Peripheral Blood Tutor

this image is suggestive of pertussis

Cleaved lymphocytes

this image is suggestive of chronic lymphocytic leukemia

Increase numbers of small lymphocytes with coarsely clumped chromatin and the presence of smudge (basket) cells

describe the sequence of maturation of monocytes

monoblast -> promonocyte -> monocyte

describe the sequence of maturation for a neutrophil

myeloblast -> promyelocyte -> myelocyte -> metamyelocyte -> band -> neutrophil

describe the difference between normochromic and hypochromic RBCs and its cause

normo = central pallor is < 1/3 cell diameter hypo = central pallor is > 1/3 diameter of cell, seen in iron deficiency anemia, for example

this cell is an eosinophil

nuclei with 2-3 lobes and very coarse chromatin, and abundant cytoplasm containing numerous red-orange granules

this cell is a basophil

nuclei with 2-3 lobes and very coarse chromatin, and cytoplasm containing many dark-blue granules

this cell is a neutrophil

nuclei with 2-5 lobes and very coarse chromatin, pale pink cytoplasm, and fine pink-purple granules

this image is suggestive of infectious mononucleosis

numerous reactive (atypical) lymphocytes

this image is suggestive of acute myelogenous leukemia

presence of myeloblasts containing Auer rods

describe the maturation sequence of RBCs

pronormoblast -> basophilic normoblast -> polychromatophilic normoblast -> orthochromic normoblast -> polychromatophilic red cell -> erythrocyte

the cell in this image is a shistocyte

red blood cell fragments that are irregularly shaped and variable in size, often with pointed ends

this cell is a burr cell

red blood cell with regularly spaced projections

this cell is an acanthocyte

red blood cells with irregularly spaced, blunt ended, projections of varying size

describe acute leukemias and the following examples of it: 1. acute lymphoblastic leukemia 2. acute myeloid leukemia

results from clonal proliferation in bone marrow of immature cells having little or no maturation. The presence of 30% blasts in peripheral blood and/or bone marrow is the generally accepted criterion for the diagnosis of acute leukemia 1. lymphoblasts; proliferation of blasts having lymphoid characteristics and is more common in children than adults 2. myeloblasts, sometimes with an Auer rod; proliferation of blasts having myeloid characteristics and the incidence increases with age.

the cell in this image is a stomatocyte

rod-shaped area of central pallor.

the cell in this image is a lymphocyte

round nuclei with very coarse chromatin, and light blue cytoplasm

this image is suggestive of pappenheimer body

small, dark blue, irregularly shaped granules often occuring in clusters within a red blood cell

this is a spherocyte

spherical, densely staining red blood cells with an absence of central pallor

the inclusions in this RBC are basophilic stipplings

uniformly distributed dark blue granules in red blood cells

describe globin abnormalities and the following examples: 1. sickle cell anemia 2. hemoglobin C disease 3. unstable hemoglobins

usually due to inherited genetic mutations. The genetic mutations result in abnormalities of the protein portion (globin) of the hemoglobin molecule. These abnormalities often cause aggregation of hemoglobin molecules resulting in the formation of crystals or inclusions 1. sickle cells, poikilocytosis, target cells; primarily occurs in persons of African descent, and can cause painful crises when the sickle cells are unable to pass through very small capillaries. 2. target cells, hemoglobin crystals; primarily occurs in persons of African descent. Affected persons commonly have enlarged spleens without other clinical symptoms 3. Heinz bodies, reticulocytes (polychromatophilic red cells); Most patients are asymptomatic until detected after a sudden hemolytic crisis due to oxidative stress, such as infections or drugs

this image is suggestive of anisocytosis

variation in red blood cell size.

the term that best describes this image is poikilocytosis

variation is RBC shape

Integrate combinations of morphologic abnormalities involving one or more cell lineages to suggest a diagnosis of a disease state

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Recognize and name the normal and abnormal forms of lymphocytes using proper medical terminology.

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Recognize and name the normal and abnormal forms of macrophages using proper medical terminology.

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Recognize and name the normal and abnormal forms of neutrophils using proper medical terminology.

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this image is suggestive of mechanical trauma

marked poikilocytosis including red blood cell fragments

describe the following variations of platelets: 1. large forms 2. hypogranular

1. > in size than a normal RBC; associated with disease states having an increased rate of platelet production 2. platelets w/few or no granules; seen in platelet storage pool defects such as gray platelet syndrome & myelodysplastic syndromes

describe the following: 1. normocytic RBC 2. microcytic RBC 3. macrocytic RBC

1. approx same size as nucleus of a small lymphocyte (normal, healthy) 2. smaller than nucleus of a small lymphocyte (seen in Fe deficiency anemia & thalassemia) 3. larger than nucleus of small lymphocyte (vit. B12 or folate def. anemias)

Correlate single morphologic abnormalities seen in any of the above cell lineages to one or more specific disease states.

