Updated - Blood film preparation and reporting

1. Peripheral blood smear examination
(Slide preparation and reporting)
Caesar Abu Arra
MSc Life sciences
BSc Medical lab. Sciences
Medicare Labs

2. Aim of blood smear
 Evaluation of anemia
 Infections
• bacteria, malaria, microfilaria..etc.
 Abnormal cells
• blasts, inclusions..etc.
 Cells morphology and count
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3. Making blood films
 Three basic steps to make blood film:
 Preparation of blood smear.
 Fixation of blood smear.
 Staining of blood smear.
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4. Preparation of blood smear
 Different types of blood smears:
 The wedge smear slide to slide method.
 The spun smear.
 Two additional types of blood smears (used for specific
purposes):
o Buffy coat smear for WBCs < 1.0×109/L.
o Thick blood smears for blood parasites .
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5. Wedge blood smear
 Smears should be made within 1 hour of blood
collection from EDTA specimens stored at
room temperature to avoid distortion of cell
morphology.
 Small drop (10 µl)
 Hold the spreader slide at a 30°- 45° angle,
and draw it back against the drop of blood.
 Air dry at room temperature.
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6. Abu Jad Caesar
Wedge blood smear

7. Procedure notes
1. The smear should be made without delay.
Any delay results in an abnormal distribution
of the white blood cells, with many of the
large white cells accumulating at the thin
edge of the smear.
2. HCT↑ ↓ The angle of the spreader slide
HCT↓ ↑ The angle of the spreader slide
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8. large angle
low HCT
small angle
high HCT
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Procedure notes

9. Spin method
 Automated method
 Placeadrop of blood in thecenter of aglassslide.
 Spin atahighspeed in aspecialcentrifugecytospin.
 Blood spreads uniformly.
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10. Characteristics of a Good Smear
 Thick at one end, thinning out to a smooth
rounded feather edge.
 Should occupy 2/3 of the total slide area.
 Should not touch any edge of the slide.
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11. tail body head
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Characteristics of a Good Smear

12. Common causes of a poor blood smear
 Drop of blood too large or too small.
 Spreader slide pushed across the slide in a
jerky manner.
 Failure to keep the spreader slide at a 30°
angle with the slide.
 Failure to push the spreader slide completely
across the slide.
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13. Common causes of a poor blood smear
 Holes in film: Slide contaminated with fat or
grease
 Cellular degenerative changes:
delay in fixing
 Inadequate fixing time
Methanol contaminated with water.
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14. Biologic causes of a poor smear
 Cold agglutinin - RBCs will clump together.
Warm the blood at 37° C for 5 minutes.
 Lipemia - holes will appear in the smear.
Nothing you can do to correct this.
 Rouleaux - RBC’s will form into stacks as coins.
Nothing you can do to correct this.
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15. Staining of blood smear
 Romanowsky stain:
Any Combination of:
Eosin Y (Acidic or anionic dye):
o Binds to cationic sites (cytoplasm & Hb)
Methylene blue (Basic, cationic or Azure B dye):
o Binds to anionic sites (nucleus and RNA)
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16. Staining of blood smear
 Buffer:
 Used to maintain an adequate pH.
 0.05M Na2PO4 (pH 6.4) or dH2O (pH 6.4-6.8)
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17. pH of the phosphate buffer
 If the pH is too acidic:
RBC :Pinker
WBC nuclei : very pale staining (very pale purple)
 If the pH is too basic:
RBC :Grayish blue
WBC nuclei :very deeply purple
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18. pH of the phosphate buffer
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19. Staining Troubleshooting
 Too Acid Stain:
Insufficient staining time
Prolonged buffering or washing
Old stain
 Correction:
 Lengthen staining time
 Check stain and buffer pH
 Shorten buffering or wash time
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20. Staining Troubleshooting
 Too Alkaline Stain:
Thick blood smear
Prolonged staining
Insufficient washing
Alkaline pH of stain components
 Correction :
 Check pH
 Shorten stain time
 Prolong buffering time
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21. Abu Jad Caesar

