MORPHOLOGY OF RED BLOOD CELL

A Seminar on

Submitted to:
Ainah Charina B. Tapic, RMT
Clinical Internship Coordinator

Submitted by:
Chabellita D. Sandialan
Arnelle Nicaea D. Delcano

DATE:
ABSTRACT

Blood cell morphology is a key tool in laboratory haematology. A skillfull

examination of a well-made blood smear constitutes the most valuable single
procedure in the hematology laboratory. In spite of normal blood figures, careful
observation of blood morphology suggested previously unsuspected disorders. For
example, in some cases the finding of hypersegmented neutrophils on the blood smear
was the first hematologic clue to a significant deficiency of vitamin B12 or folate, the
erythrocytes lacking the characteristic macrocytosis associated with such deficiencies.
The reporting of blood morphology has been improving in recent years, although in
many clinical laboratories, it still receives little attention. The blood count report from
frequently leaves only a tiny area of morphologic comments.
 TABLE OF CONTENTS

Title
Page…………………………………………………………………………………1
Abstract……………………………………………………………………………..2
Table of Contents…………………………………………………………………..3
List of Tables and
Figure………………………………………………………………………………4-7
Introduction…………………………………………………………………………8
Body of the
report……………………………………………………………………………..9-10
Conclusion…………………………………………………………………………11
Summary……………………………………………………………………………12
List of References…………………………………………………………………..13
INTRODUCTION

Blood morphology adds greatly to the value of a routine blood count. A skillful
examination of a well-made blood smear constitutes the most valuable single
procedure in the hematology laboratory. In spite of normal blood count figures,
careful observation of blood morphology suggested previously unsuspected disorders.
For example, in some cases, the finding of hypersegmented neutrophils on the blood
smear was the first hematologic clue to a significant deficiency of vitamin B12 or
folate, the erythrocytes lacking the characteristic macrocytosis associated with such
deficiencies.

The reporting of blood morphology has been improving in recent years, although in

many clinical laboratories, it still receives little attention. The blood count report form
frequently leaves only a tiny area for morphologic comments!
A blood smear is a drop of blood spread thinly onto a glass slide that is then treated
with a special stain and examined under a microscope by a trained laboratorian. It is a
snapshot of the cells that are present in the fluid portion of the blood (plasma) at the
time the sample is obtained.  The results of a blood smear typically include a
description of the appearance of the red blood cells, white blood cells, and platelets as
well as any abnormalities that may be seen on the slide.
BODY OF REPORT

Blood morphology adds greatly to the value of a routine blood count. A skillful
examination of a well-made blood smear constitutes the most valuable single
procedure in the hematology laboratory. In spite of normal blood count figures,
careful observation of blood morphology suggested previously unsuspected disorders.
For example, in some cases, the finding of hypersegmented neutrophils on the blood
smear was the first hematologic clue to a significant deficiency of vitamin B12 or
folate, the erythrocytes lacking the characteristic macrocytosis associated with such
deficiencies.

The reporting of blood morphology has been improving in recent years, although in
many clinical laboratories, it still receives little attention. The blood count report form
frequently leaves only a tiny area for morphologic comments!

A blood smear is a drop of blood spread thinly onto a glass slide that is then treated
with a special stain and examined under a microscope by a trained laboratorian. It is a
snapshot of the cells that are present in the fluid portion of the blood (plasma) at the
time the sample is obtained. The results of a blood smear typically include a
description of the appearance of the red blood cells, white blood cells, and platelets as
well as any abnormalities that may be seen on the slide.

 Red Blood Cell Morphology

Red blood cells (erythrocytes) are biconcave disks with a diameter of 7-8 microns,
which is similar to the size of the nucleus of a resting lymphocyte. In normal red
blood cells, there is an area of central pallor that measures approximately 1/3 the
diameter of the cell. Though reference ranges vary between laboratories and in
different age groups, normocytic red blood cells typically have a mean corpuscular
volume (MCV) between 80-100 fL.

Spherocytes are formed when there is a loss of part of the red blood cell membrane.
This may occur in the setting of immune-mediated hemolysis or congenital red cell
membrane defects such as hereditary spherocytosis. Spherocytes are smaller than
normal red blood cells and lack central pallor. They are less deformable and less able
to navigate through small vessels, leading to increased destruction in the spleen.

Microcytic red blood cells measure 6 microns or less in diameter. The mean
corpuscular volume is generally less than 80 fL, though the normal range varies
slightly between laboratories and in different age groups. In contrast to spherocytes,
which are also decreased in diameter, microcytes retain their central pallor. In
microcytosis due to iron deficiency, the central pallor is increased (more than 1/3 the
diameter of the cell).

