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Home , Anisocytosis, Basophilic stippling, Cabot rings, Mentzer index, Microcytosis, Pappenheimer bodies

Making the most out of the CBC and peripheral blood smear

May 2011

John D’Orazio, M.D., Ph.D. Pediatric -Oncology University of Kentucky College of Medicine [email protected] objectives

• Understand the clinical information that a (CBC) contains and how to get the most information out of it. • Appreciate the importance of the peripheral blood smear in the interpretation of hematologic conditions. • Reinforce concepts through cases via audience participation.

I have no relevant financial admissions or conflicts of interest to disclose . Complete Blood Count (CBC) “hemogram” • One of the most commonly ordered tests • UK hospital runs about 700 hemograms a day

– 15,000‐20,000 a month (Compared to ~1,000 chemistry panels per day) – 40% outpatient 60% inpatient • Directed test for blood disorders • Screening test for systemic diseases

Advia 2120 Hematology Analyzer What comes with a CBC? Lots of ifinformat ion about cellu lar bloo d elements:

 Total number  Amount of RBC’s  Total number  Composition  Average size  Average size  Absolute numbers  Amount of hgb in each of each type  Uniformity of size Diamond ‐ Pertussis Blackfan TTP ALL MliMononucleosis SiSepsis Eosinophilia

Fanconi Anemia Autoimmune HUS Thrombocytopenia Neutropenia Hereditary Immunodeficiency AML Folate, B12 Chronic DIC deficiency Aplastic Anemia CML Steroid use HIV Hemolytic Uremia Bernard‐Soulier Hypoxia, Syndrome ITP syndrome

Allergy Alloimmune Myelodysplasia Wiskott‐Aldrich thrombocytopenia The CBC is one of the most commonly used screening tests in medic ine Procedure

• Blood is collected, usually venous

– capillary, arterial blood are o.k. • Purple (lavender)‐topped tube

– Contains EDTA, an anticoagulant that works by chelating calcium

– Clotting is Ca‐dependent What happens when the lab gets the sample?

• AdAutomated CBC analyzers work by ddiietermining light scattering profiles of individual blood cells

Ce ll Dyn 4000 mo dern hema to logy ana lyzer, Abbott Laboratories, Chicago, IL ((g)Hgb)

• The oxygen‐carrying molecule in RBC’s • Measured as grams per deciliter (g/dL) of whole blood. • Tetramer comprised of 4 glblobin proteins and an iron‐containing heme moiety.

Hemoglobin Alpha globin Beta globin

Hgb A (adult) 2 2

Hgb A2 2 δ2

HbHgb F (fe ta l) 2 γ2 Almost all analyzers calculate hemoglobin by the cyanomethemoglobin method.

Drabkin’s reagent

Hgb Cyanmet‐Hgb (Hct)

• Reflects the volume percentage of RBC’s in whole blood

• Classic method: “Spun Hematocrit” – determined by centrifugation of whole blood in a narrow Air capillary blood glass tube sealed at one end. – Since "crit" tubes are fragile and dangerous to use, spun are rarely used today.

Plasma • The automated hematology analyzer calculates the Hct from the RBC and MCV by the following formula: Buffy coat (WBC) Hct (%) = RBC x MCV

In general, hematocrit = 3x hemoglobin Hematocrit (RBC) – Since the Hct is a calculated value, it is less accurate than hemoglobin Clay plug (()MCV)

• Average size of RBC’s • “Normal” varies with age – For adults = 80‐94 fL – Elevated MCV = RBC’s larger than normal – < 10 y/o, lower limit of normal = 70 fL + age ()(yrs) • “” – Infants: much higher – Decreased MCV = RBC’ s smaller MCV’ s than normal

• “microcyosis”

– Normal MCV = RBC’s “just right”

• “normocytosis” Key Concept

To make a ppproper RBC, there must be coordination between proliferation of RBC precursor cells and hemoglobinization of maturing RBC’s

- - - cell division - - - differentiation - - -

Hematopoeitic Mature Stem cell erythrocytes Cell division occurs relatively normally but Hgb Hgb production is fine but there is a problem production is defective. The cytoplasm can’t with DNA synthesis. RBC precursors divide “fill up” properly with hemoglobin before the slowly, allowing more time to accumulate Hgb cells divide, so daughter cells are small. which makes the cells large.