22.  Macroscopic view:
 Quality of the smear
 The microscopic view:
 Progressing from low power to high power:
Blood film examination - preliminary
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23. Blood film examination - preliminary
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24.  Low-Power (10x) Scan
 Determine the overall staining quality of the blood
smear.
 Determine if there is a good distribution of the cells.
o Discussed later
 Find an optimal area for the detailed examination and
enumeration of cells
Blood film examination - preliminary
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25.  High-Power (40x) Scan
 Determine the WBC estimate.
o WBCs are counted in 10 fields and averaged X 2000
o The estimate could be reported according to the table below:
Blood film examination - preliminary
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26. • High-Power (40x) Scan
 Grading scale for WBC count (X103 cell/µl)
Blood film examination - preliminary
Low WBC High WBC
Mild 3-4.5 Mild 10-15
Moderate 2-3 Moderate 15-30
Severe <2 Marked 30-100
Extreme >100
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27.  Oil Immersion (100x) Examination
 Perform a 100 WBC differential count.
 Correct WBC count that has greater than 10 NRBCs per
100 WBCs.
o Report as: WBC count was corrected due to presence of
NRBCs.
Blood film examination - preliminary
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28.  Oil Immersion (100x) Examination
 to correct a WBC count (/µl):
Uncorrected WBC (/ ) X l
Blood film examination - preliminary
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29.  Oil Immersion (100x) Examination
 Evaluate the RBCs for:
o Anisocytosis
o Poikilocytosis
o Inclusions
o Hypochromasia
o Polychromasia.
Blood film examination - preliminary
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30.  Oil Immersion (100x) Examination
 Perform a platelet estimate and evaluate platelet
morphology:
o Platelets are counted in 10 fields and averaged:
• X 15  Automated smear.
• X 20  Wedge smear is used.
Blood film examination - preliminary
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31.  Oil Immersion (100x) Examination
 Grading scale for platelets count (X103 cell/µl)
Blood film examination - preliminary
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Low Platelets High Platelets
Mild 100-150 Mild 500-700
Moderate 50-100 Moderate 700-900
Severe <50 Severe 900-1000
Extreme >1000

32.  Oil Immersion (100x) Examination
 The absolute WBC count (/µl) may be determined:
Relative count (%) X Total WBC count (/µl)
Blood film examination - preliminary
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33.  Relative vs. Absolute value:
 Relative value:
o Measures the percentage of corresponding WBC type in
peripheral blood.
Blood film examination - preliminary
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34.  Relative vs. Absolute value:
 Absolute value:
o Measures the total count of corresponding WBC type /µl
in peripheral blood.
o Gives more meaningful information than the percentage.
o It is the preferred reporting method for the WBC
differential.
• Reported as absolute cytosis or absolute cytopenia.
Blood film examination - preliminary
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35.  Relative vs. Absolute value:
Example: leukopenic patient and increased susceptibility
to infection and sepsis:
 WBC=5000 Relative Neutrophils=50%
o Absolute= 2500 cell/µl Normal
 WBC=2000 Relative Neutrophils=85%
o Absolute= 1700 cell/µl Low
Blood film examination - preliminary
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36. Abu Jad Caesar

37.  Examination of blood films should include:
 RBC
Size, Shape, color
Hemoglobin distribution
Arrangement and distribution
Inclusions
nucleated RBCs
Examination of blood films
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38.  Examination of blood films should include:
 WBC
 Total counts
 Differential counts
 Abnormal and immature WBC
Examination of blood films
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39.  Examination of blood films should include:
Platelets
 Counts should be verified by estimation
 Size
 Clumping
Examination of blood films
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40.  Examination of blood films should include:
Parasites
Examination of blood films
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41.  Pancytopenia
Deficiency in all the three cell lines RBC, WBC, and platelets.
 Aplastic anemia
 When report, recommend bone marrow assessment.
 Bicytopenia
Deficiency in two of the three cell lines
 Viruses and drugs
Terms
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42. PARASITES
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 Thick film When parasites are scanty
 Thin film  Identification of species

43. PARASITES
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Plasmodium falciparum
Trypanosoma spp.
Microfilaria

44. Megakaryopoiesis
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Platelets

45.  1 to 4 μm in diameter and vary in shape.
 Reddish-purple granules
 Life span 9-12 days
 One megakaryocyte can release several thousand platelets
(4000).
 Report as platelets are adequate with normal-sized ones
OR platelets are normal
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Platelets

