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Role of peripheral blood

In the work-up of a disease, the peripheral smear gives a very good information of what disease the patient may be suffering from. It also gives direction for further evaluation, all impacting the treatment and well being of the patient.

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Role of peripheral blood

  1. 1. Role of Peripheral blood smear examination in diagnostic work-up Dr K Richards MD(Path);DTCD Consultant Pathologist- Hematology Yashoda Hospital
  2. 2. Why do a peripheral blood film examination?
  3. 3. Automated hematology analysers
  4. 4. RBC Morphology
  5. 5. Anisocytosis • abnormal erythropoiesis • non-specific feature • either macrocytes or microcytes or both
  6. 6. Poikilocytosis • abnormal erythropoiesis • non-specific feature • megaloblastic anemia, • iron deficiencyanemia, • thalassemia, • myelofibrosis, • MDS • Congenital dyserythropoietic anemia
  7. 7. Microcytes • defect in hemoglobin formation • characteristic of iron deficiency anemia • thalassemia • severe cases of anemia of chronic disease • sideroblastic anemias
  8. 8. Macrocytes • classical in megaloblastic anemia • aplastic anemia • MDS • Alcoholics • Chronic liver disease • Hydroxyurea
  9. 9. Basophilic stippling • thalassemias, • megaloblastic anemia • infections • liver disease • lead poisoning • unstable hemoglobins • pyrimidine-5- nucleotidase deficiency
  10. 10. Hypochromasia • iron deficiency anemia • sideroblastic anemia • thalassemias
  11. 11. Dimorphic Red Cell Population • two distinct populations • development or resolution of IDA or anemia of chronic deficiency • post blood transfusion • acquired sideroblastic anemia
  12. 12. Spherocytes • hereditary spherocytosis • ABO hemolytic disease of the newborn • autoimmune hemolytic anemia • microspherocytes • sphero-echinocytes
  13. 13. Elliptocytes and Ovalocytes • hereditary elliptocytosis • hereditary pyropoikilocytosis • southeast asian ovalocytosis
  14. 14. Schistocytes • RBC fragments • thalassemias • CDA • Megaloblastic anemia • microangiopathic hemolytic anemia • severe burns • hemolytic uremic syndrome(HUS) • thrombotic thrombocytopenic purpura(TTP)
  15. 15. Acanthocytes • Abnormal phospholipid metabolism • McLeod phenotype • Splenectomy • hyposplenism • Severe Liver disease
  16. 16. Crenated RBC/Echinocytes • healthy subjects • storage artefact • uremia • cardiopulmonary bypass • premature infants
  17. 17. Target Cells • iron deficiency anemia • thalassemia • sickle cell anemia • Hemoglobinopathies • Chronic liver disease • splenectomy • Hereditary hypobetalipoproteine mia
  18. 18. Stomatocytes • Liver disease • alcoholics • MDS
  19. 19. Sickle Cells • Sickling: blood subjected to anoxia • Sickles and boat shaped forms • Target cells – often a feature
  20. 20. Rouleaux • myelomatoses
  21. 21. Autoagglutination
  22. 22. Polychromasia • Shades of bluish grey • Reticulocytes • Increased erythropoiesis • Absence of polychromasia -inadequate bone marrow response Aplastic anemia Pure red cell aplasia
  23. 23. Nucleated RBCs • More common in children • Severe anemia • Hemolytic disease of newborn • Leucoerythroblastic anemia:carcinomatoses and primary myelofibrosis • Post splenectomy • Extramedullary erythropoiesis • Sickle cell anemia • Septicemia • Cyanotic heart failure
  24. 24. Erythrocyte Inclusions: Howell Jolly Bodies • Nuclear remnants • Small round, stain purple • Post splenectomy • Splenic atrophy
  25. 25. Erythrocyte inclusions: Pappenheimer bodies • Small, peripherally sited basophilic/ almost black • Smaller than howell-jolly inclusions • Composed of hemosiderin • Related to Sideroblastic erythropoiesis and hyposplenism • Confirmed by perls’ stain • Correspond to siderotic granules of siderocytes
  26. 26. Morphology of Leucocytes
  27. 27. Toxic granulation and Cytoplasmic Vacuolation • Bacterial infection • Other causes of inflammation • Administration of Granulocyte colony stimulating factor
  28. 28. • Poorly staining (hypogranular) • Agranular neutrophils • Myelodysplastic syndromes • Some forms of myeloid leukemia
  29. 29. Chediak Higashi syndrome: • Abnormal granules • Giant but scanty azurophilic granules • Functional defect • Susceptibility to severe infection
  30. 30. Alder Reilly Anomaly: • Nucleus is obscured by cytoplasmic granules • Neutrophils function normally
  31. 31. Pelger-Huet Cells • Benign inherited condition • Pseudo pelger huet cells: MDS, AML with dysplastic maturation, chronic myeloid leukemia
  32. 32. Hypersegmented Nuclei • Megaloblastic anemia • Uremia • Iron deficiency anemia • Cytotoxic treatment – methotrexate • Hydroxycarbamide
  33. 33. Left Shift
  34. 34. Basophilia • Rarest (<1%) • Myeloproliferative neoplasms • CML: >10% impending accelerated phase/blast crisis
  35. 35. Eosinophilia • Eosinopenia: prolonged steroid administration • Eosinophilia: - Allergic conditions, - parasitic infections, - reactive eosinophilias ( Lymphomas, ALL) - eosinophilic leukemia, - idiopathic hypereosinophilic syndrome, - CML, - AML
  36. 36. Monocytes • Chronic infections and inflammatory conditions like TB, Crohn’s disease • Atypical CML, CMML • Acute leukemia with monocytic component
  37. 37. Lymphocytes • Transformed lymphocytes: viral and bacterial lymphocytes • Immunoblasts or turk cells
  38. 38. Lymphocytes Infectious mononucleosis: • Activated lymphocytes
  39. 39. Malignant Lymphoid Cells
  40. 40. Circulating blasts
  41. 41. Platelet Morphology
  42. 42. Large/Giant platelets Large Platelets: • Increased platelet production • Hyposplenism • Severe immune thrombocytopenia
  43. 43. Thrombocytosis • Acute inflammatory stress • Bleeding • Critically ill patient • Hyposplenism • Myeloproliferative neoplasm
  44. 44. Grey platelet syndrome: • Hypogranular platelets
  45. 45. Platelet satellitism • antiplatelet autoantibodies • Apparently healthy individuals
  46. 46. Hemoparasites
  47. 47. Summary • Simple • morphology • Basic and foundational • Further direction • Patient management
  48. 48. References • Dacie and Lewis practical hematology – 11th edition • Wintrobe’s clinical hematology – 13th edition
  49. 49. Thank you

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