This document provides guidance on assessing the morphology of red blood cells on a blood film. It describes how to evaluate the number, size, shape, degree of hemoglobinization, and distribution of red cells. Normal ranges are outlined as well as abnormalities including microcytosis, macrocytosis, anisocytosis, poikilocytosis, hypochromasia, and anisochromasia. Specific abnormal red cell types such as target cells, schistocytes, tear drop cells, spherocytes, and elliptocytes are also described.

1. BLOOD FILM COMMENT
II
ASSESSING MORPHOLOGY OF CELLS
KMensah

2. ASSESSING RED CELL
MORPHOLOGY

3. ASSESSING RED CELL MORPHOLOGY
Red cells should be assessed as to their:
 Number
 Size
Shape
Degree of haemoglobinization
Distribution in the blood film
Their appearance should be described using a standard
terminology.
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4. Assessing Red Cell Numbers & Distribution
In a normal blood film it is possible to find a part of the film which
is ideal for microscopic examination where the red cells are
touching but not overlapping.
If the Hb is abnormally high (a condition referred to as
Polycythaemia) the blood has a high viscosity and the film of blood
on the glass slide is thick. The red cells therefore appear packed
together throughout the whole length of the film.
 When a patient is anaemic the viscosity of the blood is low, the
blood film is very thin and there are large spaces between the red
cells.
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5. Polycythaemia
Normal distribution
Anaemia
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8. Assessing Red Cell Number & Distribution
Red cell agglutination Rouleaux formation
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9. Assessing Red Cell Sizes
Red cells are smaller than normal lymphocytes and significantly smaller than
granulocytes.
If cells are smaller than normal they are described as microcytic and if larger
than normal as macrocytic.
Red cells of normal sizes are said to be normocytic.
If red cells show greater variation in size than normal the blood film is said to
show anisocytosis.
Anisocytosis can be graded as +, ++ or +++ (mild, moderate or severe/marked)
respectively.
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10. Mature Red cell
• The mature red cell (erythrocyte) is
a biconcave disc approximately 7 μm
in diameter with an area of central
pallor occupying less than one-third
of its diameter.
• Red cells exhibit an eosinophilic
reaction when stained with any of the
Romanowsky stains.
• The average life span of a red cell is
120 days
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11. Macrocytic red cells Normocytic red cells.
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12. Microcytic red cells
Severe Anisocytosis
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13. Assessing red cell
shapes (poikilocytosis)
If red cells show more
than the normal degree of
variation in red cell shape
there is said to be
poikilocytosis
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14. Assessing Red Cell Colour/Haemoglobinization
Normal red cells are reddish-brown with approximately the
central third to quarter of the cell being paler. They are
described as normochromic.
Cells which have an area of central pallor more than a third of
the diameter of the cell are said to be hypochromic and the film
is said to show Hypochromasia.
Cells which lack central pallor are said to be hyperchromic.
These staining characteristics are determined by the
concentration of haemoglobin in the cell and by the shape of
the cell.
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15. Assessing Red Cell colour/Haemoglobinization
Cells which show a greater than normal variation in the degree
of haemoglobinization are said to show anisochromasia.
Red cells which have a blue or lilac tinge are said to show
polychromasia (‘many colours’).
Polychromatic cells are young cells, newly released from the
bone marrow.
They have not yet been remodelled to the disc shape of a
mature erythrocyte and therefore lack central pallor.
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16. Hyperchromic cells(spherocytes
& irregularly contracted cells)
Normochromic cells
Hypochromic cells
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17. Assessing Red Cell Colour
Young red cells can also be detected with a special stain of live (unfixed) cells
called a supravital stain. Young cells detected in this way are called
reticulocytes because the supravital staining causes a network or ‘reticulum’
to be deposited.
Another word usually used to describe staining characteristics of red cells is
dimorphic. The word means that there are two types of cell but it is most
often applied to a mixture of hypochromic and normochromic cells.