Problem with DNA Problems with Synthesis Hemoglobin Production

B deficiency Marrow failure 12 Iron Deficiency ↓ Globin () Folate Hydroxyurea, deficiency Chemo Red cell distribution width (RDW)

• quantitative measure of variation in size () – normal RDW range is 11.5 ‐ 14.5 % • Nutritional → high RDW’s – Day‐to‐day variation in diet • IhInher itdited anemias → low RDW’s – Fixed genetic lesion affecting hematopoiesis all the time MCV and RDW

Normal Nooarmal Microcytosis Low RDW High RDW (Thalassemia) (Fe deficiency) (cells) (cells) Events Events

RBC Size RBC Size

Normal Normocytosis Normal Macrocytosis

(Folate or B12) lls) lls) ee ee Events (c Events (c

RBC Size RBC Size “Mentzer Index”

William Mentzer, M.D. Pediatric Hematology/Oncology Professor Emeritus, UCSF • helps differentiate whether is caused from iron deficiency or from thalassemia. Mentzer Index = MCV  RBC count

< 11 > 13 thalassemia Fe deficiency

Mentzer WC, 1973, "Differentiation of iron deficiency from thalassaemia trait". Lancet 1 (7808): 882. production destruction

Circulating red cell mass represents a balance between cellular production and destruction.

To determine whether there is impaired RBC production or premature RBC destruction… always order a reticulocyte count in your anemia work‐up!

Low retic count = RBC production problem High retic count = RBC destruction

The reticulocyte count is not part of the CBC. • Supravital staining that identifies ribosomes in the cytoplasm of RBC’ s • Ribosomes persist in RBC’s for 24‐48h after leaving the marrow

– ongoing Hgb synthesis • Reticulocytes are young red blood cells only 1‐2 days removed from the marrow. • Why is the retic count normally ~1%?

– Normal RBC life‐span ~ 120d – Each day the body must replace 1 ÷ 120 =~1% of the red cell mass Reticulocyte Index • More ifinforma tive than jtjust the reticcount. •Corrects for abnormal hematocrit.

(Ac tual H c t) Reticulocyte index= (Percent reticulocytes) x (Normal Hct) <2%< 2% > 2% Production problems Destruction problems

• Hypoproliferative Anemias • Hemolysis

– Nutritional (iron, folate, B12) – Immune‐mediated – Anemia of inflammation – • Erythropoeitin defect – Membranopathies • failure – RBC metabolic abnormalities • Bone marrow infiltration • Blood loss • RBC maturation abnormality • Mechanical RBC destruction Clues to on a CBC Anemias, deconstructed…

Picasso: Girl Before a Mirror, 1932

Microcy tic NtiNormocytic MtiMacrocytic (low MCV) (MCV nl. for age) (high MCV)

• Bone marrow failure • Iron deficiency Underproduction •TEC •MDS • • Viral suppression • (low retic’s*) • Anemia of inflammation •DBA *for degree of anemia

• Membrane disorders • Hemoglobinopathies RBC destruction • Enzymopathies • Immune-mediated • Thalassemia (high retic’s) • G6PD deficiency hemolysis • Microangiopathy • Blood loss

Automated WBC Differential

• Histogram analysis of WBC’s • each "dot" represents data from a monocytes neutrophils single cell.

ll size) • Each tyyype of WBC displays a characteristic size and granularity • In this case: catter (ce ss • 65. 6% Neutrophils eosinophils • 26.2%

Forward lymphocytes • 5.6% Monocytes • 2.2% Eosinophils Side scatter (cellular complexity) • 0.4% Basophils CBC’s at UK

• Pretty much all CBC’ s start with analysis by an automated CBC analyzer. • ~75% of CBC’s have an automated differential only.

– Clue to automated differential = reported % with tenths values.