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Identify the sequence of cell types encountered during normal maturation of erythroid cells in the marrow.

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Identify the sequence of cell types encountered during normal maturation of megakaryocytic cells in the marrow.

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Identify the sequence of cell types encountered during normal maturation of myeloid cells in the marrow.

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describe the following types of artifacts: 1. stain precipitate 2. water artifact 3. crenated red cells 4. smudge cells 5. platelet satellitism 6. platelet aggregates 7. platelet superimposition 8. degenerated nucelus

1. dark blue granules or filaments on top or in between blood cells 2. refractile areas within red blood cells; caused by slow drying of smear in a humid environment or water contamination of the Wright's stain. 3. red blood cells with regularly spaced projections on their surface. may form in EDTA-anticoagulated blood over time 4. a ruptured WBC that has been smeared across the slide during slide preparation; arise from the disruption of fragile cells during smear preparation, and are commonly seen in chronic lymphocytic leukemia 5. four or more platelets touching the membrane of a neutrophil. artifact that occurs in some patients whose blood is anticoagulated with EDTA 6. clumped platelets; usually due to improperly collected or poorly anticoagulated blood. 7. a platelet overlying a red blood cell ( in different planes of focus), often with a halo around platelet; may be mistaken for red blood cell inclusions 8. dark purple nucleus with round lobes, homogenous chromatin, nuclear filaments absent; number of white blood cells (usually neutrophils) with degenerated nuclei increases with specimen age.

describe the following abnormalities to granulocytes: 1. hypo-segmentation 2. hyper-segmentation 3. Auer rods 4. toxic granulation 5. toxic vacuolation 6. dohle bodies

1. granulocytes with one or two poorly segmented nuclear lobes; may be seen in patients with Pelger-Huet anomaly or myelodysplastic syndrome. 2. neutrophil with six or more nuclear segments; seen in patients with anemia due to Vitamin B12 or folate deficiency. 3. pink, rod-shaped inclusions in myeloblast cytoplasm; may be seen in myeloblasts from patients with acute myelogenous leukemia 4. neutrophil with increased dark granules in its cytoplasm; seen in patients with severe bacterial infections. 5. round, clear spaces within granulocyte cytoplasm; may be seen in patients with severe bacterial infections. 6. pale blue, irregularly shaped inclusion in neutrophil cytoplasm; consist of ribosomes and /or rough endoplasmic reticulum and are seen in severe bacterial infections

describe the following anomalies of WBC morphologies: 1. Alder-Reilly 2. May-Hegglin 3. Chediak-Higashi 4. Pelger-Huet 5. Storage Disease

1. large, dark, pink-purple granules in cytoplasm of neutrophils; this is an autosomal recessive trait resulting in abnormal granule development in neutrophils resembling severe toxic granulation 2. neutrophils with large pale blue inclusions resembling Döhle bodies, giant platelets; due to rare autosomal dominant trait which is often asymptomatic 3. large abnormal granules and/or inclusions in white blood cells; due to a rare autosomal recessive trait which results in abnormal neutrophil function and frequent bacterial infection 4. neutrophils with monolobed or bilobed nucleus; autosomal dominant trait which results in morphologically abnormal, but functionally normal, neutrophils. 5. vacuolated lymphocytes; genetic disorders resulting in the accumulation of metabolites within cells. Vacuolated lymphocytes may be seen in mucopolysaccharidoses.

describe the following as they are related to lymphocytes: 1. reactive lympocytes 2. large granular lymphocytes 3. cleaved lymphocytes 4. plasma cells

1. lymphocytes with abundant cytoplasm often indented by surrounding red blood cells; may be associated with viral infections. 2. lymphocytes with abundant cytoplasm containing prominent granules; may be associated with viral infection or neutropenia 3. lymphocytes with large nuclear clefts; associated with pertussis (whooping cough) in children. 4. blue cytoplasm, eccentric nucleus, prominent perinuclear clearing; rarely seen in the peripheral blood except in cases of severe inflammation or end stage multiple myeloma.

describe changes in WBC morphology due to the following: 1. bacterial infection 2. infectious mononucleosis 3. pertussis (whooping cough) 4. Borrelia

