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RBC maturaon

RBC anatomy and physiology

Abnormalies of RBC distribuon

Abnormalies of RBC size

Abnormalies of RBC shape

Erythrocyc inclusions

Pronormoblast Pronormoblast

Basophilic normoblast Basophilic normoblast

Polychromatophilic normoblast Polychromatophilic normoblast

Orthochromic Orthochromic normoblast normoblast • Erythroleukemia Reculocyte • HDN Reculocyte • à Cell size decreases 25 µm 7 µm • Anemia • Cytoplasm rao increases – Acute blood loss • Nuclear size decreases – Heme synthesis • Chroman paern matures and Mature RBC – Hemoglobinopathies nucleus is expelled – Thalassemia Mature RBC • Cytoplasm stains progressively – Hemolyc acidophilic

Diameter: 7 – 8 µm Higher surface area/ Depth: 1 – 2.5 µm volume rao increases Anucleate disc gas diffusion

Volume: 80-100 fL Flexible structure Hemoglobin: 28 - 34 pg allows passage through capillaries

Lifespan: 120 days Permits survival in smallest capillaries

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Hemoglobin A α α

β β

Protoporphyrin

Globin

Heme

Fe

O2 and CO2 passively diffuse Abnormalies of RBC Distribuon Limited metabolic acvity Agglunaon Rouleaux Descripon • Irregular clumping, “grape-like” Linear “coin stack” arrangement Glycolyc pathway clusters -- • Hexose monophosphate shunt • Methemoglobin reductase Mechanism Increased plasma proteins Anbody-mediated • Rapoport-leubering shunt of Formaon (fibrinogen or immunoglobulin)

• Usually cold-reacve, an-red • Plasma cell neoplasms Caon pumps Fe2+ Clinical cell anbodies • Infecous, inflammatory or Correlaon • Some warm reacve, an-red autoimmune diseases with Membrane deformability Reduced sulydryl groups cell anbodies acute phase response

Neg charge from RBCs normally membrane sialic acid 25 nm apart Size maers! ζ

Abnormal or increased plasma proteins IgM anbodies Normocyte Abnormalies 7-8 um of RBC Distribuon Macrocyte

Proteins change Microcyte surface charge, IgM anbodies reducing zeta span the zeta potenal, and potenal gap allowing cells to forming a loosely join in rows lacework that links the RBCs

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Normocytes Macrocytes Microcytes Megaloblasc Anemias Iron Deficiency Anemia MCV usually >120 fL MCV = 64 fL

• MCV = 80 - 100 fL • MCV > 100 fL • MCV < 80 fL • Diameter of average • Diameter of average • Diameter of average cell cell 7-8 um cell >8 um <6 um • Associated with: • Associated with: Liver • Associated with: IDA; Venlaon; Happiness; disease; Megaloblasc Sideroblasc anemia; Lead Rainbows anemia; Neonates poisoning, Myelodysplasc Syndromes; Thalassemia; ACD

Anisocytosis Color maers!

Normochromic: ~ 33% of the cell is filled with hemoglobin, there is central Normal Anisocytosis pallor

Hypochromic: central area larger and paler than normal, decreased hemoglobin • Iron Deficiency Anemia • Thalassemia • Sideroblasc condions • Anemia of Chronic Inflammaon

Polychromasia: Many Poikilocytosis colors; residual RNA • Observed on Wright’s stained smears • Supravital Stains reveal reculocytes • Associated with: ² Acute and chronic hemorrhage Normal Poikilocytosis ² Hemolyc anemia ² Effecve anemia treatment ² Neonates

• Supravital Stains reveal reculocytes

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Terminology Descripon Occurrence

Acanthocytes Acanthocyte Spicules of varying Liver disease, post- length irregularly splenectomy, (spike) distributed abetalipoproteinemia

Dacryocytes Dacryocyte Single elongated or Myelofibrosis, metastac (tear) pointed extremity cancer, thalassemia

Polymerized Drepanocyte Sickle cell anemia; Sickle cell hemoglobin: sickle, Drepanocytes (sickle) trait with low O tension Spiculated crescent, or boat shaped 2

RBCS Arfact, post-transfusion, Short equally spaced heparin therapy, renal failure, Echinocytes Echinocyte (sea projecons; Burr cells; liver disease, post- urchin) crenated cell splenectomy, hyperlipidemia, MDS

Keratocytes Keratocyte One or more notches; (horn) horn-like projecons Microangiopathic anemias, DIC, TTP, HUS, abnormal Red cell fragments; heart valves, vascular Schistocyte triangles, comma anomalies Schistocytes (cut) shaped; microcyc

Can you name that spiculated cell?

Sickle cell (drepanocyte) Hemoglobinopathy (Hgb S)

• Polymerized Hgb S (low pO2) causes RBC rigidity • Cells occlude small capillaries and cause infarcons

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Hemoglobin C and SC Blister • Hemoglobin C crystals form in similar manner as S Codocytes • Elongated rectangles Knizocytes Non-spiculated RBCs • Hemoglobin SC Ovalocytes disease appears as a cross between S and C Spherocytes • Curved rectangles and bizarre shapes Stomatocytes

Terminology Descripon Occurrence

Blister/Bite Membrane content Traumac damage or removed by macrophages as inclusion; G-6-PD deficiency, cell cell passes through spleen hemoglobinopathies

Post-splenectomy, Codocyte Thin bell-shaped; increased thalassemia, (target cell) surface-to-volume rao hemoglobinopathies, liver disease, lipid diseases Name that

More than two concavies; Hemolyc anemias, Non-spiculated Knizocyte dark band of hemoglobin hereditary spherocytosis across center RBC!

