Hematology: LabCE Erythrocyte Inclusions

Howell-Jolly bodies

round, smooth, almost pyknotic, dark-purple bodies ranging in size from 0.5 to 1.0 microns in diameter. These RBC inclusions contain DNA. megaloblastic anemia abnormal erythropoiesis hemolytic anemias thalassemia sickle cell anemia

to confirm the presence of Heinz bodies, hemoglobin H bodies, or reticulocytes,

smears must be prepared after staining an aliquot of fresh whole blood with a supravital stain such as new methylene blue or brilliant cresyl blue.

Polychromatophilic RBC

they have a blue-gray appearance when compared to the other RBCs in the field. Polychromatophilic RBCs are often larger in size than mature RBCs and either lack central pallor or have diminished central pallor.

Heinz bodies

- A supravital stain, such as brilliant green, crystal violet, or new methylene blue is necessary for Heinz bodies to be observed - composed of denatured hemoglobin - glucose-6-phosphate dehydrogenase (G6PD) deficiency and other red cell enzyme disorders - are most commonly oval or round. They appear refractile and tend to be located close to or on the red blood cell membrane

Cabot rings

- appear as thin, red-violet-staining strands in the shape of rings, figure eights, or shapes of the letter B on Wright-stained smears - The rings are probably microtubules from the mitotic spindle that remain behind after the rest of the erythrocyte nucleus is extruded. * They are rarely seen in peripheral blood. Cabot rings have been observed in megaloblastic anemia, lead poisoning, severe anemia, leukemia, myelodysplastic syndromes, and other cases of dyserythropoiesis.

This image of erythrocyte inclusions from Wright-stained peripheral blood smears shows what?

Basophilic stippling

This image of erythrocyte inclusions from Wright-stained peripheral blood smears shows what?

Cabot ring

Coarse basophilic stippling

Coarse basophilic stippling is present in the cell in the center of the top slide image. The granules are larger and more prominent than those seen in fine stippling. Course basophilic stippling should be reported and can be clinically significant. Seen in lead poisoning

What is the composition of Howell-Jolly bodies?

DNA

Heinz bodies are composed of which of the following?

Denatured hemoglobin

What are Erythrocyte Inclusions?

Erythrocyte inclusions are elements that may be present in red blood cells (RBCs). The appearance, composition, and associated physiology of the inclusions are specific for each type of inclusion. Identification and reporting of these inclusions are important because their presence may indicate diseases or disorders.

Heinz bodies can be found in which of the following disorders?

G6PD deficiency

What is the composition of the granules associated with basophilic stippling?

Aggregates of ribosomes

Comparison of Erythrocyte Inclusions

A - RBC with basophilic stippling. B - Pappenheimer bodies C - Howell-Jolly bodies D - platelet that is sitting on top of an RBC. This may be mistaken for an inclusion. One of the distinguishing characteristics that can alert you to the fact that it is not an inclusion is the halo around the platelet.

In which of the following conditions would you expect to find Howell-Jolly bodies?

Hyposplenism (low functioning spleen)

This image of erythrocyte inclusions from Wright-stained peripheral blood smears shows what?

Artifact

What red blood cell inclusion may be expected in a case of glucose-6-phosphate dehydrogenase (G6PD) deficiency?

Heinz bodies

Which of the following inclusions may be observed on a Wright-stained peripheral blood smear if a patient has had a splenectomy?

Howell-Jolly and Pappenheimer bodies

Which of the following inclusions are composed of DNA? Howell-Jolly bodies Heinz bodies Pappenheimer bodies Basophilic stippling

Howell-jolly bodies

Reticulocyte

Immature red blood cell that has numerous organelles needed for hemoglobin production, such as ribosomes, mitochondria, and fragments of the Golgi apparatus. Reticulocytes appear blue-gray on the Wright or Wright-Giemsa-stained smear and are referred to as polychromatophilic red cells (indicated by the arrow in Image A) A supravital stain, such as new methylene blue N or brilliant cresyl blue, is used to stain reticulocytes (indicated by the arrows in Image B) for an actual count.