Neutrophils 54.8% Neutrophils 55% Lymphs 23.6% Lymphs 24% Monocytes 15.2% Monocytes 15% Eosinophils 4.3% Eosinophils 4% Basophils 2.1% Basophils 2%

Automated Differential Manual Differential • If the automated analysis picks up certain “flags”, then the CBC is tiikdcked for a manual assessment by the Heme techs. Nucleated Blast forms High WBC RBC’s (> 50,000) count < 30,000 Immature neutrophils

Macrocytosis

Abnormal Absolute Marked Abnormal Anisocytosis Absolute count Variant monocyte count lymphocytes

Low MCV

Certain RBC Plat el et Morphology clumps Abnormalities Bottom line…

• Today’s automated hematology analyzers are very good for most routine applications, but they’re not perfect. • AdAutomated CBC’s can’t relia bly dibdescribe the actual morphhlology of WBC’s or RBC’s – Machines can “flag” certain RBC or WBC abnormalities ((ge.g. 2+ anisocyy)tosis) • If the diagnosis that you are considering correlates with a specific WBC or RBC morphology, then order a manual slide review. – (blasts) – RBC membrane disorder (spherocytes) • Likew ise, if the CBC d’tdoesn’t “fit” with the clin ica l piticture, then more information might be obtained by examining a peripheral blood smear. CBC’s and Manual Diff’s

• Only when a manual differential is performed will anyone from the lab ppyhysicall y look at the ppperipheral blood smear.

• Remains the “gold standard” for blood interpretation

• Clinical Lab’ s Heme techs are excellent and reliable

• Exceptional smears are also reviewed by hematopathologists

• The practitioner has the option of requesting a manual differential right from the start (on the general lab order form).

• For now, but the lab may evaluate this policy (labor‐intensive)

Keys to success with blood smears

• The smear must be artifact‐free and have an adequate region of cell dispersal

Too thick! Too thin! Just right

• Take your time, and ask the hematology tech his/her impression Warm-up slides Describe those RBC’s!

Goodness that is a lot of variation in color! This person must have a high retic count!!!

1. Spherocytes 2. Polychromasia 3. Sickled forms 4. Nucleated RBC’s Describe those RBC’ s!

Just look at all that variation in red cell size!

1. 2. Polychromasia 3. Anisocytosis 4. Target Forms Describe those RBC’ s!

I say! Have you ever seen such differences in red cell shape?!

1. Polychromasia 2. Anisocytosis 3. Poikilocytosis 4. Target Forms Describe those RBC’ s!

Which term best describes this smear? 1. 2. Sickled Forms 3. RBC Stippling The : 4. Sppyherocytes final resting place for many a spherocyte… Describe those RBC’ s!

ShiSchistocytes are bkbroken red cell fragments that form with microangiopathy and abnormal shearing.

1. Sickled Forms 2. Schistocytes 3. Reticulocytosis 4. Spypherocytes Describe those RBC’ s!

Did someone mention targets?! This patient might have hemoglobin C!

1. Polychromasia 2. Anisocytosis 3. Poikilocytosis 4. Target Forms Name that Cell!

B CllCells, T CllCells and NK Cells, Oh My!

1. Monocyte 2. Lymphocyte 3. Neutrophil 4. Blast Name that Cell!

1. Neutrophil 2. Eosinophil 3. Granular Lymphocyte 4.

Findingpg basophils in the ppperipheral blood is fairly uncommon. Name that Cell!

Does anyone else think that eosinophils are beautiful? They look like they’re filled with little rubies!

1. Neutrophil 2. Monocyte 3. Eosinophil 4. Basophil Name that Cell!

1. Band 2. Monocyte 3. Lymphocyte 4. Basophil Now THAT’s a fine band! Name that Cell!

Hey look‐ it’s a little neutrophil smiley face!

1. Neutrophil 2. Monocyte 3. Eosinophil 4. Basophil Name that Cell!

Prepare to be phagocytized!

1. Neutrophil 2. Monocyte 3. Lymphocyte 4. Basophil Name that Cell!

1. Monocyte 2. Band 3. 4. Blast Ka-BOOM!!! Cases

CBC and peripheral blood smear can clinch the diagnosis. Hands on cllkickers… it’s time for audience ppparticipation fun! Toddler with pallor.