1. neutrophils with Döhle bodies, toxic granulation, and vacuolation; Increased numbers of neutrophils with toxic granulation and Döhle bodies are common. Intracellular bacteria are rarely seen 2. reactive (atypical) lymphocytes due to viral disease caused by the Epstein-Barr virus. Increased numbers of reactive lymphocytes are commonly seen in the peripheral blood 3. lymphocytes with cleaved nuclei, bacterial infection caused by Bordetella pertussis 4. extracellular spirochetes, due to bacteria which can cause relapsing fever and are transmitted by the bite of a tick or louse

describe the following: 1. spherocyte 2. teardrop cell (dacrocyte) 3. burr cell (echinocyte) 4. stomatocyte 5. acanthocyte 6. schistocyte 7. elliptocyte (ovalocyte) 8. sickle cell (drepanocyte) 9. target cell

1. spherical, densely staining red blood cells, no central pallor. (commonly seen in hereditary spherocytosis and immune hemolytic anemias.) 2. teardrop shaped red blood cells (generally result from marrow replacement by fibrosis or malignancy.) 3. red blood cells with many, regularly spaced, short projections. (associated with uremia, as seen in chronic renal disease) 4. red blood cell with a rod-shaped area of central pallor (may be seen in liver disease and acute alcoholism.) 5. red blood cells with multiple, irregularly spaced, blunt projections of varying size (seen in abetalipoproteinemia and severe liver disease.) 6. red blood cell fragments, irregularly shaped and variable in size, often with pointed ends (seen in disseminated intravascular coagulation and thrombotic thrombocytopenic purpura) 7. oval or elliptical red blood cells (seen in hereditary elliptocytosis and a variety of anemias) 8. long, narrow, curved red blood cells with a point on at least one end (seen in sickle cell anemia.) 9. alternating rings of pallor and dense staining resembling a target (seen in thalassemia and liver disease.)

describe the following RBC inclusions: 1. basophilic stripping 2. Howell-Jolly bodies 3. Pappenheimer bodies 4. Heinz bodies 5. Malarial parasites

1. uniformly distributed dark blue granules, due to darkly staining aggregates of ribosomes and may be seen in thalassemia, lead poisoning, and sideroblastic anemia. 2. dark purple, dense, round inclusions with distinct borders; nuclear fragments often seen in erythrocytes from patients who have had their spleens removed. 3. small, dark blue, irregularly shaped granules often in clusters; composed of iron and may be seen in a variety of disease states including sideroblastic anemia and following splenectomy. 4. round bodies within red blood cells (supravital stain); composed of denatured hemoglobin and may be visualized using supravital staining in patients with G6PD or unstable hemoglobins. 5. malarial ring forms are seen intracellularly; Malaria is a parasitic disease caused by any of four different species of Plasmodium.

describe anemia and the following types of anemia: 1. iron deficiency 2. thalassemia 3. vit B12/folate deficiency 4. lead poisoning 5. sideroblastic

Anemia is a decrease in the number of circulating red blood cells. Alterations in red blood cell morphology may suggest the cause of the anemia. 1. microcytic, hypochromic red blood cells with anisocytosis and increased platelets; the most frequent cause of anemia worldwide and is common in females of child-bearing age 2. poikilocytosis, target cells, and nucleated red blood cells; genetic diseases resulting in decreased globin production, and are more common in persons of Mediterranean, Southeast-Asian, and African descent. 3. oval macrocytes, anisocytosis, poikilocytosis, hypersegmented neutrophils, decreased platelets; usually found in patients with poor nutrition or receiving chemotherapy 4. coarse basophilic stippling; more common in children than adults. 5. dimorphic population of red blood cells, anisocytosis, poikilocytosis; usually a result of abnormalities of the heme synthetic pathway, either genetic or as a result of vitamin B6 deficiency.

describe the sequence of maturation of platelets

Bone marrow is the primary site of platelet production. Platelets (thrombocytes) arise from a large precursor cell called a megakaryocyte. Platelets are fragments of megakaryocyte cytoplasm megakaryoblast -> megakaryocyte -> platelet

this image is suggestive of platelet satellitism

Four or more platelets touching the membrane of a neutrophil

this image is suggestive of iron deficiency anemia

Hypochromic, microcytic red blood cells

this image is suggestive of hairy cell leukemia

Lymphocytes with filamentous cytoplasmic projections and oval or folded nuclei

Recognize and name the normal and abnormal forms of erythrocytes using proper medical terminology.