The two populations of cells usually differ in size as well as in staining
characteristics. A dimorphic film differs from one showing anisochromasia in
that there are two distinct populations of cells rather than a gradation of
staining characteristics.
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Dimorphic blood picture

19. reticulocytes
Reticulocytes Polychromatic cell
Red cell Dimorphism
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20. MICROCYTIC, HYPOCHROMIC
RED CELLS
The RBCs are smaller than the nucleus
of the small lymphocyte and have
markedly increased central pallor, which
exceeds 1⁄3rd the diameter of the
RBC.
Such RBCs, are microcytic (< 7.0 μm in
diameter) and hypochromic. Both
features, i.e. microcytosis, and
hypochromia usually coexist, and
indicate abnormal hemoglobin synthesis.
The major causes are:
 Iron deficiency anaemia
 Thalassaemia minor
 Sideroblastic anemia
 Anaemia of chronic disease
 Haemoglobinopathies
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21. Varying Degrees of Hypochromasia
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22. Polychromatic
red cell
• The polychromatic red cell is a young
erythrocyte that is slightly larger
than the mature red cell.
• It is polychromatic in colour since it
still contains some RNA remnants,
which can be demonstrated by the use
of a supravital stain such as new
methylene blue or brilliant cresyl blue,
in which case the cell is termed a
reticulocyte.
• Once this cell has lost all its RNA, it
develops into a mature fully
haemoglobinised red cell or
erythrocyte
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23. MACROCYTIC RED CELLS
Most of the red cells are larger than the
nucleus of the small lymphocyte (Size > 8.5
μm in diameter).
The major causes of macrocytic red cells
are:
 Vitamin B12 or folate deficiency
 Alcoholism
 Liver disease
 Myelodysplastic syndrome(MDS)
 Hypothyroidism
 Drugs that impair DNA synthesis
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25. TARGET OR BELL CELLS
They have a characteristic ringed appearance. This
configuration occurs because of “increased surface
area to volume ratio”, i.e. there is an increase in the
red cell membrane compared to the hemoglobin
content, so the excess membrane pools in the middle
of the cells.
Causes of target cells are:
 Thalassaemia (commonest cause)
 Haemoglobinopathies
– Hb AC or CC
– Hb SS, SC,
 Liver disease
 Post splenectomy or hypo splenic states
 Severe iron deficiency
 Hb E (heterozygote and homozygote)
 Abetalipoproteinaemia.
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26. SCHISTOCYTES: “SCHISTO”—SPLIT
OR CLEFT
Physical assault to erythrocytes within the bloodstream
can create fragments called schistocytes, which include
such strange forms as helmet cells, triangles, crescents,
and micro spherocytes. Such cells are seen when
intravascular destruction of RBCs occurs, like in:
 Disseminated intravascular coagulation (DIC)
 Severe haemolytic anemia (e.g. G6PD deficiency)
 Microangiopathic haemolytic anemia
 Haemolytic uremic syndrome
 Prosthetic cardiac valve, abnormal cardiac valve,
cardiac patch, coarctation of the aorta
 Connective tissue disorder (e.g. systemic lupus
erythematosus [SLE])
 Burns (spheroschistocytes as a result of heat)
 Thrombotic thrombocytopaenic purpura
 Uraemia, acute tubular necrosis, glomerulonephritis
 Malignant hypertension. Systemic amyloidosis
 Liver cirrhosis
 Disseminated carcinomatosis
 Chronic relapsing schistocytic hemolytic anemia.
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27. TEAR DROP CELLS
(DACRYOCYTE)
Pear-shaped cells, usually
microcytic, hypochromic.
