LabCE: Red Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions

MCH

Average weight of hemoglobin in the RBCs. 26-32 pg.

Homozygous HbE

is common in Southeast Asia and presents with very mild anemia, seldom requiring transfusion. Peripheral blood smear findings of target cells, microspherocytes, red cell hypochromia, red blood cell fragments, and nucleated red blood cells may be noted. Evidence from hemoglobin electrophoresis is required to establish a diagnosis.

RDW

red cell distribution width Anisocytosis may be generated if RDW is higher than ref. range.

Some morphologic abnormalities are significant, even when they occur in very low numbers. These include

Acanthocytes Fragmented red cells (eg, schistocytes, helmet cells, keratocytes/horn cells) Polychromatophilic cells Sickle cells Spherocytes Teardrop cells

A toddler is being treated for lead poisoning. You observe the inclusions indicated by the arrows in many RBCs on the peripheral blood smear. What is the identity of these inclusions?

Basophilic stippling

What is the identity of the erythrocyte inclusion indicated by the arrow on this image of a Wright-stained peripheral blood smear?

Basophilic stippling

Other morphologic abnormalities are significant only when seen in considerable numbers. These include:

Burr cells (echinocytes) Hypochromic cells Macrocytes Microcytes Ovalocytes Stomatocytes Target cells

the following are a few examples that could trigger a manual, microscopic peripheral blood smear review:

Hemoglobin: < 8 or >18 g/dL (<10 or > 21g/dL in a newborn) Hematocrit: <20% or > 60% in adults (<40% or >65% in a newborn) MCHC: <29 g/dL MCV: <69 femtoliters (fL) or >110fL Flags generated by the hematology analyzer that indicate possible red cell abnormalities or spurious results

A blood smear represented by the photograph was submitted for hematologic review. Based on the erythrocyte morphology and the accompanying histogram, which of the following choices is the most likely situation or condition?

Dimorphic cell population

A final category includes morphologic abnormalities that are significant but do not need to be quantified as it serves no purpose; these findings can be noted as "present." These include:

Dimorphic or double red cell population RBC agglutination Rouleaux

A 13-year-old healthy male presents to his physician for a sports physical. A complete blood count (CBC) is ordered. The automated count triggers a smear review. Which of the following conditions would be most consistent with this patient's peripheral blood picture?

Hereditary elliptocytosis

Which hematologic condition could be associated with the findings shown in this image?

Hereditary spherocytosis

What is the identification of the red blood cell inclusions indicated by the arrows on this Wright-stained peripheral blood smear?

Howell-Jolly bodies

A twenty-five-year-old asplenic male with disseminated lymphoma is admitted to the hospital. A CBC is ordered, and a peripheral blood smear is triggered for review. The image on the right is a representative field from the blood smear. What RBC inclusion is indicated by the arrow?

Howell-Jolly body

A complete blood count (CBC) was ordered for a patient recently admitted to the emergency department. The MCV on the count was 115 femtoliters (fL) (normal range 80 - 100 fL). A peripheral blood smear was reviewed; a representative field from the smear is shown on the right. Which of the following conditions could immediately be ruled out, based on the MCV and appearance of the RBCs on the peripheral blood smear?

Iron deficiency anemia associated with decreased MCV and microcytosis

RBC indices include

MCV MCH MCHC

A known case of hemolytic disease of the newborn (HDN) is presented in the image on the right. Many different cellular morophologies are present. Apart from the obvious anisocytosis (microcytes and macrocytes), which additional red blood cell morphologies are worth reporting?

Nucleated red blood cells Spherocytes Polychromatophilic cells Howell-Jolly bodies

Normocyctic

Normal cell color

Normocytic

Normal cell size

A 66-year-old man has been diagnosed with sideroblastic anemia. The inclusions indicated by the arrows in the image were seen in many of the RBCs on his Wright-stained peripheral blood smear. What is the identity of these inclusions?

Pappenheimer bodies

The upper image on the right is a Wright-stained smear. The lower image is a Prussian blue-stained smear made from the same blood specimen (Prussian blue is an iron stain). What are the RBC inclusions indicated by the arrows in the upper image?

Pappenheimer bodies

A patient is diagnosed with disseminated intravascular coagulation (DIC) based on clinical findings and laboratory results that include decreased platelets and fibrinogen, elevated D-dimer, prolonged prothrombin time (PT), and activated partial thromboplastin time(aPTT). The cells indicated by the arrows in the image on the right also provide a clue to this diagnosis. What is the identity of these cells?

Schistocytes

A CBC and reticulocyte count are ordered on a 10-year-old African-American male who was brought to the emergency department with rapid, shallow breathing and fever. The results are shown below. The image on the right is a representative field from the peripheral blood smear. What cells are indicated by the arrows in this smear?

