Mayo Clin Proc, January 2003, Vol 78 Running Head 809

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Schistocytes on the Peripheral Blood Smear

AYALEW TEFFERI, MD, AND MICHELLE A. ELLIOTT, MD
Division of Hematology and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn

T he presence of schistocytes (fragmented red blood

cells) on the peripheral blood smear suggests red blood
cell injury from damaged endothelium and is a characteris-
tic feature of microangiopathic hemolytic anemia. Micro-
angiopathic hemolytic anemia is an infrequent cause of
Coombs-negative intravascular hemolytic anemia, and its
causes include thrombotic thrombocytopenic purpura/
hemolytic uremic syndrome, disseminated intravascular
coagulation, and defective valvular prosthesis. The platelet
count is normal in microangiopathic hemolytic anemia that
is associated with valvular prosthesis but is often decreased
in both disseminated intravascular coagulation and throm-
botic thrombocytopenic purpura. The last two-mentioned
conditions may be differentiated by the presence of abnor-
mal coagulation factor assays (prolonged prothrombin or
partial thromboplastin time, decreased fibrinogen, in- current blood smear, the presence of schistocytes is accom-
creased D-dimer, and positive soluble fibrin monomer as- panied by the absence of platelets that suggests the diagno-
say) in disseminated intravascular coagulation but not in sis of either thrombotic thrombocytopenic purpura or dis-
thrombotic thrombocytopenic purpura, at least not in the seminated intravascular coagulation.
initial stages. The possibility of thrombotic thrombocyto-
penic purpura/hemolytic uremic syndrome should always 1. Elliott MA, Nichols WL. Thrombotic thrombocytopenic purpura and
hemolytic uremic syndrome. Mayo Clin Proc. 2001;76:1154-1162.
be considered in acute-onset thrombocytopenia, which is 2. Elliott MA, Nichols WL Jr, Plumhoff EA, et al. Posttransplantation
often profound (platelet count, <20 × 109/L), especially in thrombotic thrombocytopenic purpura: a single-center experience
the presence of either renal insufficiency or fluctuating and a contemporary review. Mayo Clin Proc. 2003;78:421-430.
3. George JN, Sadler JE, Lämmle B. Platelets: thrombotic
neurologic changes because of the need for immediate thrombocytopenic purpura. Hematology (Am Soc Hematol Educ
institution of specific therapy (plasma exchange).1-3 In the Program). 2002;315-334.

Mayo Clin Proc. 2004;79:809 809 © 2004 Mayo Foundation for Medical Education and Research

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