1.3-1.6 Heme

Formula for manual RBC hemacytometer count

(Avg # RBC count dilution 10)/ (length*width) (# squares counted)

RBC count

whole blood (WB) diluted w/ an isotonic diluting fluid and then RBCs counted

RBC count Normal range

4-6 million (10^6) mm³

Reticulocyte count

supravital staining then count retic

Retic normal range

0.5-1.5%

Microhematocrit (hematocrit)

WB spun down in 2 microhematocrit tubes, hematocrit determined by reader

• Packed cell volume

Normal Hematocrit range

Men: 42-54%

Women: 36-48%

Hemoglobin

WB diluted w/ reagent containing lysing agent

Normal hemoglobin range

Men: 16 ± 2

Women: 14 ± 2

Erythrocyte Sedimentation Rate (ESR)

allow specific amount of blood to sit in vertical position for one hour

Normal ESR range

Men: 0-20 mm/hr

Women: 0-15mm/hr

Retic Staining

supravital staining

• New methylene blue

• Brilliant cresyl blue

Composition of reticulum

RNA

Uncorrected retic count

(# of retic /1000 RBCs ) * 100 = reported value (%)

Corrected retic count

Observed RC * (patient HCT/ normal HCT)

*Normal HCT:

• Men: 45

• Women: 42

RPI

Corrected RC/ 2

• only divide by two if there are nRBCs and/ or shift/stress retics on smear

Absolute Retic count

(% retic (uncorrected) * RBC count ) / 100

Form of hemoglobin that cannot be measured by cyanmethemoglobin method?

sulfhemoglobin

4 causes for falsely elevated hemoglobin determination

1. High WBC count

2. High Platelet count

3. Lipemia

4. RBCs resistant to hemolysis

Rule of “3”

• RBC * 3 = ~HGB (hemoglobin)

• HGB * 3 = ~HCT (hematocrit) ± 3

if HGB and HCT don’t agree DO NOT report out results

What are the 4 ways microhematocrit are affected?

under centrifugation

• not evenly separated

Decreased blood: anticoagulant ratio (“short draw”)

• not enough blood to determine ratio

EDTA sit out overnight at room temp

• blood expands and unclear reading

Buffy coat read

• will cause the reading to be off

3 stages of ESR

1. Rouleaux ~10 mins

2. Rapid Falling ~40 mins

3. Packing ~10 mins

How do plasma proteins impact ESR?

Increase proteins leads to decrease zeta potential which increases rouleaux leading to bigger mass = bigger fall. All together increasing ESR

Which plasma protein has the greatest affect on ESR?

fibrinogen

4 ways ESR affected

Decreases blood: anticoagulant ration “short draw “

• did not put enough blood in the tube

EDTA sit overnight at room temp

• RBCs expand = false reading

Sedimentation tube not perpendicular

• will cause RBCs to packed wrong

Rack holding ESRs placed next to centrifuge

• vibrations will cause ESR to fall faster

Mean corpuscular Volume (MCV)

Indicates average VOLUME (size) of RBCs

MCV= (HCT *10) /RBC count

Normal Range for MCV

Normal: 80-100 fL

• Micro: <80 fL

• Macro > 100 fL

Mean corpuscular hemoglobin (MCH)

indicates average WEIGHT of hemoglobin in RBCs

MCH = (HGB* 10) / RBC count

• not really used that often in labs

Normal Ranges for MCH

27-31pg

Mean corpuscular hemoglobin concentration (MCHC)

average CONCENTRATION of hemoglobin in RBCs

MCHC = (HGB * 100) / HCT

Normal range for MCHC

Normal 32-36%

• <32% = hypochromia

• 36-38% = look for spherocytes

• No such thing as hyperchromia

Technique to determine RBC size

RBC should be the size of nucleus of lymph or 2/3 size of lymph itself

Anisocytosis

“size variation”

• Micro = decrease MCV

• Macro = increase MCV

• expect RDW >14.5%

Poikilocytosis

shape variations

• decrease RBC survival (hemolytic state)

Hypochromia

less color due to less hemoglobin (still red though)

polychromia

• Reticulocytes

• young non-nucleated RBC

• Purple/blue color

microcytosis

• RBCs smaller than normal <6um

• extra cell division = smaller cell

• MCV <80 fL

Macrocytosis

• RBCs larger than normal

• less cell division

• MCV >100 fL

What is this RBC shape?

Acanthocyte

Acanthocyte Morphology and diseases

Morphology

• irregular projections

• usually no central pallor

Disease(s)

• Alcoholic liver Disease

• Abetalipoproteinemia

What is this RBC shape?

Bister cells

Blister cells

Morphology

• inclusions pitted out by healthy spleen and memb. healed back around creating ‘hole’

Disease(s)

• any condition with inclusion bodies

What is this RBC shape?

