ERYTHROCYTES RELATED ABNORMALITIES AND DISEASES

1. Erythrocytic Morphology And Associated Disease (Size And Shape)

ERYTHROCYTIC MORPHOLOGY AND ASSOCIATED DISEASE (SIZE AND SHAPE)

1. Normocytes(discocytes)
- Are normal erythrocytes that are appropriately the
same size as the nucleus of a small lymphocytes

2. Macrocytes
a. RBCs greter that 8 um; MCV greter than 100fL.
b. Seen in megaloblastic anemias, such as vit. B12 folate deficiency
c. Seen in non megaloblastic anemia of liver disease
or accelerated erythropoiesis; also seen in normal new borns

3. Microcytes
a. RBCs less than 6um in diameter:
MCV less than 80fL
b. Seen in iron deficiency anemia, thalassemia,
Sideroblastic anemia and anemia of chronic disease

4. Anisocytes
a. Variation in RBC size, indicating a
Heterogenous RBC population (Dimorphism)
b. Correlates with RDW (red cell distribution width),
Especially when the RDW exceeds 15%
c. Seen in post transfusion, post treatment for a deficiency
(e.g. iron), presence of two concurrent deficiencies
(e.g. iron and vitamin B12), and idiopathic sideroblastic anemia

5. Poikilocytes
a. General term to describe variation in shape
b. Associated with a variety of pathologic conditions

6. Echinocytes
a. Have evenly spaced round projections;
central pallor area present
b. Seen in liver disease, uremia, heparin therapy,
pyruvate kinase deficiency, or as an artifact
c. Caused by change in osmotic pressure

7. Achantocytes (spur cells)

a. Have unevenly spaced pointed projections;
Lack central pallor area
b. Associated with alcoholic liver disease, post splenectomy,
Abetalipoproteinemia and Mcleod syndrome
c. Caused by excessive cholesterol in the membrane
8. Target cells (codocytes or Mexican hat cells)
a. Show a central area of hemoglobin
Surrounded by a colorless ring, and peripheral ring
Of hemoglobin: cells have an increased surface to volume ratio
b. Seen in liver disease, hemoglobinopathies, thalassemia,
Iron deficiency anemia.
c. Caused by excessive cholesterol in the membrane or a hemoglobin
Distinction imbalance

9. Spherocytes
a. Disk-shaped cell with a smaller volume
than a normal erythrocyte;
cells have a (decreased surface-to-volume) ratio
b. Lack a central pallor area
c. Associated with defects of the red cell membrane proteins

10. Teardrops (dacrocytes)

a. Pear-shaped cell with one blunt projection
b. Seen in megaloblastic anemias, thalassemia,
And extramedullary hematopoiesis (myelofibrosis,
Myelonephtitis anemia)

11. Sickle cells (drepanocytes)

a. Shapes vary but show, thin, elongated,
Pointed ends and will appear crescent shaped;
Usually lack a central pallor area
b. Contain polymers of abnormal hemoglobin
c. Seen in hemoglobinopathies SS, SC,
SD, and S/Beta-thalassemia
d. Cell shape is caused by cell membrane alterations
Due to an amino acid substitution

12. Helmet cells ( Horn cells, keratocytes or folded cells)

a. Interior portion of cell is hollow,
resembling a horn or helmet
b. Seen in microangiopathic hemolytic anemia

13. Schistocytes (RBC Fragments)

a. Damaged RBC; fragments of various
Sizes and shapes are present, often with
Pointed projections
b. Seen in microangiopathic hemolytic
Anemias (e.g. DIC, HUS, ITP), thermal injury,
Renal transplant rejection and G6PO deficiency
 14. Stomatocytes (mouth cells)
a. Characterized by an elongated or slit like are-of central pallor
b. Seen in liver disease, hereditary stomatocytosis or as an artifact
c. Caused by osmotic changes due to cation imbalance

15. Elliptocytes (ovalocytes)

a. Cigar to egg shaped erythrocytes
b. Associated with defects of the red cell membrane proteins
c. Seen in hereditary elliptocytosis,
Iron deficiency anemia (pencil forms),
megaloblastic anemia (macro-ovalocytes), thalassemia major