46.  Large and Giant platelets
Large platelets (4-7 µm)
oITP
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Platelets

47.  Large and Giant platelets
Giant platelet (7-20 µm)
oPlatelets seems to be size of RBC.
oBernard Soulier syndrome
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Platelets

48.  Large and Giant platelets
NOTE:
o When estimate, Large platelets and platelet aggregates
NOT counted.
Report as Occasional, Few, Many
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Platelets

49.  Platelet anisocytosis:
Small large giant platelets will be seen
 Report as: Platelets anisocytosis ranging in size from
tiny to large giant platelets were seen.
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Platelets

50.  Thrombocytosis
 Post infection and Inflammation
 Report as:
o Thrombocytosis (with grading).
o Platelets were estimated and approved to be about ( /µl)
 In case of microcytosis (RBC and PLT diameters are
similar) report as :
o Thrombocytosis due severe microcytosis.
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Platelets

51.  Thrombocytopenia:
Could be due to:
o Decreased production Aplastic anemia
o Increased destruction ITP
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Platelets

52.  Thrombocytopenia:
 In case of no aggregates report as:
o Thrombocytopenia (with grading).
o No platelet clumps are noted OR Negative for
microaggregates.
o Platelets were estimated and approved to be about ( /µl)
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Platelets

53.  Pseudothrombocytopenia:
In vitro EDTA dependent phenomena
oPlatelet clumping
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Platelets

54.  Pseudothrombocytopenia:
In vitro EDTA dependent phenomena
oPlatelet satellitism
• Platelets adhere to neutrophil surface
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Platelets

55.  Pseudothrombocytopenia:
Repeat on new samples (EDTA and sodium citrated)
Scan for platelet clumping in thin and thick portion of
smear
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Platelets

56.  Pseudothrombocytopenia:
Reporting criteria:
Two samples were drawn to rule out EDTA- induced
pseudothrombocytopenia:
o EDTA smear revealed platelet clumps / Platelet
satellitism
o Na+ citrated smear revealed normal platelets count and
distribution.
Conclusion: Platelets are adequate
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Platelets

57. Morphology of Normal RBC
 Biconcave disc
 Diameter 7 ~ 8 μm
 Central pallor occupy 3rd of total size
 Approx same as nucleus of mature lymphocyte
 Stained with eosin component of Romanowsky dyes
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RBC