Burr Cell

Burr Cell

Morphology

• uniform projections around cell

• central pallor

Disease(s)

• due to body change in tonicity

  • Cancer of stomach, Hemolytic uremic syndrome (HUS), PK, hemolytic anemias

What is this RBC shape?

Crenation

Crenation

Morphology

• more spiky than burr cell

• drying artifact

  • drying too fast or making slide

Disease(s)

• sometimes severe electrolyte imbalance

What is this RBC shape?

Elliptocytes

Elliptocytes

Morphology

• cigar shaped

• elongated

Disease(s)

• hereditary elliptocytes

What is this RBC shape?

Hemoglobin C crystals

Hemoglobin C crystals

Morphology

• “gold bar”

• intracellular

Disease(s)

• hemoglobin C disease

What is this RBC shape?

Hemoglobin S-C crystals

Hemoglobin S-C crystals

Morphology

• “jut” out of cell/ “glove/mitten” shape

Disease(s)

• two different mutations

  • S: changes Gln to Valine

  • C: changes Gln to lysine

What is this RBC shape?

Macro-ovalocyte

Macro-ovalocyte

Morphology

• big oval egg shape

• less cell division

Disease(s)

• megaloblastic anemia

• Pernicious anemia

What is this RBC shape?

Round Macrocytes

Round Macrocytes

Morphology

• very round

• central pallor

Disease(s)

• liver disease

• reticulocytotic

What is this RBC shape?

RBC clumps (autoagglutination)

RBC clumps

Morphology

• RBC getting stuck together

Disease(s)

• cold agglutinin antibody

• autoimmune processes

What is this RBC shape?

Rouleaux

Rouleaux

Morphology

• stacking of RBC in a line

Disease(s)

• multiple myeloma

• Waldenstrom’s Macroglobulinemia

What is this RBC shape?

Schistocytes (fragments)

Schistocytes

Morphology

• fragments of RBC

Disease(s)

• Burn patients

• Hallmark of hemolytic anemia

What is this RBC shape?

Sickle Cell

Sickle Cell

Morphology

• Pointed and/or folded ends

Disease(s)

• Hemoglobin S mutation: gln to Valine

What is this RBC shape?

Spherocytes

Spherocytes

Morphology

• dark/dense + small

• no pallor

Disease(s)

• hereditary spherocytosis

• Transfusion of blood

What is this RBC shape?

Stomatocytes

Stomatocytes

Morphology

• “coin slot”

• drying artifact

Disease(s)

• hereditary stomatocytosis

• Rn null disease

• liver disease

What is this RBC shape?

Target cells

Target Cells

Morphology

• most common

• “target” look

• hemoglobin centered or outside of cell (creates ring)

Disease(s)

• hemoglobinopathies

• liver disease

• thalassemias

What is this RBC shape?

Teardrops

Teardrops

Morphology

• teardrop shape

• red cells get squeezed coming out of BM

Disease(s)

• megaloblastic anemia

• myelofibrosis

• tumor in BM

What is this RBC shape?

Mixed cell population

Mixed cell population

Morphology

• 2 distinct RBC populations

Disease(s)

• transfusion therapy

• sideroblastic anemia

What is this RBC inclusion?

Basophilic Stippling

Basophilic Stippling

Morphology

• purple/blue dots on wright stain

• Altered RNA

Disease(s)

• lead poisoning

• Thalassemia

What is this RBC inclusion?

Howell-jolly bodies

Howell-jolly Bodies

Morphology

• round purple/black dot

• “mole”

• DNA nuclear remnants

Disease(s)

• Sickle cell

• Megaloblastic anemia

• post-splenectomy

• anemias

What is this RBC inclusion?

Pappenheimer bodies

Pappenheimer bodies

Morphology

• Clumps/cluster

• “bomb”

• non-heme iron

• Prussian blue and Wright stain

Disease(s)

• sideroblastic anemia

• thalassemia

• hemolytic anemias

What is this RBC inclusion?

Heniz Bodies

Heniz bodies

Morphology

• cannot see on wright stain ONLY supravital

• precipitated HGB

Disease(s)

• G-6-PD

What is this RBC inclusion?

Cabot Ring

Cabot Ring

Morphology

• ring form

• mitotic spindle remnant

Disease(s)

• lead poisoning

• pernicious anemia

What is this RBC inclusion?

Malarial Parasite

Malarial Parasite

Morphology

• ring form

• parasite in RBC

Disease(s)

• parasitemia

4 RBC morphologies that can be artifactually made

1. Crenation (drying artifacts)

2. Rouleaux (sit too long on slide)

3. Teardrop (too much pressure)

4. Schistocytes (too much pressure)

Define isotonic:

Solutions that are categorized as having equivalent or identical osmotic pressure

Define RPI

reticulocyte production index

• corrects for shifts/stress retics or nRBCs in RBC count

Define RDW

reflects the variability og red cell size (width)

• normal range: 11.5-14.5%

• increased correlates with anisocytosis

Define siderotic granules

another name for pappenheimer bodies