6.1 585.8 478 17.9

MCV: 57 fL RDW: 23 % MCHC: 32 fL P46,L38,M12,E4 Retic: 1.3%

• Pallor seems to have developed gradually. • No jaundice, no dark urine, no fevers • PlPale btbut we ll-appearilfling, playful • No organomegaly Toddler with pallor.

6.1 5.8 478 25% 25% 25% 25% 17.9 MCV: 57 fL RDW: 23 % MCHC: 32 fL P46,L38,M12,E4 Retic: 1. 3%

Which diagnosis is most likely?

1. Iron deficiency anemia 2. Thal assemi a

3. Vitamin B12 deficiency 4. Autoimmune hemolysis

1234 4 y/o immigrant from Nigeria.

7.7 10.8 423 21.8

MCV: 83 fL RDW: 19.1 % P61,L28,M8,E3 Retic: 9.3%

• Not previously known to be anemic. • Bloodwork on his initial “well-child” check. • 4-5 cm firm spleen felt on examination. • Muddy sclerae • II/VI systolic murmur left sternal border 4 y/o immigrant from Nigeria.

7.7 10.8 423 21.8 MCV: 83 fL 25% 25% 25% 25% RDW: 19.1 % P61,L28,M8,E3 Retic: 9.3%

Which diagnosis is most likely?

1. Trypanosomiasis 2. G6PD deficiency 3. Thalassemia 4.

1234 4 y/o with widespread bruising.

12.1 585.8 3 35.8

MCV: 87 fL RDW: 12.3 % MCHC: 34 fL P60,L28,M6,E2,Atyp4 Retic: 1.3%

1. No family history of bruising/bleeding. 2. Normal medical history. 3. NiNo increase dbldid bleeding w ihith neonata lil circumc iiision. 4. Petechiae and purpura appeared suddenly overnight. 4 y/o with widespread bruising.

12.1 5.8 3 35.8 MCV: 87 fL 25% 25% 25% 25% RDW: 12.3 % MCHC: 34 fL P60,L28,M6,E2,Atyp4 Rti13%Retic: 1.3%

Which diaggynosis is most likely?

1. Acute Leukemia 2. Idiopathic Aplastic Anemia 3. Child abuse 4. ITP (Primary autoimmune thrombocyyptopenia )

1234 Teenager with Crohn’s disease and pallor.

6.7 282.8 110 19.8

MCV: 107 fL RDW: 19.1 % P41,L48,M9,E2 Retic: 2 .3%

• Diagnosed 4 years prior with IBD

• Hospitalized a few times with Crohn’s exacerbations.

• Pallor seems to have come on gradually.

• Symptoms include some weakness and dizziness. Teenager with Crohn’s disease and pallor.

8.1 2.8 110 23.8 MCV: 107 fL 25% 25% 25% 25% RDW: 19.1 % Retic: 2.3%

Which diagnosis is most likely? 1. MlMyelogenous lkleukem ia 2. Steroid effect 3. Lupus erythematosus

4. Vitamin B12 deficiency

1234 Child in ICU with thrombocytopenia

10.1 858.5 48 29.4 Retic: 3.2% MCV: 87 fL P64,L26,M8,E2

• Admitted yesterday with high fevers and obtundation. • Bloo d cu lture pos itive for gram-negative ro ds. Child in ICU with thrombocytopenia

10.1 8.5 48 29. 4 25% 25% 25% 25% Retic: 3.2% MCV: 87 fL P64,L26,M8,E2

Which diagnosis is most likely?

1. Endocarditis 2. Disseminated intravascular (DIC) 3. Sickle cell anemia 4. Dehydrated red cells

1234 5 y/o with fever, pallor and bruising

8.1 133.8 47 23.9 25% 25% 25% 25% MCV: 79fL RDW: 13 % MCHC: 33. 4 fL Retic: 0.4%

1. 2. Viral infection 3. Acute leukemia 4. IflInflammat ory response

1234 9 y/o with abdominal cramping.

