The peripheral blood smear examination allows for estimation of cellular elements, morphology analysis of red blood cells, white blood cells, and platelets, and detection of blood parasites. Red blood cell morphology is assessed by size, shape, color, and inclusions. Abnormal shapes include elliptocytes, spherocytes, schistocytes, and sickle cells. White blood cell differential count and morphology is also evaluated. Platelet number and morphology is examined to confirm thrombocytopenia. The peripheral smear is a useful test to analyze blood cell types and detect various hematological disorders and conditions.

1. PERIPHERAL SMEAR

2. PERIPHERAL SMEAR
The role Examination of a well-made
peripheral blood smear is
a) Estimate approximately the numbers of
each of the three cellular elements
Red blood cells
White blood cells
Platelets
b)Study the morphology of these
c)See blood parasites

3. RED CELL MORPHOLOGY
a) SIZE
 A Normal red blood cell is about 7.2micrometer
in diameter
A normal red blood cell should be approximately
the same size as a normal lymphocyte nucleus
 When the variation in size is greater than the
normal , this is referred to as Anisocytosis

4. Normocytic RBC

5. Microcytes
• When red cells are
smaller than normal
,having a diameter of
less than 7.2micrometer
and MCV < 80 fl they
are called Microcytes
• When the significant
number of the cells are
smaller than normal
cells are referred to as
Microcytosis

6. Macrocytes
• Macrocytes are larger
red cells with a
diameter of >7.8µ and
MCV > 100 fl
• The significant number
of the cells are larger
than normal cells are
referred to as
Macrocytosis

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b) SHAPE
Normal red cells are biconcave discs and
appear circular on a smear
When the variation in shape is greater than
the normal this is referred to as
Poikilocytosis

8. POIKILOCYTOSIS
 They larger variety of specific abnormal shapes
are present including
• OVALOCYTES OR ELLIPTOCYTES
• PENCIL SHAPED CELLS
• SPHEROCYTES
• TARGET CELLS OR LEPTOCYTES
• SICKLE CELLS
• SCHISTOCYTES
• CRENATED CELLS
• ACANTHOCYTES
• BURR CELLS
• STOMATOCYTES etc

9. ACANTHOCYTES
• Irregularly spiculated
• Hypochromic RBCs
CONDITIONS:
-Alcoholic liver disease
-Lipoprotineamia
-Post splenectomy
-pyruvate kinase
deficiency

10. TARGET CELLS OR LEPTOCYTES
• Hb is redistributed
• Center and periphery of
the cell appear
haemoglobinised.
CONDITIONS:
-Thalassemia
-Obstructive liver disease

11. DACROCYTE(TEAR DROP CELL
• Cells with single
elongated or pointed
extremity
• Shaped like a tear drop
CONDITIONS :
-Myelofibrosis
-Severe haemolytic
anaemia

12. SICKLE CELLS
• Thin,elongated,slightly
curved red cells
• Sickle shaped
• No central pallor area
CONDITIONS:
-Sickle cell disorders

13. ECHINOCYTES(CRENATED CELL)
• Crenation is the shrinkage
of red cells through loss of
water in a hypertonic
medium.
• Cell membrane appear
wrinkled.
CONDITIONS:
-As an artifact due to slow
drying of smear.
-Seen in smears made several
hours later after collection
-Uremia

14. BURR CELLS
• Numerous , uniform
sized and irregularly
spaced red cell
projections.
CONDITIONS:
-Uremia
-Chronic liver disease
-pyruvate kinase
deficiency

15. ELLIPTOCYTES(OVALOCYTES)
• Elongated or oval cells
CONDITIONS:
-Hereditary elliptocytosis
-Thalassemia
-Iron deficiency

16. SPHEROCYTES
 Spherical red cells
 Lack of central pallor area
2types
 Macrosperocytes
 Microspherocytes
CONDITIONS :
 -Hereditary spherocytosis
 -Auto immune haemolytic
anaemia

17. STOMATOCYTE
• Central pallor area
appear like a slit.
CONDITIONS:
-Hereditary
stomatocytosis
-Obstructive liver diseases

18. SCHISTOCYTE(fragmented cell)
• Irregular shaped
triangular spiculated
cells due to
fragmentation.
CONDITIONS:
-DIC
-Hemolytic anemia

19. KERATOCYTE(Helmet cell)
• Have 1 or 2 projections
which may vary in
length.
CONDITIONS:
-Hemolytic anemia
-Intravascular coagulation
-Iron deficiency anemia

20. RED CELL INCLUSIONS
Red cell cytoplasm may contain various
inclusions which pick up some stain and visible
Basophilic stippling
Howell –jolly bodies
Cabot rings
 Pappenheimer bodies

