RBC MORPHOLOGY AND INCLUSIONS

• name it

  A) normal

  B) microcyte

  C) macrocyte

  D) oval macrocyte

  E) hypochromic macrocyte

  F) hypochromia

  G) 1+

  H) 2+

  I) 3+

  J) 4+

  K) polychromasia

  L) target cell

  M) spherocyte

  N) ovalocyte

  O) stomatocyte

  P) sickle cell

  Q) acanthocyte

  R) helmet cell

  S) schistocyte

  T) tear drop

  U) burr cell

  V) pappenheimer bodies

  W) cabot's ring

  X) basophilic stipling

  Y) howell-jolly

  Z) HbSC

  [) HbC

  \) agglutination

  ]) rouleaux

  
• When there are abnormalities in RBC morphology, they are usually attributed to abnormalities in the cell membrane, which affect cell integrity. This is why RBCs exhibit different shapes and variations.
• RBCs undergo different maturation stages, during which their morphology changes. These changes include the loss of organelles, becoming anucleated, and the cessation of hemoglobin synthesis. In some cases, remnants of these processes are left as fragments, and in specific conditions resulting in RBC inclusions.
• NORMAL ERYTHROCYTE

  • Cell Size: 7-8 um

  • Cell Shape: Biconcave o Disc-shaped o Lacks nucleus

  • “Normocytic” • MCV: 80 – 100 fL

  • MCHC: 32% - 36%

  • Area of central pallor: 2 to 3 um in diameter (1/3 of the diameter of the cell).
• Normal Erythrocyte

  
• ABNORMAL ERYTHROCYTE

  I. Variation in Size – Anisocytosis

  II. Variation in Shape – Poikilocytosis

  III. Alteration in Color – Anisochromia

  IV. Inclusions in the Erythrocyte

  V. Alterations in Erythrocyte Distribution on a Peripheral Blood Smear
• Macrocytosis

  o Diameter: >8 um

  ▪ RBCs are larger than 8 um by size hence the name macrocytosis.

  o MCV: >100 fl o Appearance:

  ▪ Large, mature erythrocytes.

  ▪ May be basophilic and slightly hypochromic.

  o Defect in nuclear maturation or stimulated erythropoiesis.

  o Can be seen in conditions:

  ▪ Megaloblastic anemia

  ▪ Myelodysplastic syndrome

  ▪ Chronic liver disease

  ▪ Bone marrow failure

  ▪ Reticulocytosis
• Macrocytosis

  • Defect in nuclear maturation or stimulated erythropoiesis.

  ▪ This results in the early release of RBCs into the bloodstream, leading to an increase in their size.

  ▪ RBCs undergo nuclear maturation, which can be disrupted by vitamin B12 deficiency, causing abnormalities in mitotic division in the bone marrow and resulting in enlarged RBCs in circulation.

  ▪ An increase in EPO stimulates hemoglobin synthesis and leads to the premature release of RBCs into circulation, resulting in reticulocytosis, which appears macrocytic and basophilic
• Nonmegalobastic anemia

  • caused by Aplastic Anemia, Chornic liver disease, and Alcoholism
• Megaloblastic anemia

  • caused by VitB12 deficiency, Folate deficiency, Myelodysplasia, Erythroleukemia, and some drugs.
• Microcytosis

  • Diameter: <6 um

  ▪ Smaller RBC size that is less than 6 um.

  • MCV: <80 fl
  • Appearance:

  ▪ Wide central pallor.

  ▪ Can be hypochromic and normochromic.

  Linked to decreased hemoglobin synthesis.

  ▪ Results to the smaller size of the RBC.

  • Seen in TAILS:

  ▪ Thalassemia

  ▪ Anemia of chronic inflammation

  ▪ Iron Deficiency Anemia

  ▪ Immune Deficiency Anemia (IDA)

  ▪ Lead Poisoning

  ▪ Sideroblastic Anemia
• name it

  A) normal

  B) slightly increased / few

  C) moderately increased

  D) many

  E) markedly increased

  
• ERYTHROCYTE MORPHOLOGY GRADING

  • The basis of population of RBC abnormalities or morphological variations in a peripheral blood smear.