25% 25% 25% 25%

1. Helminth infection 2. Lactose intolerance 3. Clostridium difficile colitis 4. Irritable bowel syndrome 1234 Another toddler with pallor

7.1 686.8 348 21.9

MCV: 57 fL RDW: 11 % MCHC: 32 fL P54,L28,M17,E1 Retic: 10.3%

• Family recently immigrated from Turkey • Firm spleen 5 cm below costal margin • Mildly icteric sclerae Another toddler with pallor

7.1 6.8 348 21.9 MCV: 57 fL 25% 25% 25% 25% RDW: 11 % MCHC: 32 fL P54,L28,M17,E1 Retic: 10.3%

Which diagnosis is most likely?

1. Iron deficiency anemia 2. Thalassemia 3. Chronic renal failure (EpO deficiency) 4. Anemia of inflammation

1234 2 y/o with pneumococcal sepsis

12.1 686.8 498 36.9

MCV: 81 fL RDW: 12 % MCHC: 34 fL P65,L23,M11,E1 Retic: 1.8%

• Normal full‐term baby • Normal growth/development • 1 prior hospitalization for pneumonia 2 y/o with pneumococcal sepsis

12.1 6.8 498 36.9 25% 25% 25% 25% MCV: 81 fL RDW: 12 % MCHC: 34 fL P65,L23,M11,E1

Which diagnosis is most likely?

1. Common variable immunodeficiency 2. HIV infection - AIDS 3. Asplenia 4. Congenital neutropenia

1234 7 y/o with pallor.

5.1 838.3 401 15.4

MCV: 103 fL RDW: 26 % MCHC: 34.3 fL P32,L48,M14,E2,nRBC4 Retic: 34.5%

• Fatigue and pallor seem to have “come out of nowhere” over the past day or two. • Patient is sallow, ill-appearing and has mild scleral icterus. • Hyperdynamic precordium with III-IV/VI systolic murmur. • No organomegaly. 7 y/o with pallor.

5.1 8.3 401 15.4 25% 25% 25% 25% MCV: 103 fL RDW: 26 % MCHC: 34.3 fL P32,L48,M14,E2,nRBC4 Retic: 34.5%

Which diaggynosis is most likely? 1. Autoimmune 2. Disseminated intravascular coagulation (DIC) 3. Acute Leukemia 4. Folic acid deficiency

1234 6 y/o with splenomegaly.

818.1 5.5 288 24.4 Retic: 8.2% MCV: 87 fL MCHC: 36 P44,L46,M8,E2 Direct Coomb’s: negative

• Child is asymptomatic • Splenomegaly appreciated on routine exam by an apt clinic resident • Pho toth erapy as a newb orn • Mother with history of cholecystectomy as a teenager 6 y/o with splenomegaly.

8.1 5.5 288 24. 4 25% 25% 25% 25% Retic: 8.2% MCV: 87 fL MCHC: 36 P44,L46,M8,E2 Coomb’s neg

Wh ke o gh ic yo h diagnosis is most likely? 1. B‐thal trait 2. G6PD deficiency 3. 4. Storage disease (Gaucher’s)

1234 18 month old well child with anemia

5.3 767.6 248 25% 25% 25% 25% 14.4 Retic: 0.2% MCV: 89 fL RDW: 13.3 P49,L41,M9,E1 ESR: 6 sec

1. Iron deficiency 2. Folate deficiency 3. Transient erythroblastopenia of childhoo d (TEC) 4. Aplastic Anemia 1234 Teenager with low-grade fevers, malaise and splenomegaly

25% 25% 25% 25%

1. Acute myelogenous leukemia 2. (EBV) 3. Systemic lupus erythematosus 4. Histiocytosis

1234 Teenager with fevers, recently back from a mission trip. 11.2 10.7 448 32.9 25% 25% 25% 25% MCV: 83 fL RDW: 15 % MCHC: 34 fL

Retic: 2.3%

1. Sleeping sickness 2. Liver fluke infection 3. Malaria 4. Chagas disease

1234 School-age child with bruising and low- grade fever

8.3 28. 4 52 24.7 25% 25% 25% 25% MCV: 91 fL RDW: 13 % MCHC: 33.4 fL Retic: 1.7%

1. Acute myygelogenous leukemia 2. Reactive left shift 3. ITP 4. Listeria infection

1234 8 y/o girl with swollen cervical

25% 25% 25% 25%

1. Lymphoma 2. Atypical bacterial infection 3. Mumps infection 4. An amazing shot of all the major normal WBC’s in the same field

