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- 1. Peripheral smear in anemia: clues to diagnosis Dr. Jasmita, Consultant, Department of Hematology, Sir Ganga Ram Hospital drjasmita@gmail.com SGRH
- 2. Peripheral smear • Components • Head • Body • Tail • Stain: Romanovsky stains • Ideal stains: MGG; Wright- Giemsa • Optimal staining of granularity • Clear demarcation of basophilia
- 3. Anemia • Reduced number of red cells or a reduction in O2 carrying capacity to meet physiological needs • Variables: Age, Sex, Altitude, smoking, pregnancy • Iron deficiency most common cause of anemia worldwide THE GLOBAL PREVALENCE OF ANAEMIA IN 2011; © World Health Organization 2015
- 4. Peripheral smear in anemia • To type the anemia: NCNC, MiHC, macrocytic, dimorphic • Guide: nucleus of a small mature lymphocyte • Determine if polychromasia is present • Important clues to the actual diagnosis in all types of anemias • Mandatory of workup of hemolytic anemias
- 5. Approach to anemia Anemia with other hematological abnormalities BM examination: Leukemia/ Aplastic anemia/ Myelophthisic anemia/ MDS/ CLD Appropriate Reticulocyte response RBC indices Evidence of hemolysis: ↑LDH, ↑Indirect Bilirubin Evaluate for blood loss Evaluate for hemolytic anemia Normal MCV: NCNC anemia Low MCV: Microcytic hypochromic anemia High MCV: Macrocytic normochromic anemia Yes Yes Yes No No No
- 6. Broad subtypes of anemia
- 8. 30 year old primigravida, 1st trimester
- 9. Another 30 year old female, primigravida
- 10. The third 30 year old primigravida
- 11. Diagnosis? • 1 year female • Failure to thrive since 6 months of age • Spleen 5 cm BCM • Pale • Hb: 4g/dL • MCV: 64fL • MCH: 20.0pg • RDW: 30.0% Thalassemia major
- 12. At 1 month post diagnosis At 5 years post diagnosis
- 13. Same case at the age of 10 years; post splenectomy
- 14. Other uncommon causes of MiHC anemia • Sideroblastic anemia • Hereditary: X-linked/ Autosomal/Pearson’s syndrome • Acquired • Drugs (isoniazid, chloramphenicol) • Lead poisoning • Zinc excess • Copper deficiency
- 16. Approach to macrocytic anemia Hypersegmented neutrophil/ macrovalocytes on P/S Megaloblastic anemia Nonmegaloblastic anemia Reticulocytosis Liver disease/ Hypothyroidism/ CDA/ PRCA/ MDS Hemolytic/ Hemorrhagic anemia Yes Yes No No B12/ FA levels Folate deficiency B12 deficiency No deficiency: DNA synthesis disorders/ Drugs
- 17. Case 1 • 21 year old male with symptomatic anemia since 2 years. There is a history leg cramps and he also reports few episodes of abdominal pain.
- 18. Peripheral smear
- 19. Bone marrow: nearly always avoidable in classical cases of megaloblastic anemia
- 20. Going back to case 1 • Baseline reticulocyte count: 13.4% • Very unusual in a case of megaloblastic anemia • Workup for hemolysis initiated: • No specific features of any hemolytic anemia on peripheral smear • LDH: 670U/L (upto 180U/L) • G6PD normal • DAT negative • HbHPLC done earlier normal • Cause for hemolysis?
- 21. Flow cytometry for PNH performed: positive Megaloblastic anemia may occur in case of hemolytic anemias due to an increased requirement. May mask the cause of hemolysis and the patient requires workup after correction of folate deficiency
- 22. 45 year old male, known alcoholic
- 23. Normocytic normochromic anemia Reiculocytosis ↑RBC Production Normal/ ↓RBC production LFT/ RFT/ endocrine dysfunction ACD Early IDA Anemia of liver ds/ renal ds/endocrine dysfunction Yes No Low Jaundice/Splenomegaly/Blood smear abn/ ↑LDH/Bilirubin Hemorrhagic anemia Hemolytic anemia BMA/BMBx Serum Iron N/High Leukemia/ metastasis/ CDA/ AA/ PRCA Yes No
- 24. Case 1: BM from a 50 year old female • Complaints of mild hyperbilirubinemia off and on, Spleen 1cm bcm • History of weakness off and on after birth of 2nd child • Hb: 90g/L, TLC: 8.5X109/L, Platelets: 350X109/L
- 26. Further history revealed: Similar symptoms in patient’s son and daughter Hereditary spherocytosis
- 27. HS: Peripheral smear spherocytosis + AD history sufficient to make the diagnosis
- 28. MFI: 5513; mean of 5 ctrls MFI: 3889 %↓ in EMA: 29% %residual cells: <1% EMA dye binding test Flow cytometric OFT
- 29. Case 2: 50 year old male with jaundice since 1week with increasing fatigue and mild splenomegaly Autoimmune hemolytic anemia
