Red Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
Continuing Education Credits
This collection of informative case studies covers many current topics in red cell disorders. Topics include macrocytosis, intracellular RBC inclusions, echinocytes and acanthocytes, schistocytes, ovalocytes, and rouleaux. Numerous high-quality photomicrographs and real-life situations help ensure learning and retaining needed information.
Objectives
- Recognize normal and abnormal red blood cell morphologies.
- State the criteria for performing and reporting peripheral blood smear reviews.
- Evaluate red blood cell size, shape, and staining characteristics.
- Correlate observations of key red blood cell abnormalities on peripheral smears with associated clinical conditions.
Course Outline
- Introduction to Red Blood Cell Morphology
- Normal Red Blood Cell Morphology
- Normal Red Blood Cell (RBC) Characteristics
- Initial Evaluation of RBC Morphology From Automated Analyzers
- Criteria for Peripheral Blood Smear Review
- The Peripheral Smear: Reviewing Red Blood Cell Morphology
- Introduction to Red Blood Cell Morphology Reporting
- Table 1: Guidelines for Reporting Red Blood Cell Morphology
- Abnormal Red Blood Cell Morphology Review
- Red Cell Morphology Reference Tables
- Variations in Red Blood Cell Sizes
- Table 2: MCV Classification
- Variations in Hemoglobin Content
- Table 3: Hemoglobin Content (MCHC) Classification
- Variations in Red Blood Cell Shapes
- Table 4: Poikilocytosis Review
- Abnormal Red Blood Cell Distribution
- Table 5: Rouleaux and Agglutination
- Dimorphic (Double Cell) Population
- Red Blood Cell Inclusions
- Table 6: Red Blood Cell Inclusions Review
- Red Blood Cell Nonneoplastic Conditions
- Introduction to Case Studies
- Hemolytic Conditions with Spherocytosis
- Case StudyA 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 in the report?
- Case Study (continued)Which hematologic condition could be associated with the findings shown in this image?
- A known case of hemolytic disease of the fetus and newborn (HDFN) is presented in the image on the right. Many different cellular morphologies are present. Apart from the obvious anisocytosis (microcytes and macrocytes), which additional red blood cell morphologies are worth reporting?
- A 49-year-old patient with pneumonia was treated with high-dose intravenous penicillin. The patient became jaundiced with yellow sclera. The image on the right is typical of other fields that were observed on the 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 pos
- Macrocytosis-Associated Conditions
- 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 peri
- 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?
- Intracellular RBC Inclusions
- A 25-year-old asplenic patient 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?
- 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?
- A 66-year-old patient has been diagnosed with sideroblastic anemia. The inclusions indicated by the arrows in the image were seen in many of the RBCs on the Wright-stained peripheral blood smear. What is the identity of these inclusions?
- A 10-year-old child came to a physician's attention because of recent jaundice and icteric sclerae after taking the medication Primaquine. Some key results from the immediate laboratory work revealed:ParameterPatient ResultReference RangeHematocrit24%36–47%MCV79.5 fL78-95 fLRDW13%11.5–15.0%The blood smear findings are reflected in the images to the right. The upper image is a Wright-Gi
- Red Blood Cell Populations
- 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 most likely?
- Conditions with Poikilocytosis
- Hemoglobin E (HbE) and HbE/Beta-Thalassemia
- A five-month-old child is brought to the pediatrician by the 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 key 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.Para
- A CBC and reticulocyte count are ordered on a 10-year-old African-American child who was brought to the emergency department with rapid, shallow breathing and fever. Key results are shown below.ParameterPatient ResultReference RangeWBC28.0 x 109/L3.2–9.8 x 109/LRBC3.88 x 1012/L4.50–5.70 x 1012/LHemoglobin10.0 g/dL13.6–17.2 g/dLMCV82 fL80–110 fLRDW 23%11–14.5%Reticuloc
- True or False: Sickle cells along with target cells, as shown in this image, confirm a diagnosis of sickle cell disease (HbSS).
- 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
- 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?
- 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?
- A 5-year-old child was brought to the emergency department with bloody diarrhea and severe abdominal pain. A complete blood count was performed, key results are below:ParameterPatient ResultReference RangeWBC9.6 x 109/L4.3–10.8 x 109/LHemoglobin9.1 g/dL11.5–13.5 g/dLHCT28%37–48%MCV80 fL86–98 fLRDW13.1%11–15%Platelets90.1 x 109/L150–450 x 109/LThe peripheral bloo
- Ovalocytes/Elliptocytes
- Stomatocytes
- A 13-year-old healthy patient presents to the 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?
- Multiple Erythrocyte Abnormalities
- Case Study
- Case Study: Splenectomy Morphologies
- Case Study: Poikilocytosis and Basophilic Stippling
- This slide is from a 28-year-old patient 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?
- The image on the right is a representative microscopic field from a patient with post-splenectomy syndrome. Identify each of the labeled cells in the field. (Note: Individual laboratory procedures dictate how, or if, each of these cells would be reported in this case).
- References
- References
Additional Information
Level of Instruction: Intermediate
Intended Audience: Medical laboratory scientists and technicians seeking review, cross-training, or continuing education opportunities. It is also appropriate for medical laboratory science students, medical students, and pathology residents.
Author Information:
C. William Reiquam, MD (1923-2015) was a clinical professor of pathology at the School of Medicine, University of Colorado. One of his areas of expertise was hematology.
Until his recent passing, Elmer W. Koneman, MD was Professor Emeritus, Department of Pathology, University of Colorado School of Medicine. Dr. Koneman was a Board Certified Pathologist and former tenured professor. He was the author of numerous journal articles and books.
Reviewer Information: Laurie Bjerklie, MA, MLS(ASCP)CM is
currently an Education Developer for MediaLab and LabCE. She earned a B.S. in
Medical Laboratory Science from the University of North Dakota and an M.A. in
Curriculum and Instruction from Saint Xavier University. She has over 15 years
of experience in higher education and has held program director and faculty
positions in both MLT and MLS programs.