Mature erythrocytes lack a nucleus and are shaped like biconcave disks. The biconcave shape is the result of an increased amount of membrane relative to cell contents. A biconcave disk provides the ideal ratio of surface area to volume which aids oxygen transport. The ability of erythrocytes to deform in shape aids their passage through very small capillaries. Abnormal erythrocytes that have less flexible shapes may become damaged when they pass through capillaries.

Recognize and name the normal and abnormal forms of platelets using proper medical terminology.

Platelets are small disks that may be round to oval. Platelets are cytoplasmic fragments and do not have a nucleus. Cytoplasm: Platelet cytoplasm stains light blue. The amount of platelet cytoplasm is variable. Granules: Platelets contain cytoplasmic granules which stain light purple. Platelet granules may be absent in certain disorders.

this image is suggestive of lead poisoning

Red blood cells with coarse basophilic stippling

describe myelodysplastic syndrome

Result in the failure of the bone marrow to produce adequate numbers of peripheral blood cells. The marrow failure is a result of acquired genetic damage and cytogenetic abnormalities are commonly seen. Abnormalities in the granulocytic, erythroid, and/or megakaryocytic cell lines may be seen Morphology: hypogranular platelets, macrocytic red blood cells, pseudo Pelger-Hüet cells, blasts - often precede acute myelogenous leukemia.

describe the key features of an eosinophil

Size: 10 - 15 microns in diameter Nucleus: 2 to 3 lobes very coarse chromatin nucleoli absent Cytoplasm: abundant numerous red-orange granules

describe the key features of a basophil

Size: 10 - 15 microns in diameter Nucleus: 2 to 3 lobes very coarse chromatin nucleoli absent Cytoplasm: dark blue-black granules granules often overlie nucleus some granule stain loss is common

describe the key features of a neutrophil

Size: 10 - 15 microns in diameter Nucleus: 2 to 5 lobes joined by thin filaments very coarse chromatin nucleoli absent Cytoplasm: pale pink fine, pink-purple granules

describe the key features of a monocyte

Size: 12 - 24 microns in diameter Nucleus: folded or indented sieve-like chromatin nucleoli absent Cytoplasm: abundant, gray-blue vacuoles commonly present few granules may be present

describe the key features of a lymphocyte

Size: 7 - 15 microns in diameter Nucleus: round very coarse chromatin nucleoli absent Cytoplasm: variable amount light blue few granules may be present

describe membrane abnormalities & list some examples

The majority of red blood cell membrane abnormalities have a genetic basis. Membrane abnormalities usually involve a deficiency of, or a defect in, a structural protein. Structural protein abnormalities result in variations in red blood cell shape. - hereditary spherocytosis, elliptocytosis, pyropoikilocytosis

this cell is a sickle cell

long, narrow, curved red blood cells

this cell is a teardrop cell

looks like a teardrop

Describe the steps necessary for the preparation of a Wright-stained peripheral blood smear and its proper microscopic evaluation.

Wright's stain consists of absolute methanol, eosin, and methylene blue. Absolute methanol is used to fix blood cells to the glass slide, preventing removal of the cells during washing. Eosin is an acidic dye which stains basic objects red. Methylene blue reacts with phosphate buffer (pH 6.6-6.8) to form oxidant products which stain acidic objects blue. Place a properly prepared blood slide on a level staining rack, smear side up. Add Wright's stain to slide until completely covered and allow it to stain for a minimum of five minutes. Add an equal amount of dilute phosphate buffer. Mix by gently blowing on the surface until a metallic green sheen forms and allow to stain for ten minutes. Rinse the slide with fresh distilled water to completely remove the excess stain. Clean residue off the back and allow it to air-dry. OK area: Red blood cells do not overlap and are round with central pallor; white blood cell features are clearly seen. The good area of the smear should be examined in a systematic, non-overlapping pattern at both low (10 - 25x objective) and high (40 - 100x objective) magnification. The smear and stain quality should be evaluated by scanning the entire slide. The distribution of cell types should be assessed (i.e. clumping of cells, excessive platelets or white blood cells in the smear tail). White blood cell number may be estimated and reported as low, normal, or high. Rare or abnormal cells may be detected and should be identified at high magnification. The morphology of individual red blood cells, white blood cells, and platelets may be evaluated. Platelet numbers may be estimated and reported as normal, decreased, or increased. A white blood cell differential count may be performed. The relative numbers of white blood cell types may be determined by performing a white blood cell differential count. A minimum of 100 consecutive white blood cells are counted, classified, and reported as percentages of the total white blood cells counted. Nucleated red blood cells, if present, should be counted separately and reported as the number per 100 white blood cells