- 31. Case 3: 56 year old male presenting with anemia in winter months Peripheral smear Bone marrow Cold type AIHA secondary to WM
- 32. Cold type AIHA Children • Mycoplasma pneumonie/ influenza infection • Self resolving Adults • Usually associated with a CLPD specially WM • May be the first presenting sign • Bone marrow, SPE and flow cytometry may be done to exclude a clonal B-cell population
- 33. Case 4 • A 30 year old male presented with chronic ITP • He was started on dapsone • The patient’s Hb fell from 13 to 8 in 1 week • A PS was done • Classical bite and blister cells G6PD deficiency
- 34. Reticulocyte preparation • Reticulocyte count • Extended incubation timings: • Heinz body • Golf ball inclusions in HbH disease Golf ball inclusions
- 35. Case 5 and 6 • 32 year female • Low grade fever, generalized weakness since 15 days • Petechiae since 1 week • Confusion, headache since 2 days • 30 year female, primigravida • Increasing edema and renal dysfunction after delivery • Referred with a creatinine of 6mg/dL
- 36. Peripheral smear
- 37. Differentiating TTP from HUS TTP TMA Severe thrombocytopenia Renal dysfunction but no renal failure Neurological manifestations commoner HUS TMA Oliguric/ anuric renal failure Moderate thrombocytopenia
- 38. Case 5 and 6 • 32 year female • Low grade fever, generalized weakness since 15 days • Petechiae since 1 week • Confusion, headache since 2 days • 30 year female, primigravida • Increasing edema and renal dysfunction after delivery • Referred with a creatinine of 6mg/dL Thrombotic thrombocytopenic purpura Hemolytic uremic syndrome
- 40. Schistocyte index: 8.2% PT, APTT normal FSC RBC PLT-O LFR HFR MFR
- 41. Case 7 • 25 year old male • Presented with acute onset chest pain • Similar episodes in the past • Irreversibly sickled cells • Reversibly sickled cells: Oat shaped, boat shaped cells Sickle cell anemia in sickle crisis
- 42. Sickling test with sodium dithionite
- 43. Case 8 • 54 year old female • Admitted with Swine Flu, bilateral pneumonia • Hb: 7.1 g/dl; RBC: 2.17 mill/µl; PCV: 21.2%; MCV: 97.8 fl; MCH: 32.7 pg; MCHC: 33.4 g/dl; RDW:20.9%; platelets:100,000/µl and TLC:5,800/µl
- 45. Case 9 • 45 year old male, k/n c/o Rheumatoid arthritis • Generalised weakness since 3-4 months Parameter CBC 03/04/2017 Value Hemoglobin 7 gm/dl TLC 11,820/µL Platelets 755000/µL MCV 68.6 fl RET –He 20.8pg Corrected reticulocyte count 0.86% DLC - N - 23%, L-72%, M-3%, E-2% Absolute lymphocyte count 6146/µL
- 47. Peripheral blood flow cytometry T-cell large granular lymphocytic leukemia
- 48. Large granular lymphocytic leukemia IDA; thalassemia trait
- 49. Case 10 • 56 year old lady with symptomatic anemia • No cause identified • Progressively developed thrombocytopenia but no manifestations of bleeding
- 51. Leucoerythroblastic blood picture • Myelophthisis • Myeloproliferative neoplasms-PMF • Acute Hemolysis • Infections • Granulomatous inflammation of BM • Severe trauma/ blood loss
- 52. Case 10 Metastatic carcinoma
- 53. Case 11: 60 year female, anemia req PRBC
- 55. Bone marrow biopsy Primary myelofibrosis Basophilia with leucoerythroblastosis and prominent tear drops
- 56. Anemia with or without other cytopenias not responding to treatment Exclude MDS A bone marrow should be done
- 57. Features of dysplasia Dysmyelopoiesis Dyserythropoiesis Dysmegakaryopoiesis Pseudo Pelger-Huet abnormality and hyposegmented neutrophils Hypogranularity Small or unusually large size Nuclear hypersegmentation Dohle bodies Auer rods Pseudo Chediak Higashi granules Nuclear budding Irregular nuclear membrane Internuclear bridging Karyorrhexis Multinuclearity Megalobalstosis Ring sideroblasts Cytoplasmic vacuolization Per-iodic acid Schiff positivity Micromegakaryocytes Nuclear hypolobation and monolobation Multinuclear megakaryocytes with presence of widely separated equally sized nuclei
- 59. Increased blasts
- 60. Take home message • Peripheral smear is a key to correct diagnosis in nearly all types of anemias • Describing a smear as hemolytic anemia is incorrect. Make an attempt to identify cause of hemolysis always. • Careful peripheral smear examination helps rationalize tests ordered • Raise a critical alert if schistocytes are seen; can be possibly life saving by early institution of therapy. Thank You!