Seen most prominently in
 Newborn
 Thalassemia major
 Leucoerythroblastic reaction
 Myeloproliferative syndrome
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28. SPHEROCYTES
Ball-shaped red cells, decreased
surface/volume ratio, hyperdense
(>MCHC)
Causes of spherocytosis are:
 Hereditary spherocytosis
 ABO incompatibility
 Autoimmune hemolytic anemia
 Microangiopathic hemolytic anemia
(MAHA)
 SS disease
 Hypersplenism
 Burns
 Posttransfusion
 Pyruvate kinase deficiency
 Water-dilution hemolysis
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29. ELLIPTOCYTES
Elliptical and normochromic cell, seen
normally in less than 1% of RBC.
Causes of elliptocytes are:
 Hereditary elliptocytosis
 Iron deficiency anemia (increased
with severity)
 SS disease and SA trait
 Thalassaemia major
 Leucoerythroblastic reaction
 Malaria
 Megaloblastic anemia
 Any anaemia may occasionally
present with 5 to 10% elliptocytes
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30. BURR CELLS (ECHINOCYTES)
10-30 spicules equal in size and evenly
distributed over RBC surface; caused by
alteration in extracellular environment.
Burr cells are seen in:
 Renal failure from any cause
 Liver diseases, especially when uremia
coexists
 Storage artefact—if blood is kept in a
tube for several hours before
preparation of the smear
 Stomach cancer or bleeding peptic
ulcer
 Dehydration
 Pyruvate kinase deficiency
 Immediately after red cell transfusion
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31. BITE CELL or (DEGMACYTE)
 Appears as a cookie with a bite
taken out.
 These defects occur when certain
drugs cause oxidative damage of
hemoglobin, often in patients with
glucose-6- phosphate
dehydrogenase (G6PD) enzyme
deficiency.
 Bite cells apparently occur when
the spleen removes the Heinz
bodies from the RBCs.
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32. Blister & Bite cells
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33. STOMATOCYTE
When examined on dry smears, it
has a central slit or stoma
(mouth).
Seen in:
 Few stomatocytes may be
present in normal people
 Various cardiovascular and
pulmonary disorders
 Hereditary
 Alcoholism
 Liver disease
 Malignancies
 Drug induced.
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34. HOWELL-JOLLY BODIES
Small, well-defined, round, densely stained
inclusions; 1 μm in diameter, eccentric in
location that represent DNA fragments which
were once part of the nucleus of immature red
cells. Associated with rapid or abnormal RBC
formation.
Howell-Jolly bodies are seen in
 Post splenectomy or hyposplenia (a normally
functioning spleen usually removes all
intraerythrocytic inclusions including
nuclear remnants very efficiently)
 Newborn
 Megaloblastic anemias
 Dyserythropoietic anemias
 Rarely iron-deficiency anemia
 Hereditary spherocytosis
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35. SPUR CELL (ACANTHOCYTES) –
“ACANTHO”- THORN
Cells with 5-10 spicules of varying length;
spicules irregular in space and thickness, with
wide bases; appear smaller than normal cells
because they assume a spheroid shape. Results
from changes in membrane lipid content.
Spur Cell is seen in:
 Spur cell anemia, usually alcoholic cirrhosis,
causes an increase in the cholesterol:
phospholipid ratio in the red cell membrane,
leading to hemolysis.
 Post splenectomy or hypo splenic state
 Hypothyroidism
 Abetalipoproteinemia: 50–100% of cell
acanthocytes
 Associated abnormalities (fat
malabsorption, retinitis pigmentosa,
neurologic abnormalities)
 Malabsorption
 Vitamin E deficiency.
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36. HEINZ BODIES
 Heinz bodies are erythrocyte
inclusions of denatured hemoglobin
caused by oxidation of globin
portion of hemoglobin molecule.
 Removal of Heinz bodies may lead
to formation of bite cells.
 Trigger is drugs or certain foods
like fava beans and onions.
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37. SIDEROTIC GRANULES/
PAPPENHEIMER BODIES
They are irregular dark blue iron containing
granules occurring in small clusters,
predominantly in the cell periphery.
