the WBC count.

- Physiologic increase (no trauma/injury) - Pathologic increase (trauma/pathology)Leucopenia – substantial decrease in

the WBC count.N.V. = 5,000 – 10,000/cu mm

Neutrophilia NeutropeniaInfections,

Inflammation, Metabolic disorders

Acute hemorrhage, corticosteroids

Stress, post-surgery, burns, HDN

Lithium drugs, neoplasms

Decreased production - Inherited/acquired stem

cell disorder - Benzene toxicity, cytotoxic

drugs Increased destruction - Immune mechanism,

sequestration BM depression, IM,

varicella, Typhoid SLE, hepatitis or any viral

infections

NEUTROPHILLS

Eosinophilia Eosinopenia

Allergic disorders (asthma)

Parasitic infections (nematodes)

Skin disease (eczema)Hodgkin’s diseaseScarlet FeverPernicious anemia

Stress due to trauma or shock

Mental distressCushing’s

syndromeACTH

administration

EOSINOPHILLS

BASOPHILIA BASOPENIA

Chronic myelocytic leukemia.

Polycythemia. Hodgkin’s disease.

Hyperthyroidism.

Pregnancy.

Basophil

Lymphocytosis Lymphopenia

Viral infections (German measles )

Infectious Mononucleosis (kissing dis.)

Mumps (parotitis), pertussis

Tuberculosis, syphilis, thyrotoxicosis

Congestive heart failure, SLE

Renal failureAdvanced

TuberculosisHigh levels of

adrenal corticosteroids

LYMPHOCYTES

MONOCYTES

SBE, Syphilis, Tuberculosis

Protozoan infectionsMycotic or fungal

infectionsMalaria, Systemic

lupus erythematosusRheumatoid arthritis

Monocytosis Monocytopenia

Lymphocytic leukemia

Aplastic anemia

Abnormalities of WBCs(qualitative)

Morphologic abnormalities involving either the nucleus or cytoplasm

Functional abnormalities

Inherited or Acquired

Toxic Granulation

MorphologyIncreased granulation. Granulation more basophilic and larger than normal.

Found in Severe bacterial infection. Non specific finding - seen in

tissue damage of various types. Normal pregnancy. Therapy with cytokines

Dohle BodiesMorphologySmall pale blue cytoplasmic inclusions, often in the periphery of the cell.Consist of ribosomes and endoplasmic reticulumFound in Infective and inflammatory states. Severe burns Tuberculosis Post chemotherapy Pregnancy May-Heggling Anomaly

Russell bodiesMorphologyare eosinophilic, large, homogenous immunoglobulin-containing inclusions usually.

Found ina plasma cell undergoing excessive synthesis of immunoglobulin; the Russell body is characteristic of the distended endoplasmic reticulumThis is one cell variation found in multiple myeloma.

Hypersegmentation or right shift of neutrophil nuclei

MorphologyAverage lobe count increased OR increased % of neutrophils with 5 - 6 lobes OR > 3% neutrophils with 5 lobes or more.

Found in Megaloblastic anaemia Iron deficiency Chronic infection Liver disease Uraemia

Hypogranulation

MorphologyReduced granulation in neutrophil cytoplasm.

Found in Myelodysplastic syndromes

Phagocytosed Parasites

MorphologyMalaria - Plasmodium falcifarum

Found in Severe malaria infection

Macro Neutrophils

MorphologyTwice the size of a normal neutrophil with tetraploid DNA content.

Found in Occasionally in the blood of

healthy subjects. Inherited Administration of G-CSF Megaloblastic anaemia Chronic infection

Shift To The Left

MorphologyPresence of precursor of granulocytes in the peripheral blood

Found in Normal in pregnancy or neonate. Infections. Bone marrow fibrosis. Bone marrow infiltration by

malignancies

Pseudo Pelger Huet Anomaly

MorphologyBilobed neutrophils with more condensed chromatin

Found in Inherited Myelodysplastic

syndromes. Idiopathic myelofibrosis. Chronic granulocytic leukemia. Therapy with colchicine, ibuprofen. Infectious mononucleosis, malaria,

myxedema. CLL

Neutrophil aggregation

MorphologySmall clumps of neutrophils. Happens in vitro if EDTA anticoagulated blood is allowed to stand. May lead to incorrect WBC.

Found in In vitro finding. Infectious mononucleosis. Bacterial infections. Auto immune disease.

Atypical Lymphocytes

MorphologyPleomorphic. Large with diameter of 15 - 30 µm. Abundant, strongly basophilic cytoplasm. Basophilia may be confined to the cytoplasmic margins.

Found in Viral infections - EBV, CMV, Hep A,

Measles.  Bacterial infections - brucella,

tuberculosis. Protozoa – malaria. Immunization. SLE.

Thank You