describe extrinsic abnormalities of RBCs and the following examples: 1. mechanical 2. antibody-mediated 3. heat 4. parasites 5. cold agglutinins

abnormalities of RBC morphology resultinjg from action of external forces on RBCs 1. schistocytes caused by shearing during transit through artificial heart valves or networks of fibrin strands in small vessels 2. microspherocytes, nucleated red blood cells; Antibodies directed against red blood cell surface antigens may result in the removal of a portion of the red blood cell by splenic macrophages, forming spherocytes 3. anisocytosis, poikilocytosis, microspherocytes, schistocytes; elevated temperatures may result in red blood cell fragmentation and membrane loss. 4. intracellular and/or extracellular parasites; may result in hemolysis 5. red blood cell aggregates (clumps); due to the presence of autoantibodies, often as a sequela of infection

the WBC in this image is a reactive lymphocyte

abundant cytoplasm often indented by surrounding red blood cells

the cell in this image is a target cell

alternating rings of pallor and dense staining resembling a target

this image is suggestive of vit B12/folate deficiency anemia

characterized by macrocytosis, anisocytosis, poikilocytosis, and hypersegmented neutrophils

this image is suggestive of stain precipitate

dark blue granules or filaments in between or on top of blood cells

this image is suggestive of a granulocyte with degenerated nucleus

dark purple nuclei with round lobes, homogeneous staining chromatin, and an absence of nuclear filaments

describe lymphoproliferative disorders: 1. chronic lymphocytic leukemia 2. prolymphocytic leukemia 3. large granular lymphocytosis 4. hairy cell leukemia 5. multiple myeloma 6. peripheralization of lymphoma

disorders are due to a clonal proliferation of abnormal lymphocytes. Lymphocyte proliferation may occur at any site in the body, most commonly in bone marrow, lymph node, spleen, or gastrointestinal tract. 1. increased small lymphocytes with coarsely clumped chromatin, smudge (basket) cells; most common form of leukemia and is more prevalent in older adults 2. prolymphocytes; occurs primarily in older men and presents acutely with markedly increased lymphocytes and massive splenomegaly. 3. large granular lymphocytes; often a clonal disorder and may be associated with neutropenia, slpenomegaly, and rheumatoid arthritis 4. lymphocytes with filamentous cytoplasmic projections and oval or folded nuclei (hairy cells); more common in adult males and is associated with splenomegaly and pancytopenia 5. rouleaux formation (four or more red blood cells lined up resembling a stack of coins); clonal proliferation of plasma cells, usually in the bone marrow, often associated with the production of large amounts of circulating immunoglobin 6. neoplastic lymphocytes; clonal proliferation of lymphocytes occurring in tissue, but occasionally a few neoplastic lymphocytes may be seen in the peripheral blood

describe myeloproliferative disorders and the following examples: 1. polycythemia vera 2. chronic myelogenous leukemia 3. primary thrombocytosis 4. agnogenic myeloid metaplasia

due to a clonal proliferation of stem cells in the bone morrow. The stem cells may mature along one or more cell lineages (i.e. myeloid, erythroid, megakaryocytic). -chronic in nature and may progress into an acute myeloid leukemia over an extended period of time 1. anisocytosis, poikilocytosis, occasional nucleated red blood cells, increased neutrophils, basophils, and platelets; characterized by a marked increase in erythrocyte mass and an increased tendency for thrombosis of arteries and veins. 2. increased neutrophils, basophils, platelets, and myeloid precursors; characterized by a large increase in granulocyte production and the presence of the Philadelphia chromosome 3. increased numbers of platelets, abnormal platelets, platelet aggregates; characterized by a marked increase in platelets, abnormal platelet function, and an increased risk of hemorrhage and/or thrombosis 4. immature erythroid and myeloid cells, teardrop cells; characterized by increase immature erythroid and myeloid cells in the peripheral blood, marrow fibrosis, and splenomegaly

this image is a monocyte

folded nuclei with sieve-like chromatin, and gray-blue cytoplasm.

this image is suggestive of Pelger-Huet anomaly

granulocytes with bilobed nuclei. Mononuclear granulocytes

this image is suggestive of hemoglobin C disease

hexagonal crystals with blunt ends

this cell is a giant platelet

larger than a normal RBC

describe the sequence of maturation of lymphocytes

lymphoblast -> prolymphocyte -> lymphocyte