58. Abu Jad Caesar
Erythropoiesis

59. RBC Abnormality
 Examination of blood films for RBC’s should
include:
 Anisocytosis
 Poikilocytosis
 Hemoglobin distribution
 Arrangement and Distribution
 Inclusions
 NRBCs
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60. RBC Abnormality
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61. Arrangement and Distribution
 Normal arrangement and distribution:
 The thin portion of the smear where RBC’s are slightly
separated from one another or at most, barely touching,
with no overlap.
 The thin area should represent at least 3rd of the entire
film.
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62. Arrangement and Distribution
 Normal arrangement and distribution:
 The reviewer should avoid the thicker portion of the
slide where cells are overlapping and the edges of smear
where cells may be distorted in size, shape, and color.
o An exception is to be made when scanning for platelet
clumping
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63. Arrangement and Distribution
 Rouleaux
 RBC’s appear as stacks of coins (linear)
 Due to ↑ Globulins or fibrinogens
 seen in:
o Multiple myeloma
o Macroglobulinemia
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64. Arrangement and Distribution
 Agglutination
 More irregular and round clumping than linear rouleaux
 Seen in:
o Cold agglutinin
o Anti RBC antibodies
o Autoimmune HA
o Macroglobulinemia
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65. Inclusions
 Basophilic stippling (Punctate basophilia)
 Aggregates of Ribrosomes.
 Multiple blue black inclusions (coarse or punctate )
 Seen in:
o Lead and arsenic poisoning
o Thalassemias
o Alcoholism
o Megaloblastic anemias
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66. Inclusions
 Howell Jolly bodies
 Large round inclusions which are remnant of nuclear
chromatin
 Appear singly or doubly in an eccentric position on the
cell periphery
 Deep purple
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67. Inclusions
 Howell Jolly bodies
 Seen in:
o Postsplenectomy
o Megalobalstic anaemia
o Haemolytic anaemia
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68. Inclusions
 Pappenheimer Bodies
 Ferric compound complexed with protein
 Small dark blue bodies of uniform size.
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69. Inclusions
 Pappenheimer Bodies
 Unlike basophilic stippling:
o Basophilic stippling appears homogeneously over the cell
whereas Pappenheimers tend to appear as single or clusters
in the cells periphery.
 Unlike Howell–Jolly bodies:
o Howell–Jolly bodies appear to be
larger
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70. Inclusions
 Pappenheimer Bodies
 Seen in:
o Sideroblastic erythropoiesis
o Postsplenectomy
o Hemolytic anemia
o Thalassemia
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71. Inclusions
 Heinz bodies
 Result of denatured or precipitated hemoglobin
 Purple, blue, large, single or multiple inclusions
attached to the inner surface of the red blood cell.
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72. Inclusions
 Heinz bodies
 Stained by supravital stains
 Not Stained by Romanowsky stain.
 Seen in:
o Postsplenectomy
o oxidant stress of drugs and
chemicals
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73. Inclusions
 Cabot rings
 Represent a part of the mitotic spindle, remnants of
microtubules, or a fragment of the nuclear membrane.
 Have no internal structure
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74. Inclusions
 Cabot rings
 Red or reddish purple
 Could be appear in a figure-of-eight conformation
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75. Inclusions
 Cabot rings
 Seen rarely in
o Megaloblastic anemias
o Postsplenectomy
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76. Poikilocytosis
 Shape variation
 Mention the abnormal shapes rather than the term
poikilocytosis.
 Grading scale:
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77. Poikilocytosis
 Spherocytes
 Loss of biconcavity
o ↓ Surface-to-volume ratio
o ↑ Osmotic fragility
 Smaller diameter
 Dense-staining
o No central pallor area
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78. Poikilocytosis
 Spherocytes
 Seen in:
o Hereditary spherocytosis