Teardrop cells in a peripheral blood smear from a patient whose bone marrow was
extensively replaced by B lymphoblastic leukemia. Teardrop cells may be seen in the
setting of marrow infiltration (by fibrosis, granulomatous inflammation, hematologic
or metastatic malignancy), splenic abnormalities, megaloblastic anemia, and
thalassemia. True teardrop cells have slightly rounded or blunted ends. In contrast,
teardrop cells that are formed as an artifact of smear preparation have very sharp
points, all facing in the same direction.
Cabot rings are thin, threadlike, red to violet rings or “figure 8” shaped inclusions in
red blood cells. Cabot rings are remnants of the mitotic spindle, and can be seen in
megaloblastic anemia, medication effect, myelodysplasia and other forms of
dyserythropoiesis. In this image of a blood smear from a patient with vitamin B12
deficiency, the Cabot ring is visible as a faint ring-shaped inclusion in the
polychromatophilic cell in the center of the field.

Peripheral blood smear of a 38-year-old female with long-standing Crohn’s disease

(CD) and development of microcytic anemia. The smear shows numerous target cells
and a spur cell (top right). All liver function tests were abnormal indicating that the
target cells are due to liver disease secondary to CD. This patient originally had a
concomitant iron deficiency. Spur red cells have elongated projections while Burr
cells are red cells with circumferential blunted borders. The former is typically seen in
liver disease while the latter is seen in uremia. The “Burr” morphology, in this case, is
artifactual related to slide preparation and not related to uremia.

Acanthocytes in two patients with liver disease. Acanthocytes (also called spur cells)
are spiculated cells with irregular, pointed or clublike projections that are unevenly
distributed on the cell surface. Central pallor is absent. Acanthocytes form as a result
of membrane lipid abnormalities, and can be seen in liver disease,
neuroacanthocytosis, severe malnutrition, and abetalipoproteinemia.

Sickle cells (drepanocytes) are elongated red blood cells with pointed ends. They are
seen in sickling hemoglobinopathies such as sickle cell anemia (homozygous
hemoglobin SS), hemoglobin SD disease, and hemoglobin S/beta-thalassemia.

Echinocytes (Burr Cells) have multiple short, blunt projections evenly spaced over the
cell surface. The central pallor is retained. Echinocytes can be seen in uremic
patients. They can also be seen as an artifact of slide preparation or prolonged
specimen storage.

Stomatocytes are red cells with a slit-like or “fish-mouth” central pallor. Stomatocytes
may be seen in patients with alcoholic liver disease, hereditary stomatocytosis, or Rh
null disease, among other conditions. They may form in vitro in the presence of
certain cationic medications or low pH.

Red cell fragments (schistocytes) in a patient with microangiopathic hemolysis due to

thrombotic thrombocytopenic purpura (TTP). Small triangulocytes and larger,
crescent-shaped helmet cells are present. Both of these are red cell fragments and
would be included in the schistocyte count. When numerous small schistocytes are
present, automated cell counters may count the small red cell fragments as platelets,
leading to a falsely elevated automated platelet count.

Oxidative hemolysis induced by furosemide in a patient with G6PD deficiency. In

oxidative hemolysis, the peripheral smear may show irregularly contracted red blood
cells, hemighost or blister cells, and spherocytes. Irregularly contracted cells lack
central pallor, and the hemoglobin appears condensed and irregularly distributed in
the red blood cell.

Clumping (agglutination) of red blood cells is frequently caused by cold agglutinins.

Cold agglutinins are IgM antibodies that may arise following viral or Mycoplasma
infections, or in the setting of plasma cell or lymphoid neoplasms. Agglutination of
red cells can interfere with red blood cell indices.
The red blood cell count may be falsely decreased, and the MCV falsely increased, as
clumps of red cells are measured as single cells. The hemoglobin level will be
accurate, as this parameter is measured after lysing the red cells.

Polychromasia (polychromatophilic cells) in a neonate. Polychromatophilic cells are

young red blood cells that have been recently released from the bone marrow. They
are larger than mature red cells, and are bluish in color. Polychromasia is increased in
hemolysis, blood loss, and marrow infiltration. Normal neonates have a higher
number of polychromatophilic cells than older children and adults. Polychromasia

Howell-Jolly body: the red blood cell in the center of the image contains a Howell-
Jolly body. Howell-Jolly bodies are small (0.5-1 micron) purple inclusions that
contain DNA. They are thought to represent chromosomes that have separated from
the mitotic spindle that is left behind when the red cell nucleus is extruded. These
inclusions are generally removed by the spleen.
Patients with asplenia or hyposplenism may have increased Howell-Jolly bodies on
their peripheral blood smear. A nucleated red blood cell is also present at the bottom
left side of the image. Howell-Jolly body

Proerythroblasts (also called pronormoblasts) are the earliest erythroid precursors.