Fine Basophilic Stippling

In the center of this field is a red cell containing small blue granules throughout the cell. This is an example of fine basophilic stippling and would not be reported.

Which of the following statements characterize a reticulocyte?

Its reticulum is visible with a supravital stain, such as new methylene blue.

Which of the following disorders or diseases is associated with coarse basophilic stippling?

Lead poisoning

In which of the following conditions might Cabot rings be observed in erythrocytes on a Wright-stained peripheral blood smear?

Megaloblastic anemia and lead poisoning

The arrows in the image point to Heinz bodies in erythrocytes. Which of the following stains was used to confirm the presence of these inclusions?

Supravital stain

The slide shows what type of cells?

Normal red blood cells.

If present, how many Howell-Jolly bodies are usually seen within a given erythrocyte?

One

The cells indicated by the arrows are...

Polychromatophilic red blood cells

Which of the following is NOT present in the normal bone marrow and would be associated with a disease or disorder? Siderocyte Sideroblast Ringed sideroblast Erythroblasts

Ringed sideroblast

Which of the following terms most accurately identifies the cell indicated by the arrow in this bone marrow slide that was stained with Prussian blue iron stain?

Ringed sideroblast

immature (nucleated) erythrocyte containing siderotic granules

Sideroblast

A mature erythrocyte containing siderotic granules is referred to

Siderocyte

Howell-Jolly bodies in nucleated red cell

Since Howell-Jolly bodies are nuclear remnants, they can also be seen in the cytoplasm of the young nucleated red cells.

In which of the following disorders would you probably observe coarse basophilic stippling on a Wright-stained peripheral blood smear?

Thalassemia and lead poisoning

Cabot ring with a figure 8

The arrow in the image on the right points to a Cabot ring with a "figure 8" configuration.

Which of the following statements best describes the appearance of Cabot rings?

Thin, reddish-violet-staining strands in the shapes of rings, figure eights, or the letter B

normal erythrocyte

This slide shows a field of normal erythrocytes as they appear when stained with Wright stain. Normal erythrocytes are 7 to 8 µm in size and approximately one-third of the central portion of the cell is pale, referred to as central pallor. As seen in the image, there are no inclusions present in normal erythrocytes.

The presence of erythrocyte inclusions may indicate the presence of disease. True or false

True

Ringed sideroblasts

When a red cell precursor contains too much iron, the siderotic granules form a ring around the nucleus. If five or more siderotic granules form a ring around at least half the periphery of the nucleus of a nucleated red blood cell, the cell is referred to as a ringed sideroblast. The ringed sideroblast is an abnormal (pathological) form of a sideroblast. The ringed sideroblast is associated with sideroblastic anemias and myelodysplasias.

To detect siderosomes

a stain must be used that is specific for iron, such as Prussian blue.

Heinz bodies

clumps of precipitated hemoglobin, are indicated by the arrows.

Siderotic granules

iron-containing granules

Dark refractile ring

it is an artifact and should not be reported. A Cabot ring would stain red-violet and would not be refractile.

Pappenheimer bodies

- may be seen in the cytoplasm of mature and immature erythrocytes on a Wright-stained peripheral blood smear. - small dark purple granular bodies of varying size, frequently clustered in groups of two, three, or more near the edge of the cell - composed of degenerating cellular remnants that contain iron - most likely caused by accelerated red cell division or impaired hemoglobin synthesis *** should be confirmed with an iron stain, such as Prussian blue stain *** sideroblastic anemia, thalassemia, and following a splenectomy

Sideroblast

-Prussian blue-stained bone marrow. A sideroblast indicated by the red arrow, is a nucleated red cell containing siderotic granules. These granules are generally found in the periphery of the cell. Siderocytes are indicated by the blue arrows.

Siderocyte

-Stained with Prussian blue stain. The inclusions in the cell may or may not have been visible on a Wright-stained smear. If they were visible on a Wright stained smear, they would be designated as Pappenheimer bodies.