Erythrocytes with Pappenheimer bodies are
called siderocytes. These are iron-containing
inclusions which can be demonstrated by Perl’s
or Prussian blue stains. Siderotic granules are
seen in
• Splenectomy
• Hemolytic anemia
• Myelodysplastic syndromes
• Lead poisoning
• Sideroblastic anemia
• Subsequent to transfusion therapy.
In their presence iron deficiency can be ruled
out.
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38. SICKLE CELLS
Crescent-shaped sickle cells develop
in people homozygous for the
hemoglobin S (HbS) gene and in
those heterozygous for HbS and
either a thalassemia or another
abnormal hemoglobin such as HbC.
There is substitution of valine for
glutamic acid at the sixth residue
of the b chain, establishing sickle
cell anemia as a disease of molecular
structure, “a molecular disease”
based on one point mutation.
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39. POLYCHROMATOPHILIA
(POLYCHROMASIA)
(more than one color)
Primitive reticulocytes, are larger than
mature erythrocytes.
 They stain on Romanowsky
preparations as bluish-gray or purple
because of the substantial RNA
remnants.
 This phenomenon is called
polychromatophilia because the cells
derive its hue from the combination of
blue from the RNA and red from the
hemoglobin.
 Mostly they are present when a high
level of erythropoietin circulates in a
response to anemia.
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40. NUCLEATED RED CELLS
These cells have a dark, dense nucleus in the
center of a bluish (polychromatophilic) or red
(orthochromatic) cell periphery. They may
result in response to marked stimulation of the
bone marrow by erythropoietin in patients with
severe anemia and the causes are:
 Newborn (first 3–4 days)
 Intense bone marrow stimulation
 Acute bleeding severe hemolytic anemia,
(e.g. thalassaemia, SS hemoglobinopathy)
 Postsplenectomy or hyposplenic states:
Spleen normally removes nucleated RBCs
 Leukoerythroblastic reaction, seen with
extramedullary haematopoiesis and bone
marrow replacement
 Fungal and mycobacterial infection
 High WBC count with left shift.
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41. BASOPHILIC STIPPLING
Numerous small, purplish
inclusions, which result from
RNA and
mitochondrial remnants.
Seen in
• Lead toxicity
• Thalassaemias
• Haemoglobinopathies
• Macrocytic anemias
In their presence iron
deficiency can be ruled out
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42. CABOT RINGS
Cabot rings are delicate thread-like
inclusions, remnants of the nuclear
membranes,
in the RBC.
They can take on a variety of shapes
and sizes such as a basophilic.
Purplish rings, figures-of-eight,
incomplete rings appearing in the center
or near
the periphery of erythrocytes.
Significance: Cabot’s rings are seen in
• Pernicious anemia
• Lead poisoning
• Alcoholic jaundice
• Severe anaemia
• Leukaemia
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43. ROULEAUX FORMATION
A stack-like arrangement of red blood cells
where the biconcave surfaces of RBCs are next
to each other, a phenomenon that may
be seen on a peripheral smear. The appearance
of rouleaux may be artificially caused by a poor
preparation of the smear or by viewing the
slide in a thickened area. Rouleaux formation
may be seen in:
• An increase in cathodal proteins, such as
immunoglobulins and fibrinogen
• Multiple myeloma
• Macroglobulinemias
• Acute and chronic infections
• Connective tissue diseases
• Chronic liver disease
• Diabetes mellitus
• Malignancies.
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44. Grading of Cells
Grading of Inclusions
• Rare 0 to 1/hpf
• Few 1 to 2/hpf
• Mod 2 to 4 /hpf
• Many >5/hpf
Qualitative Grading of Abnormal RBC Morphology
• Grade Degree of Abnormalities
• 1 to 5 cells/10 fields Slight
• 6 to 15 cells/10 fields Moderate
• >15 cells/10 fields Marked
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45. ASSESSING WHITE CELL
MORPHOLOGY

46. 46
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47. ASSESSING WHITE CELL MORPHOLOGY
• Assess if the leukocyte count is normal, increased or decreased
relative to RBCs present.