These are large cells with basophilic, agranular cytoplasm, round nuclei, and high
nuclear-cytoplasmic ratios. The chromatin is evenly dispersed, but is slightly more
dense than myeloblast chromatin. One or more nucleoli may be visible. A
perinuclear clear area (hof) may also be seen. A single proerythroblast is seen in the
center of this image. Polychromatophilic and orthochromic normoblasts are present
on the right side of the field.

Basophilic normoblasts (also called basophilic erythroblasts or early erythroblasts) are

smaller than proerythroblasts, with more condensed chromatin and lower nuclear-
cytoplasmic ratios. The cytoplasm is deep blue, and a pale perinuclear halo may
present. The two cells in the center of the field are basophilic normoblasts.

Orthochromic normoblasts (also called orthrochromatophilic normoblasts,

orthrochromatophilic erythroblasts, or late erythroblasts) are slightly larger than
mature red blood cells. They have small, round nuclei and dense, pyknotic chromatin.
The cytoplasm is generally slightly more basophilic than the cytoplasm of a mature
red blood cell.

Erythroid precursors at various stages of maturation. Basophilic normoblasts are

present at the center of the field. Polychromatophilic normoblasts and orthochromic
normoblasts are present near the bottom of the field. As erythroid precursors mature,
the cell size and nuclear-cytoplasmic ratio decrease, and the chromatin becomes
progressively more condensed. The cytoplasm changes color from deep blue to gray-
blue to gray-pink as the hemoglobin content increases.

A deficiency of either vitamin B12 or folic acid results in megaloblastic erythroid

cells-megaloblasts. These deficiencies result in a decrease in DNA synthesis which
slows and inhibits DNA replication (nuclear division). Nuclear maturation is slowed
whereas cytoplasmic maturation (largely dependent on RNA function) is unaffected.
The impaired nuclear maturation is seen as open, loose, immature chromatin (cut-
salami pattern). In contrast to the nucleus, the cytoplasm of megaloblastic cells is
abundant with normal hemoglobinization. This disparity between nucleus and
cytoplasm is known as nuclear-cytoplasmic asynchrony. Although most noticeable in
erythroid cells failure of DNA synthesis also affects myeloid and megakaryocytes.
Giant bands and hypersegmented polymorphonuclear neutrophils are common.

Vacuolated erythroid precursors can be seen in copper deficiency, Pearson syndrome,

and myelodysplastic syndromes. In this image, a vacuolated erythroid precursor is
adjacent to another dysplastic erythroid precursor with megaloblastic features
(nuclear-cytoplasmic asynchrony) and nuclear irregularities. The patient had acute
myeloid leukemia with myelodysplasia-related changes.
CONCLUSION

The review of red blood cell morphology is a critical step in the evaluation of a
patient with anemia. It can be very useful in evaluating microcytic, normocytic, and
macrocytic anemias and is especially helpful in the work-up of patients with
hemolysis. Assessment of RBC morphology can be the best tool for laboratory
hematology professionals to recommend clinical and laboratory follow-up in a patient
with anemia and to select the right tests for definitive diagnosis.
SUMMARY

The foundation of laboratory hematologic diagnosis is the complete blood count and
review of the peripheral smear. In patients with anemia, the peripheral smear permits
interpretation of diagnostically significant red blood cell (RBC) findings. These
include assessment of RBC shape, size, color, inclusions, and arrangement.
Abnormalities of RBC shape and other RBC features can provide key information in
establishing a differential diagnosis. In patients with microcytic anemia, RBC
morphology can increase or decrease the diagnostic likelihood of thalassemia. In
normocytic anemias, morphology can assist in differentiating among blood loss,
marrow failure, and hemolysis—and in hemolysis, RBC findings can suggest specific
etiologies. In macrocytic anemias, RBC morphology can help guide the diagnostic
considerations to either megaloblastic or nonmegaloblastic causes. Like all laboratory
tests, RBC morphologies must be interpreted with caution, particularly in infants and
children. When used properly, RBC morphology can be a key tool for laboratory
hematology professionals to recommend appropriate clinical and laboratory follow-up
and to select the best tests for definitive diagnosis.
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