  • This allows the physician to assess the severity of the condition and ensures standardization in the overall procedure of analyzing the peripheral blood smear.
• NORMOCHROMIC

  • moderately pinkish-red appearance with a lighter-colored center

  • Has a "central pallor" → 1/3 of the cell
• Mean Corpuscular Hemoglobin Concentration (MCHC)

  • represents the total concentration of hemoglobin in all red blood cells.
• Hypochromic

  • Erythrocytes were not able to retain its normal color.
  • “Central pallor” exceeds 1/3 of the cell’s diameter, resulting to a pale appearance.
  • Inadequate iron stores, which is a result of decreased hemoglobin synthesis. ▪ Results to the inadequate colorization of the RBCs, and appear pale.
  • Seen in iron deficiency anemia (IDA).
• hypochromic

  
• name it

  A) one-half

  B) two-thirds

  C) three-quarters

  D) thin rim

  
• name it

  A) normal RBC

  B) hypochromic RBC

  C) severe hypochromia

  
• Hyperchromic

  • Hemoglobin level: >36 g/dl ▪ RBC appears spherocytic.
  • “Central pallor” is not seen.
  • Deeper red coloration.
  • Increased Mean Corpuscular Hemoglobin Concentration (MCHC).
  • Specific conditions, such as dehydration or chemical exposure, may affect the spherocytic shape and color variation of RBCs.
• hyperchromic

  
• Polychromatophilia

  • Refers to an anucleated erythrocyte that is grayish or blue hue in Wright Stain
  • Lacks hemoglobin
  • Diffusely distributed RNA residuals.
  • Appears as Reticulocytes in supravital stains.
• name it

  A) 1 - 3

  B) 4 - 5

  C) 6 - 12

  D) more than 12

  
• polychromasia

  
• name it

  A) normal RBC

  B) polychromasia

  
• Acanthocytes

  • “Thorn Cells” or “Spur Cells”
  • Appearance:

  ▪ Small, dense RBC.

  ▪ Multiple thorny, spike-like projections (spicules) that are irregularly distributed.

  • Commonly seen in:

  ▪ Spur cell anemia

  ▪ Abetalipoproteinemia

  ❖ Decreased plasma lipids, that results to membrane defect or loss of membrane integrity.

  ❖ Patients were not able to absorb lipids in the small intestine, which results to low levels of lipids.

  ▪ Sever liver disease (i.e. Cirrhosis of the liver).

  ▪ Postsplenectomy
• acanthocytes

  
• acanthocytes

  
• Echinocytes

  • “Sea Urchin” o Crenated RBC o Short projections (spicules) that are evenly spaced.
  • Rounded tip.
  • Osmotic imbalance, which results to the loss of intracorpuscular water.
  • Commonly seen in: ▪ Artificial drying. ▪ Usually smearing artifacts.
• echinocytes

  
• Burr Cells

  • Associated with Echinocytes.
  • Elongated or irregular in shape projections.

  ▪ Less spherical

  • Decreased deformability, results to premature destruction.

  ▪ Influenced by surface area to volume ratio.

  • Commonly seen in:

  ▪ Uremia

  ▪ Pyruvate kinase deficiency

  ▪ Renal diseases

  ▪ Burns

  • Can also be seen in:

  ▪ Peptic Ulcers

  ▪ Gastric Ulcers

  ▪ Gastric Carcinoma
• Burr cells

  
• Elliptocytes

  • Aka “Ovalocyte”, and is cigar shaped.
  • Membrane defect results to loss of membrane integrity.
  • Commonly seen in:

  ▪ Hereditary elliptocytosis

  ▪ Iron deficiency anemia

  ▪ Thalassemia (abnormality in beta globin chains) major

  ▪ Myelophthisic anemias

  • Can be seen also in:

  ▪ Hemolytic anemia

  ▪ Sickle cell trait

  ▪ Other types of Thalassemia
• Elliptocytes

  
• Spherocyte

  • Small, round, dense, with no central pallor.
  • Loss of the cell membrane, which decreases surface-area-tovolume ratio.
  • Inherited structural defects of the membrane or physical trauma.
  • Commonly seen in:

  ▪ Hereditary spherocytosis

  ▪ Immune hemolytic anemia

  ▪ Extensive burns (along with schistocytes)
• Spherocyte

  
• NaCl-based or glycerol-based red cell osmotic fragility tests

  • allows for the identification of spherocytes or the amount of surface-area to-volume ratio of RBCs.
• Microspherocytosis

  ▪ Linked to ABO (common blood type) hemolytic disease, which can occur in fetuses and newborns due to blood-type differences between the mother and the fetus.
• Stomatocytes

  o Slit-like area of central pallor.

  ▪ Resembles of that opening of a mouth.

  o Increase in Sodium (Na+) and decrease in Potassium (K+) in cytoplasm.

  ▪ If there is ionic imbalance, this might result to variation in RBC shape variation.

  o Commonly seen in:

  ▪ Hereditary stomatocytosis

  ▪ Rh deficiency syndrome

  ▪ Acquired stomatocytosis (liver disease, alcoholism)

  ▪ Artifact

  o Can also be seen in:

  ▪ Infectious mononucleosis

  ▪ Lead poisoning

  ▪ Thalassemia
• stomatocytes