ERYTHROCYTE INCLUSION AND ASSOCIATED DISEASE

1. Nucleated RBCs (nRBCs)

a. Usually orthochromatic normoblasts (metarubricyte)
but can appear in any erythrocytic stage of maturation
b. Indicate bone marrow stimulation or increased erythropoiesis

2. Hollow-Jolly bodies
a. Small, round DNA fragment (0.5-1.0 um in diameter)
Usually one per cell, but can be multiple
b. Stain dark purple to black with Wright’s stain
c. Not seen in normal erythrocytes;
Normally pitted by Splenec macrophages
d. Seen in sickle cell anemia, beta thalassemia major,
and other severe hemolytic anemias, megaloblastic anemia,
alcoholism, post-splenectomy

3. Basophilic Stippling
a. Multiple, tiny, fine and coarse inclusions
(ribosomal RNA remnants) evenly dipersed throughout the cell;
“blueberry bagel” appearance
b. Stain dark blue with Wright’s stain
c. Seen in thalassemia, megaloblastic anemia,
Lead poisoning, and alcoholism

4. Pappenheimer bodies
a. Small, irregular, dark staining, iron granules
usually dumped together at periphery of the cell
b. Stain with Peri’s Prussian blue stain;
Appear dark violet with Wright’s stain
c. Caused by an accumulation of ribosomes,
mitochondria and iron fragments
d. Seem in sideroblastic anemia, hemoglobinopathies, thalassemia,
e. Megaloblastic anemia, myelodysplastic syndrome (RARS)
 5. Cabot rings
a. Thin, red-violet, single to multiple
Rings like structures that may appear in loop of figure-eight shapes
b. Seen in megaloblastic anemia,
Myelodysplastic syndromes, lead poisoning
c. Compoun fragments of nuclear material

6. __

7. Hemoglobin SC crystals (Washington monument)

a. 1-2 blunt, finger-like projections extending from the cell
Membrane
b. Seen in hemoglobin SC disease

8. Heinz bodies
a. Multiple inclusions ranging in size from 0.3-2.0um
b. Invisible with Wright’s stain; must use a supravital stain to visualize
c. Seen in G6PD deficiency, beta thalassemia major, Hgb H disease,
an unstable hemoglobinopathies, drug-induced anemias

9. Malarial Parasites
a. Include P.vivax, P. falcifarum, P.malariae, and P. ovale

ERYTHROCYTE HEMOGLOBIN CONTENT AND ASSOCIATED DISEASE

1. Normochromasia
a. Cells have the normal one-third clear, central pallor area

2. Hypochromasia
a. Central pallor area is greater than one-third the diameter of the cell
b. MCH and MCHC usually decreased
c. Often associated with microcytosis
d. Seen in:
 Iron deficiency anemia
 Thalassemias
 Anemia of chronic disorder
 Sideroblastic anemia
 Myelodysplastic syndromes

3. Polychromasia
a. Variation in hemoglobin content showing a
slight blue tinge when stained with wright’s stain
b. Indicates reticulocytosis; supravital reticulocyte stain to enumerate
c. Usually slightly macrocytic
 4. Hyperchromasia (term no longer used)
a. Current terminology is spherocyte; lacks a central pallor area

ABNORMAL ERYTHROCYTE DISTRIBUTIONS AND ASSOCIATED DISEASE

1. Rouleaux
a. Stacking or “coining” pattern of RBCs due to abnormal
or increased plasma protein
b. May see excessively blue color to smear
macroscopically and microscopically
c. Seen in hyperprotenemia, multiple myeloma, Waldenstorm,
macroglobulinemia, and conditions that produce
increased fibrinogen (chronic inflammation)
d. Maybe an artifact; considered
Normal in thicker area of the peripheral smear
e. True rouleaux formation is determined in the
thin area of the peripheral smear

2. Agglutination
a. Characterized by clumping of erythrocytes
with no pattern
b. Occurs when erythrocytes are coated with
IgM antibodies and complement
c. Seen in cold autoimmune hemolytic anemia (cold agglutinin disease)
d. Warm blood to 37 deg Celcius to correct a
false low RBC and hematocrit and falsely high MCHC (>37g/dL)
when using an automated cell counting instrument.