• Normally , the ratio of RBC:WBC is 500:1 in a PBS.
• Assess whether or not WBC anomalies are present.
• Then perform manual counts on the abnormal leukocytes in order
to grade them appropriately.
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48. Terminologies used for abnormalities of White cell & Platelet numbers
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49. Some Individual Cells of Hematopoiesis
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51. Myeloblast
• The myeloblast varies from 15 to 20 μm in
diameter and has a large round nucleus that
occupies about 80% of the cell.
• The chromatin is arranged in fine strands,
giving an evenly stained reticular appearance
with approximately one to three nucleoli.
• The cytoplasm is very basophilic and
agranular.
MYELOID MATURATION
51
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52. Promyelocyte
• The promyelocyte is the next
stage in the maturation process.
• It is approximately the same size
as the myeloblast, and the nucleus
still contains nucleoli but the
chromatin strands are coarser and
hence stain less evenly.
• The cytoplasm is still basophilic
but now contains azurophilic or
primary granules.
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53. Myelocyte
• The myelocyte may be up to 25 μm in
diameter.
• The nucleus is round and the chromatin
strands are thicker and stain more
deeply than in the promyelocyte.
• There are no nucleoli present.
• The nuclear to cytoplasmic (N/C) ratio
is decreased.
• Primary granules may be seen in the
early myelocyte while the late or more
developed myelocyte contains specific
or secondary granules.
• The composition of these granules
determines whether the myelocyte will
develop into a neutrophil, eosinophil or
basophil
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54. Metamyelocyte
• The metamyelocyte, which is
between 10 and 18 μm in diameter, is
characterized by an indented
nucleus resembling the shape of a
broad bean.
• The chromatin strands are thicker
and stain more deeply than in the
myelocyte, and the cytoplasm
contains many fine specific granules.
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55. Band form/Stab cells
• The band form, 10 to 15 μm in
diameter, is smaller than the
metamyelocyte.
• It has a deeply indented U-shaped
nucleus composed of coarsely
clumped chromatin.
• The cytoplasm is pink and contains
many specific granules.
• An increase in band forms and less
lobulated neutrophils in relation to
more mature, well-lobulated
neutrophils is known as a left shift
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56. Grading of Left Shift Neutrophils
• This term is also used when neutrophil precursors are present in the blood.
• Left Shift neutrophils are graded with respect to the severity of the infection
present as follows:
 Mild Left Shift : Band cells or stab cells on PBF
 Moderate Left Shift : Metamyelocytes – Myelocytes seen on PBF
 Severe Left Shift: Promyelocytes seen on PBF
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57. myeloblast promyelocyte myelocyte metamyelocyte band neutrophil
MATURATION
57
Myeloid maturation
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58. Hypersegmented
neutrophils
• A hypersegmented neutrophil is one
in which the nucleus has six or more
lobes.
• An increased number of
hypersegmented neutrophils are
found in megaloblastic anaemia and
following antimetabolite cytotoxic
therapy.
ABNORMAL MYELOID CELLS
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59. Pelger-Huët anomaly
• This is a congenital anomaly.
• In the heterozygous form, the
neutrophils have one or two nuclear
lobes.
• The chromatin pattern is dense and
pyknotic, and often the lobes are joined
by a fine strand of chromatin giving the
appearance of spectacles.
• In the homozygous form, the
neutrophils contain only single, round
nuclei with a dense chromatin pattern
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60. Toxic granulation
• The presence of blue-black granules
within the cytoplasm of neutrophils
is known as toxic granulation.
• These granules are azurophilic
granules that have become activated
owing to the presence of a bacterial
infection or a toxic state.
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61. Toxic vacuolation
• Toxic vacuolation is commonly seen in
the cytoplasm of neutrophils
containing toxic granules.
• These vacuoles, known as phagocytic
vacuoles, contain phagocytosed
bacteria.
• Vacuolation may also be induced in
neutrophils that have been stored in
EDTA for more than 24 hours.
