Shagana. J.A /J. Pharm. Sci. & Res. Vol. 6(4), 2014, 213-216 Diagnostic Cells in the Peripheral Blood Smear Shagana. J.A Student ,Saveetha Dental College Abstract: A blood film or peripheral blood smear is a thin layer of blood smeared on a microscope slide .Peripheral blood smear are usually examined to investigate hematological problems and occasionally, to look for parasites within the blood. An examination of the blood smear may be requested by physicians or initiated by laboratory staff. With the development of sophisticated automated blood-cell analyzers, the proportion of blood- count samples that require a blood smear. Nevertheless, the blood smear remains a crucial diagnostic aid. From the peripheral blood smear we can examine the number of white blood cells , platelets and to detect the rouleax formation,anaemia, platelet clumps and leukocytic clumps and other abnormalities. Key words : peripheral blood smear, schistocytes, lymphocytosis, thrombocytosis INTRODUCTION: hemolytic anemia,that provide important evidence of A peripheral blood smear is a glass microscope slide this cause of hemolytic anemia.[3] coated on one side with a thin layer of venous blood.The b.) Spherocytes : slide is stained with a dye, usually Wright’s stain, and Spherocytes are small, dense spheroidal RBCs with examined under a microscope[1]. A physician-initiated absence of Central pallor. It may result from request for a blood smear is usually a response to perceived hereditary spherocytosis, autoimmune hemolytic clinical features or to an abnormality shown in a previous anemia or alloimmune hemolytic anemia so it is not complete blood count. A laboratory-initiated request for a diagnostically specific. When compared to blood smear is usually the result of an abnormality in the Spherocytes , microspherochytes may be present in complete blood count or a response to “flags” produced by less number of patients.An osmotic fragility assay, an automated instrument. The indications for smear review Coombs’ test, serum bilirubin, LDH, and differ according to the age and sex of the patient.Its major haptoglobin, and other laboratory assays may be roles are in the differential diagnosis of anemia and indicated.[4] thrombocytopenia and in the identification and c.) Rouleax formation: characterization of leukemia and lymphoma [2].We will In rouleax formation RBCs are arranged in a form of discuss about the diagnosis of RBC , WBC and platelets coinstack ie,) linear arrangement. It is due to morphologic abnormalities from the peripheral blood increase in the blood concentration of fibrinogen , smear. globulin and paraprotein. The associated clinical disorders like multiple myeloma , acute and chronic RBC MORPHOLOGICAL ABNORMALITIES : inflammatory disorder , Waldenstrom's Normal red blood cells are round to very slightly ovoid macroglobulinemia. In the absence of acute or cells and a central pale area.Any deviation in size, volume, chronic inflammatory disease ,serum and urine or shape of red cells which represents an abnormal red analysis should be performed to determine if a blood cell. The main disadvantage of the smear is a non- paraprotein is present.[5] uniform distribution of red blood cells over the smear, with d.) Bite cells : small crowded red blood cells at the thick edge and large Bite cells are also known as degmacytes in which flat red blood cells without central pallor at the feathered RBCs are peripheral single or multiple defect . It can edge. be found in normal individuals receiving large a.) Schistocytes: quantities of aromatic drugs which contains amino, The cell shape is the considerable diagnosis nitro or hydroxyl groups. Bitecells can be importance in the hemolytic anaemia.Some types of accompanied by red cells with vacuoles, hemolytic anemia yield such a distinctive blood acanthocytes, schistocytes. Heinz body test, G-6-PD smear that the smear is often sufficient for diagnosis. level, and other studies of red blood cell metabolism Microangiopathic hemolytic anemia may indicate may be indicated.[6] pregnancy-associated hypertension, disseminated e.) Macrocytes: cancer, chronic disseminated intravascular Oval macrocytes are oval shape red cells with coagulation, the hemolytic–uremic syndrome, or normal MCH. These cells suggests impaired bone thrombotic thrombocytopenic purpura. Therefore marrow DNA synthesis and it may indicate folate or this type of anemia is of considerable clinical vitaminB12deficiency.bone marrow examination significance.In microangiopathic hemolytic anemia, may be needed . Round macrocytes are round shape examination of the blood smear is also important to red cells and slightly larger than normal macrocytes. validate the platelet count, since red-cell fragments The cell suggests bone marrow impaired DNA and platelets may be of similar size.Blood-smear synthesis, stress erythropoiesis, or excessive surface features similar to those seen in microangiopathic membrane. Clinical causes include obstructive hemolytic anemia are also a feature of mechanical jaundice, alcoholism, impaired DNA synthesis from 213 Shagana. J.A /J. Pharm. Sci. & Res. Vol. 6(4), 2014, 213-216 chemotherapy or inherited diseases, zone of pallor in the peripheral blood smear. myeloproliferative disorders, myelodysplastic Microcytosis and hypochromia are characteristic of syndromes, or splenectomy thn.