1234 Take home • The CBC and peripheral blood smear offer a wealth of information regggarding pathophysiology. – Heme/onc diagnoses – Atopy, Rheumatology – Infectious disease “John, always review the – Others primary data yourself…”

• There is bbfitenefit to reviiiewing bloo d smears yourself, especially in difficult or challenging cases.

Or ask your friendly hematologist for help! Howard Weinstein, MD Chief, Pediatric Hematology/Oncology, MGH [email protected]; 323‐6238 What the !@#$ are they talking about?

• Polychromasia, RBC’s of different staining color, Polyypchromatophilia implies reticulocytosis

RBC’s of different shape, mixed • Poikilocytosis population (old + transfused cells)

RBC’ s of different size; • Anisocytosis reticulocytosis, high RDW

RBC fragments, microangiopathic • Schistocytosis processes (DIC), shearing

• , Ovalocytosis RBC’s look elliptical, membranopathy • Drepanocytosis Sickle cell forms, Hgb S disease

• Spherocytosis No central pallor in rbc’s; HS or AIHA

• Howell‐Jolly bodies Functional asplenia Sppyherocytes Schistocytes

Elliptocytes Drepanocytes

Poikilocytes Target cells Stomatocytes Decreased Increased

Neutrophils • Kostmann’s syndrome • • Cyclic neutropenia • Tissue destruction • Bone marrow failure • Corticosteroids • Leukemia • Leukemoid reaction • Autoimmune neutropenia • GCSF administration • Benign neutropenia of childhood • Infection/sepsis • Drug‐induced (Bactrim, chemotherapy) • Myelodysplasia

Lymphocytes • Congenital immunodeficiency • Viral infection (e.g. EBV) • Severe infection • Some fungal, parasitic infections • Drugs (Corticosteroids, alkylating) • Rare bacterial infection (Pertussis) • GI disease • Allergic reactions/drug sensitivities • Acquired Immunodeficiency • Immunologic disease Monocytes • Corticosteroids • Inflammatory responses • Recovery phase of neutropenia • Myeloproliferative disorders Eosinophils • Bacterial infection • Parasitic infections • ACTH administration • Allergic conditions • Drug therapy Basophils • Corticosteroids • Bone marrow failure • Myeloproliferative syndromes Normal blood cells

monocyte band

pltltlatelet lymphocyte

neutrophil

basophil eosinophil Anemia‐ a suggested approach

• Does the child look anemic? • Does the child act anemic? • Key physical exam parameters: – Look at the conjunctiva under the lower eye lid – Splenomegaly? Tachycardia? Petechiae/purpurae? • The lab tests to order will be dictated by: – The degree of pallor, presence of symptoms – Physical findings (jaundice, HSM, adenopathy, etc) – Apparent pace of the anemia – What diagnoses are being considered • Start out with a CBC, but always order a reticulocyte count too! – The retic count distinguishes between RBC destruction and underproduction Red blood cells Mean corpuscular hemoglobin (MCH)

• Average amount of Hgb inside each RBC • High MCH’s go along with large (macrocytic) RBC’s • Low MCH’s correlate with microcytosis and anemias caused by impaired Hgb synthes is. Mean corpuscular hemoglobin concentration (MCHC)

• Average concentration of hemoglobin inside a red cell. • Takes red cell volume into account • Decreased MCHC values (hypochromia) seen in conditions where Hgb is abnormally diluted inside RBC’s • Iron deficiency anemia • Thalassemia • Increased MCHC values (hyperchromia) seen when Hgb is abnormally concentrated inside RBC’s • Spherocytosis • Abnormal Hgb ((,S, C) If MCHC > 35 fL, thin k sphht!erocytes! • Severe burns hematocrit (%) But in general, suspect anemia for hgb < 10 g/dl orhct< 30%. < 10 for hgb suspect anemia general, But in Always check the age-appropriate cut-offs. Therefore, there is noabsolutevaluefor “anemia” for all kids. Normal hematologic valuesdependon age andgender. Source: Vampire Handbook, Boston Children’s Hospital 1 y/o with pallor