o Immune hemolytic anemia
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79. Poikilocytosis
 Target cell
 Codocytes
 ↑ membrane cholesterol and phospholipid and ↓ cellular
hemoglobin.
 ↑ surface-to-volume ratio
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80. Poikilocytosis
 Target cell
 Seen in:
o Obstructive liver disease
o Iron deficiency anemia
o Thalassemia
o Post-transfusion
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81. Poikilocytosis
 Leptocyte
 Synonymous with target cell, BUT:
o Red cells with large unstained central area.
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82. Poikilocytosis
 Leptocyte
 Seen in:
o IDA
o Thalassemia
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83. Poikilocytosis
 Elliptocyte and ovalocyte
 Elliptocytes
o Pencil, rod, or cigar shaped
o Hb appears to be concentrated on both ends of the cell
o Seen in IDA
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84. Poikilocytosis
 Elliptocyte and ovalocyte
 Ovalocyte
o More egg-shaped
o Have a greater tendency to vary in their Hb content
o Seen in megaloblastic anemia
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85. Poikilocytosis
 Elliptocyte and ovalocyte
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86. Poikilocytosis
 Teardrop cell
 Dacrocytes
 Physiologic mechanism is unknown
 Seen in:
o IDA
o Pernicious anemia
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87. Poikilocytosis
 Stomatocyte
 RBC with narrow slit-like area of central pallor
 Normal size, but are not biconcave
 Seen in:
o Acute alcoholism
o Hemolytic anemia
o Malignancies
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88. Poikilocytosis
 Acanthocyte
Thorn Cells, Spur Cells
3 to 12 irregular, uneven length spicules distributed
along the periphery of the cell membrane
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89. Poikilocytosis
 Acanthocyte
 Seen in:
o Severe hepatic disease
o Autoimmune HA
o Postsplenectomy
o Vitamin E deficiency
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90. Poikilocytosis
 Echinocyte
 Burr Cells, crenated cells
 10 to 30 regular spicules, evenly placed over the surface
of RBC
 Considered pathologic and should be reported.
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91. Poikilocytosis
 Echinocyte
 Seen in:
o Liver disease
o Renal disease
o Severe burns
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92. Poikilocytosis
 Fragmented cells
 Several types
1- Schistocytes
2- Helmet Cells (bite cell) usually 2 projections
3- Keratocytes
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93. Poikilocytosis
 Fragmented cells
 Sometimes counted as platelets
o Estimate platelets and report thrombocytosis due to presence
of RBC fragments
 Seen in : DIC, TTP, HUS
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94. Poikilocytosis
 Fragmented cells
 Several types
4- Prekeratocyte (Blister cell) resemble a women’s handbag
o RBC’s containing a peripherally located vacuole.
o Keratocytes are RBC’s that have been caught on fibrin strands in
circulation, and rather than splitting, the cell hangs over the fibrin
fusing two sides of the cell together, creating a vacuole.
o Seen in:
 Oxidative stress G6PD deficiency
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95. Anisocytosis
 Size variation
 Grading scale:
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96. Anisocytosis
 Size variation
 Normocytic
 Microcytic
 Macrocytic
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97. Anisocytosis
 Normocyte
 MCV 80-100 fl
 Diameter 7 to 8 μm
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98. Anisocytosis
 Microcytes
 MCV <80 fl
 Diameter <7 μm
 Results from a defect in hemoglobin formation
 Seen in:
o IDA
o Thalassemia
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99. Anisocytosis
 Macrocytes
 MCV >100 fl
 Diameter >9 μm
 Result from impaired DNA synthesis.
 Seen in:
 Megaloblastic anemia (↓ B12 and folic acid).
 Aplastic anaemia
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100. Anisocytosis
 Anisocytosis is a feature of most anemias.
o Report as anisocytosis (with Qual. or Quan. Grading):
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RDW: 16-18  Slight
RDW: 18-22  Moderate
RDW: >22 Marked or severe