[7] iron deficiency anemia and other microcytic, f.) Blister cells hypochromic anemias [anemia of chronic disease, Blister cells are red blood cells with vacuoles or hereditary hemoglobinopathies with diminished markedly thin areas at periphery of membrane. globin synthesis, red blood cell enzyme deficiencies These cells are characteristic of glucose-6-phosphate . Serum iron studies, erythrocyte sedimentation rate dehydrogenase (G- 6-PD) deficiency and other (ESR), hemoglobin electrophoresis, bone marrow conditions imposing oxidant stress on the examination, and serum and urine lead quantitation erythrocyte.[8] are other laboratory studies may be indicated.[13] g.)Elliptocytes l.) Hyperchromia Elliptocytes are cells with an elliptical shape, while Hyperchromia is an increase in the red blood cell ovalocytes have an oval shape. Severe elliptocytosis hemoglobin concentration. Since it is usually is characteristic of hereditary elliptocytosis, but can associated with spherocytosis, peripheral smear be prominent in thalassemia, sickle cell trait, and Hb examination reveals many spherocytes and C trait. Rare elliptocytes occur in normal peripheral microspherocytes. Heinz body hemolytic anemia, blood smears. Other diseases where elliptocytosis hereditary pyropoikilocytosis, and severe burns. If occurs include iron deficiency anemia, megaloblastic indicated, an osmotic fragility assay, Coombs’ test, anemia, myelophthisic anemia, and mechanical serum bilirubin, LDH, and haptoglobin, and other trauma.[9] laboratory assays may be indicated.[14] h.) Nucleated red blood cells m.) Polychromasia Nucleated red blood cells are immature red blood Polychromasia is the occurrence of slightly cells. the presence of NRBCs indicates markedly immature red blood cells, which are larger than accelerated erythropoiesis or severe bone marrow normal and have a blue-gray coloration. stress in an adult. The presence of NRBCs in the Polychromasia is due to the presence of ribosomal peripheral blood of an adult always indicates a protein in immature red blood cells, which pick up significant disease process. NRBCs in the peripheral the basophilic component of the Wright-Giemsa blood of an infant indicates significant stress. stain. Small numbers of these cells (0.5 - 2%) are Clinical conditions associated with peripheral normally present in the peripheral blood and signify normoblastosis include acute bleeding, severe the presence of erythropoietic activity in the bone hemolysis, myelofibrosis, leukemia, myelophthisis, marrow. The MCV may increase slightly in response and [10] to significant polychromasia. Decreased i.) Keratocytes polychromasia is seen with hypoproliferative Keratocytes are damaged red blood cells. Such marrow states.[15] damage characteristic occurs from fibrin deposits n.) Howell-Jolly bodies ,microangiopathic hemolytic anemia, thrombotic Howell-Jolly bodies are small dense, perfectly round thrombocytopenic purpura (TTP), prosthetic heart basophilic red cell. It represent nuclear material valves, severe valvular stenosis, malignant derived from nuclear fragmentation or incomplete hypertension, or march hemoglobinuria. Keratocytes nuclear expulsion during normoblastic maturation. occur in normal newborns with bleeding peptic Howell-Jolly bodies are identified in splenectomized ulcer, aplastic anemia, pyruvate kinase deficiency, patients . It may also seen in smaller numbers in vasculitis, glomerulonephritis, renal graft rejection, patients with megaloblastic anemia, severe severe burns, iron deficiency, thalassemia, hemolytic processes, hyposplenism, and myelofibrosis with myeloid metaplasia, myelophthisitic anemia.[16] hypersplenism and post- splenectomy. These cells o.) Acanthocytes are pathologic and should never be ignored.[11] Acanthocytes are spheroid RBCs with a few large j.) Microcytes : spiny (thorny) projections.Occasional acanthocytes Microcytes are small red blood cells with less can be seen after splenectomy, in patients with amounts of hemoglobin. This is due to iron alcoholic cirrhosis, and in hemolytic anemias caused deficiency and defective hemoglobin synthesis, by pyruvate kinase (PK) deficiency. imbalance of globin chains, or defective