21. Cabot rings
 Pale staining rings or
figures of eight in the RBC
 These are probably
artifacts resulting from
damage to lipoprotein of
the stroma of red cells
 Seen in Haemolytic
anaemia,megaloblastic
anaemia,leukaemia and
after splenctomy

22. Basophilic stippling
 RBCs show presence of
numerous basophilic
granules distributed through
the cell cytoplasm
 These inclusions are
precipitated ribosomal RNA
 This is found in metal
poisoning
 megaloblastic anemia
 Hemolytic anemia
 thalassemia

23. Howell –jolly bodies
 Small round densely
stained dark blue
particles 1µm in
diameter in the
periphery of red cells
 These are remnants of
nucleus (aggregates of
chromatin material
)Feuglen positive for
DNA

24. Pappenheimer bodies
 These are aggregates of
ferritin and are located
close to cell membrane .
 During erythropoesis
when hemoglobin
synthesis is not complete
some iron granules are
left behind in the red cell
forming siderotic
granules or Pappen -
heimer bodies

25. Pappenheimer bodies
• With Romanowsky stain
these appear pale blue
but easily demonstrable
with Perl’s stain.such
red cells with
Pappenheimer bodies
are called siderocytes
• Sideroblastic aneamias
• Megaloblastic anaemia
• Hemolytic anaemia
• Post splenectomy

26. COLOUR
 When RBC are stained with one of the Romanowsky
stains,they take up pink colour Because of the biconcave
shape the stain darker at the periphery and lighter at the
centre (ie, area of the central pallor)

27. NORMOCHROMIC RBC
 When RBC show this
typical staining ,they are
said to be
Normochromic
 area of central pallor
which may be up to a
third of the diameter of
the cell

28. Hypochromia
• When the area of the
central pallor is
enlarged (more than
1/3 of the diameter of
RBC) the cells appear
more pale ,and are said
to be Hypochromic

29. Polychromasia
 Cells may appear a little
bluish colour amidst the red
cells of the haemoglobin, so
they appear a little purplish
or greish , known as
Polychromotophilic
 This staining is found in
young erythrocytes ,just
after their release from
bone marrow,when they
still contain RNA in the
cytoplasm .RNA picks b lue
colour ,reticulocytes

30. RETICULOCYTES
 Reticulocytes are immature
RBCs released from bone
marrow
 These RBCs are slightly larger
with 20% more volume than
RBCs
 Reticulocytes are stained in a
living state invitro using basic
dyes like Brilliant cresyl blue and
New methylene blue known as
supravital stain ,demonstrating
blue filament ous or granular
material

31. Morphology of WBC
 Leukocytes or white blood cells are another formed
elements of blood .There is usually 1 WBC for every 500 RBC
present .
WBCs are divided into two types
Granulocyte : cytoplasm contain granules
Agranulocyte : No granules in the cytoplasm
 There are three types of granulocyte named according to
their staining characteristics in blood films. They are
neutrophils,eosinophils and basophils.
Mononuclear cells are divided into lymphocytes and
monocytes.

32. Morphology of WBC

33. NEUTROPHIL
 Diameter: 12-16µm
 pink/orange cytoplasm
with fine granulation
 Nucleus: dark purple
blue
 dense heterogeneous
chromatin
 2-5 lobes

34. EOSINOPHIL
 Diameter: 14-16µm
 Cytoplasm : full of
granules
 Granules: large
retractile orange-red
 Nucleus: blue dense
chromatin
 Normally 2 lobes

35. BASOPHIL
• Diameter: 14-16µm
• Cytoplasm: pink
• Granules: dark blue –
black obscure nucleus
• Nucleus: blue

36. LYMPHOCYTE
 Diameter: small 7-9 µm
large 12-16µm
 Cytoplasm : abundant
clear, pale blue
Granules: small(a granular)
large (a variable number
of azurophilic pinkish-
purple granules)
 Nucleus: dark blue round
dense homogeneous
chromatin

37. MONOCYTE
 Diameter: 14-20µm (are
the largest normal blood
cells)
 Cytoplasm: grey blue
 Granules: a very fine
pinkish blue granules
 Nucleus: blue
 large irregularly shaped
and folded (kidney
shaped or horse shoe
shaped)

38. …
TC 4,000-11,000 cells/cu mm
Neutrophil = 40-75%
Lymphocyte = 20-40%
DC Eosinophil = 1-6%
Basophil = 0-1%
Monocyte = 2-10%

39. Variations in the WBC count
Total WBC count
 Increase in Total WBC count > 11,000 /µl is known as
Leukocytosis
 Decrease in Total WBC count < 4,000 / µl is known
as Leukocytopoenia
CORRECTION FOR NUCLEATED RBCs
 10 or > NRBCs - Make correction
uncorrected WBC count X 100
number of nRBC’s per 100 WBC’s + 100