8.2 828.2 351 25% 25% 25% 25% 23.9 MCV: 71 fL RDW: 18.4 % Retic: 2.6%

1. Lead poisoning 2. Malaria 3. Babesiosis 4. Hemoglobin C disease

1234 Febrile infant with pancytopenia

25% 25% 25% 25%

1. Lysosomal storage disease 2. Histoplasmosis 3. Chronic Granulomatous Disease (CGD) 4. PliPneumococcal sepsis

1234 12 y/o with fever, bruising and pallor.

25% 25% 25% 25%

1. Candidal infection 2. Histoplasmosis 3. Burkitt’s lymphoma/leukemia 1234 4. Gaucher’s disease Albino child with frequent infections.

25% 25% 25% 25%

1. Abetaproteinemia 2. Tyrosinase neutropenia 3. Chronic granulomatous disease 4. Chediak-Higashi syndrome 1234 This is not a staining artifact!

25% 25% 25% 25%

1. Obstructive liver disease 2. Abetalipoproteinemia 3. Thalassemia 4. Severe burns

1234 Common Sources of Error for Automated CBC machine

Clotting Carboxyhemoglobin Cryoproteins Giant

Heparin Smudge cells Agglutination Hyponatremia Nucleated RBCs Uremia

WBC count >50,000/μL DIC Platelet clumping Hemolysis Medications RBC inclusions Excess EDTA

Hyperbilirubinemia Lipemia

Infections Hyperglycemia Anemia: not enough red cells.

IdInadequat e oxygen-carrying hemogl lbiobin capacity it Howell jolly bodies Sickle cell disease Elliptocytes

Elliptocytes (ovalocytes) : elongated RBC - Large number (up to 100%) is the hallmark of hereditary elliptocytosis - Low number (up to 5 - 10%) is observed in various situations, including iron deficiency and megaloblastic anemias - If they are very large = macro ovalocytes (see "macrocytes") stomatocytes

Stomatocytes : folded RBC leading to an aspect mimicking a mouth and its lips (slit- like appearance) - Many situations, including hemolytic anemias, either constitutive or acquired Cold agglutinin disease

Cold agglutinin disease ; aggregates disappear after the sample is warmed at 37°C echinocytes

Echinocytes or crenated or contracted cells : up to 50 protrusions (spines or spurs) may be observed - They correspond usually to an artifact (glass slides, old samples, saline solutions) - Excess in lipids (not diet fed samples) - Various congenital haemoglobin and enzymatic disorders - Acute renal failure formation, myeloma

Rouleaux formation : RBC do not stick to each other in normal conditions because their external membrane is negatively charged; if neutralization occurs, RBC stick face to face, leading to the so-called "rouleaux formation" - All inflammatory disorders (slide) - monoclonal gammopathies with excess of monoclonal immunoglobulin (does not occur in light chain myeloma) Acanthocytes : crenation is limited (3 to 12 sp ines or spurs ) Hereditary acanthocytosis (abetalipoproteinemia) Liver diseases (cirrh osi s) wi th dysli pi demi a As a part of artefact, mixed to echinocytes

Basophilic stippling : numerous thin and dark granules scattered throughout the RBC, related to abnormal hemoglobin synthes is - Thalassemic syndromes (including thalassemic trait) - Sideroblastic anemias ((,g,lead, drugs, idiopathic) - Agnogenic myeloid metaplasia - Newborn (stippling is delicate) babesia plasmodium

Cabot rings : remnants of the mitotic spindle, appearing as purple rings or loops within RBC ‐ All major dhiidyserythropoietic changes Papenheimer bodies

Pappenheimer bodies : small dark RBC inclusions ;;y usually one to three within the cell, they are located near the periphery of the cytoplasm - All dyserythropoietic states lead to their production, and number may raise sharply (up to 100% of RBC) in splenectomized or asplenic patients