Sect 2 - Cell Morphologies & Inclusions

importance of reporting morphologies

1. helps with diagnosis

2. gives provider into about progression/severity of disease

3. confirms finding/flags from analyzer

why peripheral smears are ordered

Provider ordered it

Specific manual testing by hematology (LAP/FMH testing)

Met criteria from the analyzer flags, needs verified

Pediatric patients (esp. fingerstick draws)

Specifically asked for by pathologist for confirmation of abnormal cells

LAP stain

stain used for bacteria or cancer; always look for neutrophils (specifically stained granules)

Fetal-Maternal hemorrhaging

What does FMH stand for?

fresh blood samples & copy of analyzer printout

make several stained & unstained slides

When a peripheral smear is specifically ordered to be sent to the pathologist for confirmation or abnormal cells, what are the 2 requirements neede?

1. patient's full name (first and last)

2. sample ID number or DOB

patient identifiers needed on slides when labeled (2):

1 month

How long are slides kept?

push (wedge)/cover slip method

technique used when making a peripheral smear

1. using right size blood drop

2. speed at which you spread

3. angle at which the drop is spread

3 factors that help determine a good technique is being used for a peripheral blood smear:

optimal smear

min length 2.5 cm

transitional from thick to thin

straight feathered edge

no streaks, waves, or troughs

true

T or F:

Always mix the specimen before making a peripheral smear

Wright's stain

stain used for performing manual differentials

Romanowsky stain

another name for a Wright's stain

Methylene Blue

Eosin

Glycerin

three components of a Wright's stain

Supravital stain

Stain used for Retic counts and identification of other inclusions in suspected disease processes for confirmation

true

T or F:

The Supravital Stain does NOT kill the cells, so we can observe them living

New Methylene Blue

Brilliant Cresyl Blue

two types of Supravital stains

RNA

DNA

Heinz bodies (denatured hgb(

Siderotic granules of RBC

What cell components are stained by the Supravital stain?

stain is orange

buffer pH

stain is purple

buffer pH >6.0 or too alkaline

Caused by excess stain to buffer and not adequately rinsed

CFU in cell maturation

G = granulocytes

E = erythroid cells

M = macrophage/monocyte cells

M = megakaryocyte cells (platelets)

Normocytic

Red Cell Distribution Width

What is A?

Microcytic

Red Cell Distribution Width

What is B?

Macrocytic

Red Cell Distribution Width

What is C?

Dimorphic

Red Cell Distribution Width

What is D?

**hint: seen in blood transfusion pts (2 pops present)

the patient (microcytic)

In D, the left curve represent which population?

donor (normocytic)

In D, the right curve represents which population?

Anisocytosis

Variation in sizes of RBCs

(RDW is indicator of this: ↑ RDW = ↑ anisocytosis = more variation is sizes)

Conditions associated: blood transfusion

Microcytes

RBCs that are abnormally small

- MCV < 80fl

- oval & big central pallor

Conditions Assoc: Iron deficiency anemia, thalassemia minor, chronic inflammatory, lead poisoning, hemoglobinopathies, and sideroblastic anemia

Macrocytes

RBCs that are abnormally large

- MCV >100fl

- NO central pallor

Conditions Assoc: Liver disease, vitamin B12 deficiency, folate deficiency, neonates, and reticulocytes

Poikilocytosis

variation in RBC shape

- reporting is specific to lab

Conditions Assoc: Severe anemia, Hemolytic states

Polychromasia

indication of immature erythrocyte

- basophilic color = blue

Conditions Assoc: Increased erythropoiesis, Hemolysis, Acute & Chronic hemorrhage, Regenerative RBC process

Spherocytes

created by defect in membrane proteins in RBCs (decreased surface area:volume ratio)

- MCHC >36%

- NO central pallor, dense

Conditions Assoc: Hereditary, Hemolytic anemias (Immune/Autoimmune), Post-transfusion, Severe burns

Microspherocytes

like spherocytes, but smaller

- CRITICAL FINDING & SIGNIFICANT

Conditions Assoc: Autoimmune hemolytic anemia, Post transfusion

Codocytes (Target Cells)

caused by a membrane defect

- excess membrane cholesterol and phospholipids; decreased cellular hgb

- red/salmon color

- "bullseye"