101. Anisocytosis
 Mixture of large and small with normal MCV and high
RDW usually due:
Recent blood transfusion
Anemia or recovery stages of anemia.
o Report as Anisocytosis with dimorphic RBC population
(with grading):
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RDW: 16-18  Slight
RDW: 18-22  Moderate
RDW: >22 Marked or severe

102. Hemoglobin Distribution
 MCHC used in conjunction with MCV used
do describe anemias
Normochromia
Hypochromia
Hyperchromia
Polychromasia
Anisochromia
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103. Hemoglobin Distribution
 Normochromia: MCHC 32-36%
 Normal intensity of staining.
 The central pallor < 3µm (<3rd of total size)
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104. Hemoglobin Distribution
 Hypochromia : MCHC < 32%
 Unusually palely RBC (↓Hb content)
 The central pallor > 3µm (>1/3 rd of total size)
 Seen in:
o IDA
o Thalassemia
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105. Hemoglobin Distribution
 Hypochromia : MCHC < 32%
 Grading:
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106. Hemoglobin Distribution
 Hyperchromia : MCHC > 36%
 Decreased or absent central pallor
 Seen in:
o Sperocytosis (↓surface-to-volume ratio)
o hemolytic anemias (hemolysis caused by burns)
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107. Hemoglobin Distribution
 Hyperchromia : MCHC > 36%
 Even though true hyperchromia does exist it is not
reported as such:
o It is reported in terms of the cell abnormalities resulting
from the increased volume of hemoglobin and the
decreased surface area (e.g spherocytes).
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108. Hemoglobin Distribution
 Polychromasia
 Premature RBC in circulation called Polychromatophilic
cells actually reticulocytes.
 Gray-blue in color and usually larger than normal RBC
o Result of the residual RNA involved in Hb synthesis.
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109. Hemoglobin Distribution
 Polychromasia
 Seen in:
o Acute and chronic blood loss.
o Recovering from anemias
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110. Hemoglobin Distribution
 Polychromasia
 Grading excellent indicator of therapeutic effectiveness
when patient is given iron or vitamin therapy as treatment
of anemia
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111. Hemoglobin Distribution
 Anisochromia
 Hypochromic cells and normochromic cells in the
same film
 Seen in:
o Development or recovering from anemias
o Post-transfusion
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112. Hemoglobin Distribution
 MCHC used in conjunction with MCV used do
describe anemias
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113. White blood cells
 WBC categories:
 Granulocytes (PMN):
o Neutrophils, Eosinophils and basophiles
o Granules in their cell cytoplasm.
o Multilobed nucleus
 Agranulocytes (MNC):
o Lymphocytes and monocytes.
o Do not have granules (contain non specific azurophilic
granules)
o Nonlobular nuclei.
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114. Neutrophil
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115. Neutrophil
 Terms
 Shift to the left
o Release of younger granulocytes (specifically bands and
metamyelocytes from the bone marrow).
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116. Neutrophil
 Terms
 Shift to the right
o An abnormal cell maturation situation that occurs when
hypersegmented cells are seen.
• It is indicative of vitamin B12 and/or folate deficiency.
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117. Neutrophil
 Cytoplasm
o Pink
 Nucleus
o Dark purple blue
o Dense chromatin
o 3-5 lobes
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118. Neutrophil
 Report as:
o Mature/normal appearing neutrophils.
o In case of leukocytosis neutrophilic leukocytosis
o Absolute / relative neutrophilia or neutropenia
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119. Neutrophil
 Neutrophilia
o Acute bacterial infection.
o Many inflammatory processes.
 Neutropenia
o Typhoid fever
o Brucellosis
o Viral diseases.
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120. Abnormal neutrophil
 Abnormal neutrophil morphology:
Band or stab forms
Hypersegmentation (≥ 6 lobes)
Vacuolization
Toxic granulation
Dohle bodies
Nuclear pyknosis and karyorrhexis
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121. Band or Stab
 Cytoplasm
o Pink
 Nucleus
o U shaped nucleus of uniform thickness.
o Purplish red
o Dense chromatin
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122. Band or Stab
 Normally form 5-10% of WBC’s
 Increased bands:
o Acute infection (usually bacterial)
o Non infectious inflammatory disease
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123. Band or Stab
 Include it when calculate absolute neutrophil
 Report as:
o Many/Few neutrophilc bands OR with shift to the
left
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124. Hypersegmentation
 Neutropils with ≥ 6 lobes
 Normally < 3% of WBC’s
 Seen in megaloblastic anemia
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125. Hypersegmentation
 Report as:
o Few/many hypersegmented neutrophils OR with shift to
the right.
o Further hematological examinations are recommended
(B12 & folic acid).
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126. Vacuolization
 Vacuoles in neutrophil contain ingested microorganisms.
 Seen in:
o Severe infection (leukemoid reaction)
o Non infectious inflammation
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127. Toxic granulation
 ↑ staining density and number of granules
 Seen in:
o Bacterial infection and leukemoid reaction
o Other inflammation
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128. Döhle bodies
 Pale blue inclusions at the periphery of the cytoplasm
 Strands of RER that have aggregated
o Bacterial infection and leukemoid reaction
o Inflammation
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129. Nuclear pyknosis and karyorrhexis
 Degenerative changes in nucleus of neutrophil :
 Pyknosis: Condensation and shrinkage of cells through degeneration.
 Karyorrhexis: A necrotic stage with fragmentation of the nucleus,
whereby chromatin is distributed irregularly throughout the cytoplasm.
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130. Nuclear pyknosis and karyorrhexis