Sickle cells

Note the iron-stained bone marrow preparation in the image to the right. The cells as shown can be associated with which type of anemia?

Sideroblastic anemia

A 12-year-old child presents with jaundice and scleral icterus. The image to the right captures a representative section of the peripheral blood smear. Which of the following are significant findings that should be included on the report?

Spherocytes Polychromatophilic cells

The cells indicated by the arrows provide a clue to the diagnosis of chronic idiopathic myelofibrosis (primary myelofibrosis). What is the identity of these cells?

Teardrop cells

The condition highly associated with the peripheral blood picture in the image on the right is:

Transfusion dimorphism

A patient has an elevated MCV on the automated CBC and a peripheral blood smear is reviewed. A representative field is shown on the right. What conditions could cause the RBC and WBC morphologies that are present in this microscopic field?

Vitamin B12 deficiency Folate deficiency

MCHC

average concentration of hemoglobin in individual RBC 32-36 g/dL Hypochromasia or hyperchromasia if outside of ref. range.

MCV

average size of the RBCs 80-100 fL Macrocytosis or microcytosis if out of ref. range.

HbE/beta thalassemia

hemolysis requiring repeated transfusions. Severe anemia, low MCV, and elevated RBC are characteristic of HbE/beta thalassemia.

Which of the following conditions may be associated with the abnormal red blood cell morphologies shown in this image?

Autoimmune hemolytic anemia

This slide is from a 28-year-old female who received a kidney transplant, which was preceded by a splenectomy six months prior to the kidney transplant. What red cell morphologic abnormalities should be reported?

Elliptocytes Schistocytes

Sickle cells along with target cells, as shown in this image, confirm a diagnosis of sickle cell disease (HbSS).

False hemoglobin electrophoresis is necessary to establish the underlying condition

A ten-year-old boy came to a physician's attention because of recent jaundice and icteric sclerae after taking the medication Primaquine. The immediate laboratory work revealed: Hct 24% (normal 36%-47%), MCV 79.5 fL (normal 78-95fL), RDW 13% (normal 11.5-15.0%). His blood smear findings are reflected in the images to the right. The upper image is a Wright-Giemsa stained smear while the lower is a supravital-stained smear. Which condition should be considered for this patient when analyzing his symptoms, history, and laboratory results?

G6PD deficiency

The top image on the right represents a Wright-stained microscopic field from a peripheral blood smear. The bottom image represents a microscopic field from a blood smear stained with a supravital stain. Which of the following conditions is associated with the defective erythrocytes indicated by the arrows in these images?

G6PD deficiency

A 5-year-old girl was brought to the emergency department with bloody diarrhea and severe abdominal pain. A complete blood count produced these results The peripheral blood smear is represented in the image to the right. Which of the following conditions could be present in this patient when considering the information above and the cells indicated by the arrows on the peripheral smear?

Hemolytic uremic syndrome (HUS)

The condition most likely associated with the peripheral blood picture shown in the image on the right is:

Iron deficiency anemia

A five-month-old Asian child is brought to the pediatrician by her mother who is concerned because the child is not eating well. Upon examination, it is noted that the child's spleen is palpable. A CBC and reticulocyte count are ordered, and the results are shown below. A Wright-stained peripheral blood smear is also reviewed. A representative microscopic field from that smear is shown on the right. Knowing that the family is from a region of Thailand where Hb E carriers are prevalent, the physician orders a hemoglobin electrophoresis, which detects HbE. The blood count results and peripheral blood smear results also provided clues to the eventual diagnosis of HgbE/beta thalassemia. Which of the following RBC morphologies are present in this microscopic field?

Microcytes Target cells Nucleated red blood cells

A 49-year-old male with pneumonia was treated with high-dose intravenous penicillin. He became jaundiced with yellow sclera. The image on the right is typical of other fields that were observed on his peripheral blood smear. Since penicillin may, in some individuals, cause autoimmune hemolytic anemia, the clinician requested a direct antiglobulin test (DAT) be performed. The DAT was positive, indicating that antibodies to the drug were produced, which then attached to the drug on the surface of the red cells. Hemolysis occured due to the drug-induced antibody attachment, leaving the patient with various abnormal red blood cell morphologies. Which of the following cell types would you report for this patient?

Nucleated red blood cells Spherocytes Polychromatophilic cells

What are the abnormal red blood cells (RBCs) indicated by the arrows that may be suggestive of an individual possessing the Rh null phenotype?

Stomatocytes

Dimorphic population

Two circulating red cell populations red blood cell transfusions; myelodysplasia; refractory anemia with ringed sideroblasts; hemolytic processes involving a reticulocyte response; and erythropoietin therapy.

An 8-year-old male's peripheral blood smear is shown in the image on the right. The condition present is most likely sickle cell anemia.

True