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Red Blood Cell (RBC):- Part 2 – Peripheral blood smear, Normal Picture and RBC Morphology

October 2, 2021HematologyLab Tests

Sample

  • To assess RBC morphology make fresh smears and smears from the blood in EDTA.

Precautions

  1. A well-made smear is needed.
  2. A well-stained smear is also important.
  3. Otherwise, the analysis of cell morphology may be greatly distorted by poorly made and poorly stained smears.

Indications

  1. This is done to see the morphology of RBC as variation and abnormality in size, shape, structure, Hb contents and, staining characteristics.
  2. Can diagnose the type of Anaemia.
  3. Can diagnose Thalassemia.
  4. Also, can find other abnormalities like hemoglobinopathies.
  5. This also helps to see the effect of chemotherapy and radiation.
  6. Special stains can find infections, infestation, leukemia, and other diseases.
    Peripheral blood smear evaluation

    Peripheral blood smear evaluation

Pathophysiology

  1. There are various sizes and shapes of RBC seen in the peripheral blood smear like:
    1. Normocytic when the size is normal (7 to 8 µm).
    2. Normochromic when the color is normal.
    3. Microcytic when the size is smaller than normal RBC and these are less than 6 µm.
      1. In iron deficiency anemia and thalassemia and hemoglobinopathies.
    4. Macrocytic when the size is larger than > 8 µm.
      1. Found in liver diseases, alcoholism, and oval in megaloblastic anemia.
    5. Anisocytosis is an abnormal variation in size from the normal diameter of 6 to 8 µm,  seen in severe anemia like iron deficiency, hemolytic anemia, and hypersplenism.
    6. Hypochromasia when the RBCs are pale with decreased Hb concentration.
    7. Poikilocytes when RBCs have variation in shapes.
    8. Spherocytes when RBCs are round without the central pale area.
Spherocytes

Spherocytes

    1. Elliptocytes are oval or elongated RBC.
      1. Found in hereditary elliptocytosis.
Ellipotocytes

Ellipotocytes

    1. Sickle cell is a crescent-shaped RBC seen in sickle cell anemia.
    2. The target cell is RBC with a dark central area and clear space between this dark area and periphery.
      1. Found in iron deficiency anemia, liver disease, post-splenectomy, and hemoglobinopathies.
Target cells

Target cells

    1. Schistocytes or helmet shape RBCs Are irregularly contracted cells or fragmented RBCs.
    2. Burr cells are RBCs with spinous processes.
Burr cells

Burr cells

    1. Acanthocytes are RBCs with small cells with thorny projections.
      1. found in liver disease, renal failure, and abetalipoproteinemia.
Acanthocytes

Acanthocytes

    1. Teardrop cell is RBCs with a tear like an appearance.
    2. The nucleated cell is RBCs with the presence of a nucleus. These are normoblast or megaloblastic cells.
Red blood cell morphology

Red blood cell morphology

  1. In the peripheral smears also note for Inclusion:
    1. Howell-Jolly bodies. These are spherical purple bodies within RBCs, these are nuclear debris.
    2. Heinz inclusion bodies. These are small round inclusion of denatured hemoglobin, seen with supravital stain or under phase microscopy.
    3. Siderocytes are the RBCs containing siderotic granules which stain blue with Prussian blue stain.
    4. Basophilic stippling is the presence of punctate stippling seen with Wright stain.
      Red blood cell inclusion

      Red blood cell inclusion

  1. Reticulocytes are also seen. These are RBCs containing RNA and stain pinkish-blue in color. With methylene blue show a reticular network.
  2. Rouleaux formation is the pilling of RBCs on each other or aggregated RBCs.
    Red Blood cell rouleaux

    Red Blood cell rouleaux

Normal cells in the Peripheral blood

  • Band form neutrophils = 2 to 6%
  • Neutrophils = 50 to 70%
  • Eosinophils  = 1 to 5%
  • Basophils = 0 to 2%
  • Lymphocytes = 20 to 44%
  • Monocytes = 2 to 10%

Interpretation of the peripheral blood smear:

  • Screen the slide and note any of the abnormalities present in the smear as regards RBCs.
  • Also, it can evaluate the number or any abnormality of white cells.
  • Also, the number of platelets can be evaluated.
  • So the peripheral smear gives the following information.
    • Any abnormality of RBCs.
    • Any abnormality in white cells.
    • can assess the number of platelets.
  • One can see the following picture in various types of anemia :
    1. In hemolysis, or hemorrhage or in increased erythropoiesis. There are basophilic or polychromatophilic macrocytes
    2. Megaloblastic anemia shows oval macrocytes with an increased number of lobules in the neutrophils.
    3. Hemoglobinopathies anemia there are target cells e.g. in thalassemia and Hb C.
    1. Target cells are also seen in iron- deficiency anemia and liver diseases.
    2. Thalassemia and lead poisoning show microcytes with stippling.

      Red blood cells morphology and their etiology:

      Type of RBCs abnormality Etiology for the abnormality
      Microcytic            Anemia Microcytic hypochromic
      1. Iron-deficiency anemia
      2. Thalassemia
      3. Sideroblastic anemia
      4. Lead poisoning
      Macrocytic           Anemia macrocytic megaloblastic
      1. Megaloblastic anemia
      2. Liver diseases
      3. Myelodysplastic syndrome
      4. Increased reticulocyte count
      Spherocytes        RBC spherocyte
      1. Hereditary spherocytosis
      2. Hemolytic anemia
      3. Post transfusion
      Target cells        RBC target cell
      1. Thalassemia
      2. Liver diseases
      3. Sideroblastic anemia
      4. Hemoglobinopathies
      Teardrop cells   RBC tear drop poikilocyte
      1. Severe anemia
      2. Pernicious anemia
      3. Myeloproliferative anemia
      Elliptocytes     RBC elliptocyte
      1. Hereditary elliptocytosis
      2. Thalassemia
      3. Iron-deficiency anemia
      Sickle cells        Sickle cell RBCs
      1. Sickle cell anemia
      2. Sickle-thalassemia
      Stomatocytes  RBC Elliptocyte
      1. Malignant tumors
      2. Acute alcoholism
      Burr cells         RBC burr cells
      1. Renal diseases
      2. Liver diseases
      3. Bleeding gastric ulcer
      4. Severe burns
      Acanthocytes  RBC acanthocyte
      1. Alcohol intoxication
      2. Postsplenectomy
      3. Vitamin E deficiency
      4. Congenital abetalipoproteinemia
      Hemet cells    RBC Helmet cell
      1. G-6-PD deficiency
      2. Pulmonary emboli
      Schistocytes   RBC Schistocyte cell
      1. Hemolytic uremic syndrome
      2. Thrombotic idiopathic thrombocytopenia (ITP)
      3. Disseminated intravascular coagulopathy (DIC)
  • Note please see more information on CBC and peripheral blood smear.

Possible References Used
Go Back to Hematology

Comments

kunjal gatecha Reply
August 28, 2020

very informative. thank you

Muhammad mustapha Abbas Reply
June 16, 2021

✌️✌️

Ahsan Reply
October 1, 2021

Good article. Shapes of some abnormal RBC type are missing that must be added.

Dr. Riaz Reply
October 2, 2021

Please, thanks for the comments. Can you specify missing abnormal cells?

jamal Reply
January 4, 2022

very well

Dr. Riaz Reply
January 5, 2022

Thanks.

Add Comment Cancel


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