Conditions Assoc:

Hemoglobinopathies (sickle cell (HgbS), HgbC)

Thalassemia's (decreased production in alpha & beta chains)

Iron-Deficiency Anemia (IDA)

other: Splenectomy, Obstructive liver disease

Dacryocytes (Tear Drop)

RBC squeezing and passing through spleen/fibers

- "tear drop" shape facing different directions

Conditions Assoc: Primary myelofibrosis, Ineffective erythropoiesis, Megaloblastic anemia, Thalassemia

artifacts if all tear drops face same direction

Elliptocytes (Ovalocytes)

abnormal cytoskeletal proteins

- cannot change back to normal shape, but still able to carry O2 like regular RBCs

- irregular, elliptically shaped RBCs

Conditions Assoc: Hereditary elliptocytosis, Iron Deficiency Anemia (IDA)

Sickle Cell (Drepanocyte)

abnormal presence of Hgb S (cell inflexible)

- polymerization of deoxygenated hgb (taking O2 out - polymerizes & changes shape)

- NO central pallor

- crescent shaped

- normal MCV

Conditions Assoc: Sickle-cell anemia

<120 days

life span of Sickle cell

Degmacyte (Bite/Helmet cell)

spleen pits out the Heinz body

- cell body is denatured hgb due to oxidative injury

- seen in Wright's stain

- RBC has "bite" taken out of it

Conditions Assoc: G6PD deficiency, Drug induced hemolysis

Heinz body

Which degmacyte cell is seen in the supravital stain?

Echinocytes (Burr Cells)

regular contracted cells with short, evenly spikey projections & preserved central pallor

Conditions Assoc: KIDNEY PROBLEMS: Uremia, Secondary ATP deficiency, altered membrane lipid

artifact due to hypertonicity/alkalinity of stain solution

Acanthocytes

increased cholesterol/phospholipid ratio (increase surface area); decreased lecithin

- spiny projections on the surface of RBC

- slight loss of central pallor

- hint: ACANT = I CANT make normal shape :(

Conditions Assoc: Hemolytic anemia, Alcoholic cirrhosis (liver issue), Vitamin E deficiency, Post-splenectomy, Severe liver disease, Pyruvate kinase (PK) deficiency, Congenital abetalipoprotienemia

Stomatocytes

increased permeability to sodium

- bowl-shaped with slit like area in central pallor

- looks like a screwhead for flat screwdriver

Conditions Assoc: LIVER PROBLEMS: Acute alcoholism (screwdrivers), Hereditary Stomatocytosis, Liver disease, Cirrhosis, Hemolytic anemia

artifacts due to staining solution is too acidic

Schistocytes

fragmentation of RBCs due to membrane damage

- CLINICALLY SIGNIFICANT (life or death)

- should not be seen in peripheral blood

Conditions Assoc:

Disseminated Intravascular Coagulation (DIC)

Pulmonary Emboli (clot in lungs)

Microangiopathic hemolytic anemia (small clots in vessles)

Other: Thrombotic thrombocytopenia purpura (TTP), G6PD deficiency, Hemolytic uremic syndrome (HUS), Burns, Heart valves

HbC Crystals

lysine replaces glutamic acid in beta chain

- rectangular and dense

- looks like "bar of gold"

Conditions Assoc: Hgb C; Hgb S (glutamic acid replaced with valine)

too alkaline stain

Causes RBCs to become crenated (look like Echinocytes/Burr cells)

Abnormality in peripheral smear that is caused by slide making techniques

too acidic stain

Causes RBCs to become Stomatocytes

water artifacts

What type of artifact will you have if the slide is not allowed to dry properly?

makes identification of morphologies harder to determine than normal

true

T or F:

Abnormal cells should be distributed EVENLY through the slide for them to be considered notable or significant

Basophilic stippling

Cabot Ring

Howell-Jolly body

Pappenheimer body

RBC inclusions:

Basophilic stippling

Components: RNA and mitochondrial segments (precipitated ribosomes)

Wright stain used

lead posining

Coarse Basophilic stippling is seen in:

increased polychromasia

Fine Basophilic stippling in seen in:

Cabot Rings

Components: Nuclear membrane remnants, part of mitotic spindle, remnant of microtubules

Conditions Assoc: post-splenectomy, hemolytic anemia, megaloblastic anemia

Wright stain used

Howell-Jolly Body

Components: DNA nuclear fragments, fragment of nucleus that was extruded or fragments of chromosome separated by the mitotic spindle

Conditions Assoc: post-splenectomy, hemolytic anemia, megaloblastic anemia

Wright stain used

Pappenheimer body

Unused iron (non-heme) that was in excess

Conditions Assoc: sideroblastic anemia, post-splenectomy

Wright stain used

Heinz body

Body found in periphery of the RBC that is precipitated due to denatured Hgb due to oxidative injury

Conditions Assoc: G6PD deficiency

Supravital stain used

false; see Bite/Helmet cells

T or F:

Heinz bodies can be seen in the Wright Stain

parasitic infection only found within RBCs

What type of infection is Malaria?

protozoan transmitted by the bite of a female Anopheles mosquito

How is Malaria transmitted?

Plasmodium falciparum

most common type of Malaria seen in lab

produces delicate rings; do not enlarge the cell

Plasmodium falciparum

Which type of Malaria?

Rouleaux

appears as a "stack of coins"

clumping induced by circulating paraproteins

Condition associated: paraproteinemia (plastic cell myeloma) & Multiple myeloma

Cold Agglutinin

random clumps of red cells (warming sample will break them up) that are caused by cold temperature of the sample

very high MCV (>130)

Conditions Assoc: Associated with EBV infection:

Mono in kids

Mycoplasma infections in adults

IgM anti-I antibodies

Cold agglutinins are most commonly associated with which anitbodies?

Dohle bodies

Toxic granulation

Vaculization

Hypersegmentation

Ehrlichiosis

WBC inclusions:

Dohle bodies

round-oval pale grayish-blue inclusions composed of RNA that are found in the periphery of the cytoplasm of neutrophils

Conditions Assoc: burns, infections, physical trauma, neoplastic disease, may also indicate May-Hegglin anomaly

neutrophils

Which type of WBC do you ONLY see Dohle bodies?

Vacuolization

formation of vacuoles within or adjacent to cells that is only seen in neutrophils

related to bacterial infection and caused by increased activity of phagocytosis in the cell

observed in pts that are septic

neutrophils

Which type of WBC do you ONLY see

Vacuolization?

Toxic Granulation

observed in bacterial infection where granules are darker in the neutrophils

seen in vacuolization and Dohle bodies

>5 lobes

How many lobes must a neutrophil have in order to be considered hypersegmented?

megaloblastic anemia

What type of anemias would hypersegmentation be seen in?

Ehrlichiosis

infectious disease caused by bacteria that belongs to the Rickettsia group that is transmitted by bite of infected tic

pale purple circle in cell of granulocytes

decreased WBCs and platelets

increased liver enzymes

other lab findings associated with Ehrlichiosis

Analyzer flags for clumping

Pt results do not match previous results (check for micro clots, verify analyzer results)

What situation would call for a platelet estimation to be done?

equation of platelet estimation

150,000-400,000/ul

normal range for platelets

adequate, increased, decreased

terms used when resulting out platelet estimations

Agranular platelet

platelet without granulation

- giant

- associated with rapid platelet production

giant platelets

platelets the size of WBCs & RBCs (looks like WBCs without nucleus)

Conditions Assoc: thrombocytopenia, myelofibrosis, CML, Bernard-Soulier Syndrome

bizzare platelets

irregularly shaped

large sized platelets

pseudopods

associated with Myelofibrosis

neutrophils

Which WBC does platelet satellitism occur with?

more than 4 platelets

How many platelets are involved in order to call satellitism?

in vitro artifact in EDTA anticoagulant blood

platelet satellitism is associated with:

inadequate mixing

over-filling anticoagulant tubes

"sewing machine" method

factors that cause platelet clumping

water

What type of artifact?

Pyknotic cell

What type of artifact?

platelet superimposed

What type of artifact?

stain precipirate

What type of artifact?

same direction

Dacryocytes that face __________ are considered artifact

dead cells

What are pyknotic cells?