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62. Döhle bodies
• Döhle bodies are blue-staining
bodies present in the cytoplasm
of toxic neutrophils.
• They consist of endoplasmic
reticulum
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63. Agranular neutrophils
• Agranular neutrophils may be seen
in bacterial infections after the
neutrophil has undergone the
process of degranulation.
• They are also a characteristic
feature of the myelodysplastic
syndrome
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64. Reactive Lymphocytes
• Reactive lymphocytosis occurs in a number of viral illnesses: infectious
mononucleosis, cytomegalovirus infection, varicella infection and viral
hepatitis.
• It occurs in the bacterial infection Bordetella pertussis and is also seen
in what is described as ‘non-specific’ acute infectious lymphocytosis.
• Such reactions must be clearly distinguished from lymphatic leukaemias
or any other lymphoproliferative neoplasm.
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65. 65
Reactive Lymphocytes
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66. Atypical lymphocytes
• Some are very large, some have primitive nuclei with a diffuse chromatin pattern and
nucleoli, some nuclei are lobulated, some cells have voluminous basophilic cytoplasm.
• The cells are pleomorphic, i.e. they vary greatly in size and shape.
• Large numbers of atypical lymphocytes, similar to those seen in infectious mononucleosis,
can also occur in infection by cytomegalovirus, hepatitis A virus and adenovirus and during
the parasitic infection, toxoplasmosis.
• Smaller numbers of atypical lymphocytes are seen in many other viral, bacterial, rickettsial
and protozoan infections.
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67. 67
Atypical Lymphocytes
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68. ASSESSING PLATELET
MORPHOLOGY

69. Assessing platelet morphology
• Platelets may be normal , adequate, large or appear in clumps.
• Very large platelets are sometimes referred to as giant platelets.
• An increased variability in platelet size is referred to as platelet anisocytosis.
• Platelet size is of diagnostic significance, particularly if considered in relation to the
platelet count.
• Small or normal-size platelets in association with thrombocytopenia suggest that the
cause is a failure of bone marrow production.
• Thrombocytopenia with large platelets is more likely to be caused by peripheral
destruction or consumption of platelets with the bone marrow responding by increasing
platelet production.
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70. Assessing platelet morphology
• Platelet size is also useful in assessing the likely cause of
thrombocytosis.
• In reactive thrombocytosis (e.g. caused by severe infection
or inflammation) the platelets are usually of normal size.
• Whereas, when thrombocytosis is a feature of a
myeloproliferative disorder (chronic granulocytic leukaemia,
essential thrombocythaemia or polycythaemia rubra vera)
platelet size is generally increased and some giant platelets
are present
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71. Assessing platelet morphology
• Platelets may show normal, defective or absence of
granulation.
• If an artefact is excluded then the detection of defectively
granulated platelets is of diagnostic significance.
• It occurs as a rare congenital anomaly (the grey platelet
syndrome), but usually it is consequent on a bone marrow
disease such as one of the myeloproliferative or
myelodysplastic disorders
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72. Thrombocytes
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73. Platelets Satellitism & aggregation
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74. Platelet clumping/aggregation
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77. How to “Comment on Red cells”
Comment on red cells takes the following trend systematically:
• Number of red cells seen
• Sizes of the red cells seen(which size forms the majority??)
• Degree of haemoglobinization of the red cells
• Different Shapes of the red cells seen
• Distribution in the blood film
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78. How to “Comment on White cells”
Comment on white cells should be done as follows:
• Number of white cells seen (Normal,Increased or decreased population)
• Types of the white cells seen(which types form the majority??)
• The WBC anomalies seen (nuclear pattern & shape, cytoplasmic shape & granulation etc.)
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79. How to “Comment on Platelets”
Comment on platelets takes the following trend systematically:
• Number of platelets seen ( Normal, increased or decreased)
• Sizes of the platelets seen(which size forms the majority??)
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83. Thank you for your attention!

84. HAVE A NICE DAY!!!
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