40. Variations in Neutrophils
 Neutrophila ;- Increase in the percentage of
neutrophils in the differential count .it may be
 Relative Neutrophila ;-the total count is lowered by
decreased numbers of lymphocytes
 Absolute Neutrophila;- the total number as well as
the percentage of neutrophils
 Neutropoenia ;- Decrease in the percentage of
neutrophils in the differential count

41. Variations in lymphocytes
 Lymphocytosis
 Relative Lymphocytosis ; Absolute number of lymphocytes
in blood may not be increased ,but due to a decrease in the
number of other cells esp. Neutrophils ,the percentage of
lymphocytes in the DC is increased
 Absolute Lymphocytosis ; an actual increase in the total
number of lymphocytes in the blood as well as the percentage
of lymphocytes in the DC is increased
 Lymphopoenia ; Decrease in the percentage of lymphocytes
in the differential count

42. Variations other white blood cells
 Monocytosis
 Eosinophilia
 Basophilia

43. Evaluate WBC morphology
Note if any abnormal white cell morphology is present
 Toxic granulation
 Dohle bodies
 Cytoplasmic Vacuolation
 Hypersegmentation
 Hyposegmentation
 Smudge cells

44. Toxic granulation
• Neutrophil contain
prominent granules
CONDITIONS:
-Severe bacterial infection
-Hereditary disorders

45. Dohle bodies
• Presence of small round
or oval light blue
stained bodies in the
periphery of the
neutrophilic cytoplasm.
CONDITIONS:
-Severe infections
-Burns
-Exposure to toxic agents

46. Cytoplasmic Vacuolation
• Occurrence of vacuoles in
the cytoplasm and
nucleus,due to the
reactive changes seen in
infections
CONDITIONS:
-Severe infections
-Burns
-Chemical poisoning
-Malignancy

47. Hyper segmentation
• More than 4 lobes in
neutrophils.
CONDITIONS:
-May due to inherited
disorders
-macrocytic anemia

48. Hypo segmentation
• Failure of normal lobe
development(<3 lobes).
CONDITIONS:
-Acute myelocytic
leukemia
-Severe infections
-Toxic states
-Hereditary disorders

49. LEFT SHIFT

50. SMUDGE CELLS
• Degenerated
lymphocytes with out
cell wall.
CONDITIONS:
-Presence of few-> faulty
technique
-Large amount-> chronic
lymphocytic leukemia

51. PLATELETS
 Examine blood smear for thrombocytopenia –
confirm counts, cause
 Platelet count – – about 10 – 20 per oil
 immersion field or number of platelets in 10 oil.imm.
fields X 15,000
 select area where RBCs barely touch
 Falsely low platelet ct – small clots, Platelet
aggregates
 platelet satellitism, abnormally large platelets

52. PLATELETS
 Blood smear for high platelet counts – confirm
counts, cause
 Spurious thrombocytosis – red cell fragments,
fragments of leukaemic cells, fungi, bacteria
 NORMAL PLATELETS: 1.5 – 4 lakhs/ cu mm

53. . ABNORMALITIES OF PLATELET
• GIANT PLATELET
• Larger plateles upto 7
micrometers in size

54. Platelet satellitism
Platelet satellitism
describes the
phenomenon of
adherence of platelets to
white cells.
 It is an in vitro
phenomenon of no clinical
significance.
However it is important
that it is detected since
the platelet count will be
low.

55. Platelet aggregates
• Platelet aggregates may
becomposed of
apparently intact
platelets, degranulated
pale grey platelets or a
mixture of both, as in
this example. If the
platelet count is low it is
essential to examine the
blood film carefully for
platelet aggregates.

56. HAEMOPARASITES
Examine carefully for the presence of of any
haemoparasite
 Malaria
 Microfilaria
 Trypanosoma
 LD bodies in monocytes
 Borrelia in relapsing fever
 Leptospira inWeils disease

57. HAEMOPARASITES
Malarial Parasite Microfilaria

58. ..
Trypanosoma LD bodies in monocytes

59. ..
Borrelia in relapsing fever
.

60. REPORTING FORMAT
Normal blood picture
• RBC: Normocytic and Normochromic
• WBC: Count and distribution within normal
limits
• Platelets : seen adequate
• Haemoparasite: Not seen
• Impressioin: Normocytic Normochromic blood
picture.

61. References
CMC manual
 A Practical manual -clinical Pathology, Sabitri
Sanyal & AparnaBhattacharyya 2 Edition
Clinical Pathology; Thejendra singh
Dacie and Lewis: PRACTICAL HAEMATOLOGY

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