Ovalocyte Oval to elongated; with Many diseases, severe in central pallor and hereditary diseases of RBC (elliptocyte) hemoglobin at ends membrane

Dense hemoglobin content; Many diseases, severe in Spherocyte lack central pallor hereditary spherocytosis

Stomatocyte Uniconcave; very thick cup; Many diseases, severe in (mouth cell) oval or slitlike central pallor hereditary stomatocytosis

Target cell (Codocyte) • Extreme membrane:cytoplasm rao increase

• Deficient hemoglobin producon Spherocyte in hemoglobinopathies, • Decreased thalassemia, iron deficiency, liver membrane:cytoplasm rao disease • No central zone of pallor • Elevated MCHC

• Immune hemolyc anemia, DIC, thermal injury, hereditary spherocytosis Elliptocyte (membrane defect) • Hereditary membrane disorder • IDA, Thalassemia

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Terminology Descripon Occurrence

Round granules; variable Basophilic sppling Accelerated number / size; distributed Basophilic erythropoiesis, Impaired throughout the cell; erythropoiesis, lead sppling aggregates of ribosomes poisoning (RNA) Cabot rings Figure-8, or incomplete Myelodysplasc Cabot ring ring; microtubules of the syndrome, Pernicious mitoc spindle Anemia, Thalassemia

Denatured or precipitated Unstable hemoglobins; RBC Inclusions Heinz bodies hemoglobin; with supravital Thal; G-6-PD deficiency stain, round-shaped, Heinz bodies oxidave stress; Post- varying size, close to cell splenectomy membrane Increased or abnormal Small, round bodies Howell-Jolly bodies Howell-Jolly erythropoiesis: thal, PA, composed of DNA usually erythrodysplasia; bodies eccentric; usually single Post-splenectomy Clusters of iron granules; Post-splenectomy, Pappenheimer Pappenheimer usually at cell periphery; diseases with accelerated, bodies visible with Prussian blue disordered, or impaired and Wright’s stain erythropoiesis

Basophilic sppling • Ribosomal aggregates and mitochondrial remnants • Formed during drying of the smear

Heinz bodies

• Hemoglobin or globin precipitate forms rigid inclusion; distorts membrane • Crystal violet or new methylene to visualize • Bite cells on Wright’s

Pappenheimer bodies (sideroc granules) • Small irregular purple granules (clusters) • Presumpve evidence of excess iron in the cell (ferrin and precipitated iron phosphate) • Confirmed with an iron stain (Prussian blue) • RBCs containing sideroc granules are siderocytes

Ringed Sideroblasts

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• A 48 yr old female was admied to a hospital because of difficulty in breathing, wheezing, cough and fague. Her history included diabetes and hypertension. • CBC data: – Hemoglobin = 8.2 g/dL – RBC count = 1.73 x 1012/L – MCV = 109.8 fL. – Hct = 19% – MCH = 47 pg – MCHC = 43.1 g/dL – Her WBC count and platelet count were within the reference intervals

• Evaluate the CBC informaon for this paent

• Because of the abnormal values found in the • What should the laboratory professional report CBC, the laboratory professional made a blood about the RBCs on the crical area of this smear? smear and performed a WBC differenal and complete evaluaon of the RBCs and platelets. • Which results of the CBC might be affected by the findings on the smear?

• The laboratory professional warmed the EDTA • A 20-year-old African-American male presented to the emergency room because of the onset of sample from this paent at 37 oC for 15 severe abdominal pain while on vacaon skiing in minutes and then repeated the CBC. The new Colorado. smear appeared as below. • CBC: – 9 – Hemoglobin = 8.2 g/dL WBC: 11.8 x 10 /L – RBC: 2.95 x 1012/L 12 – RBC count = 2.63 x 10 /L – HGB: 9.2 g/dL – MCV = 91 fL – HCT: 26.8 % – Hct = 24% – MCV: 84 fL – MCHC: 36.2 g/dL – MCH = 31.2 pg – PLT: 205 x 109/L – MCHC = 34.2 g/dL • WBC differenal: Normal • 12 NRBCs/100 WBCs • Explain what may have happened in this case?

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• Is the white count valid? • Detail the morphologic features observed during erythrocyte maturaon • Why does the paent have so many NRBCs in the peripheral blood? • Associate erythrocyte shapes and inclusions with biochemical and physical processes

• Predict a disease process related to erythrocytes when given unfamiliar clinical • What is the most likely diagnosis? data

References

• Bessis, M. Blood Smears Reinterpreted, 1973, p. 61 • Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Tesng, CAP Press, 1998. • Clinical Laboratory Hematology, McKenzie, S. and Williams, L., Pearson, 2010, 2014. • John Landis: [email protected]

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