 Due to:
 Prolonged time in circulation.
 Increased numbers in inflammatory and neoplastic disorders
 Old blood samples.
 New fresh sample is preferred.
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131. Nuclear pyknosis and karyorrhexis
 Could be mistaken with NRBC’s.
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132. Eosinophil
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133. Eosinophil
 Cytoplasm
o Full of orange-red granules
 Nucleus
o Blue purple
o Coarsely granular chromatin
o 2 Lobes (like a pair of glass)
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134. Eosinophil
 Eosinophilia
o Parasitic infection
o Allergic Disorders
o Eosinophilic leukemia
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135. Basophil
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136. Basophil
 Cytoplasm
o Pale blue with coarse violet-blue granules
 Nucleus
o Blue purple
o Coarsely granular chromatin
o 2 Lobes
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137. Basophil
 Basophilia
o Allergic Reactions
o Infections
Smallpox
Chicken pox
Influenza
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138. Monocyte
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139. Monocyte
 Cytoplasm
o Pale gray-blue
o Vacuoles and granules may be observed
 Nucleus
o Blue-purple
o large irregularly, folded, kidney shaped, ….etc
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140. Monocyte
Often mistaken for a large lymphocyte
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141. Monocyte
 Monocytosis
o Tuberculosis
o Brucellosis
o Malaria
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142. Lymphocyte
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143. Lymphocyte
 Cytoplasm
o Light sky blue
 Nucleus
o Dark blue
o Dense chromatin
o Round
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144. Lymphocyte
 Report as:
o Mature-appearing lymphocytes with homogenous chromatin
pattern (Resting lymphocytes).
o In case of leukocytosis Lymphocytic leukocytosis
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145. Lymphocyte
 Lymphocytosis
o Lymphocytic leukemia
o Hepatitis
o Mumps
o Syphilis
 Lymphocytopenia
o Severe bacterial infection
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146. Lymphocyte
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147. Abnormal lymphocyte
 Abnormal lymphocyte morphology:
Reactive lymphocytes
Smudge cells (Basket cell)
Turk cell (Transformed lymphocyte or immunoblast)
Atypical Lymphocytes (Malignant-appearing cell)
All should be reported
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148. Reactive lymphocyte
 Normally < 10% of the total lymphocytes
 Nucleus:
o Slightly large with more open chromatin
 Cytoplasm:
o Abundant and irregular (↓N:C)
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149. Reactive lymphocyte
 Seen in:
o Infectious mononucleosis
o Viral infections
 The term atypical should not be used interchangeably with
reactive lymphocyte.
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150. Smudge cell
 Normally < 1%
 Remnants of cells that lack:
o Identifiable cytoplasmic membrane and Nuclear structure.
 Associated with abnormally fragile lymphocytes (mostly
CLL)
 Should be reported.
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151. Turk cell
 Reactive lymphocyte with large nucleolus, abundant and
deeply basophilic cytoplasm
 Seen in bacterial and viral infection
 Round nucleus
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152. Atypical Lymphocyte
 Malignant-appearing cells
 Discussed later
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153. Leukemia
 Two major types according to cell maturity:
 Acute
o The malignant cells are immature (stem cells, blasts, or other
immature precursors.
 Chronic
o The cells are predominantly mature.
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154. Leukemia
 Two major types according to cell lineage:
Myeloid (Myelogenous)
o Granulocytic leukemia
o Monocytic leukemia
o Megakaryocytic leukemia
o Erythrocytic leukemia
Lymphoid (Lymphocytic)
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155. Leukemia
 So, four major types of leukemias:
 Acute myeloid leukemia (AML)
 Chronic myeloid leukemia (CML)
 Acute lymphoblastic leukemia (ALL)
 Chronic lymphocytic leukemia (CLL)
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156. Acute vs. Chronic
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157. WBC Reporting
 WBC Reporting should includes:
Leukocytosis/Leukocytopenia.
Maturation stage
Absolute value of major cell.
Chromatin (fine, coarse, clumped)
Nucleolus ??
Amount of cytoplasm ??.
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158. WBC Reporting
 WBC Reporting should includes:
For Leukemia, recommend flow cytometry for
immunological markers
For CML Recommend Philadelphia chromosome
(BCR–ABL fusion genepositive >95%)
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159. Granulocytopoiesis
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160. Granulocytopoiesis
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161. Granulocytopoiesis
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162. Granulocytopoiesis
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163. Erythropoiesis
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164. Lymphopoiesis
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165. Monopoiesis
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166. Thrombopoiesis
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167. CML
 CML is characterized by three phases
Chronic phase
Accelerated phase
Blast phase
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168. CML
 Chronic phase
 Neutrophilic leukocytosis
o From segmented neutrophils to occasional blasts (≤10%)
But mainly mature
 Basophilia/eosinophilia
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169. CML
 Chronic phase
 Thrombocytosis (~50% of cases).
 Normocytic anemia
 ↑ uric acid , LDH, Vitamin B12
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170. CML
 Accelerated phase
 Worsening of anemia
 Basophils (>20%).
 Shift to the more immature myeloid forms (blasts 10-19%).
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171. CML
 Accelerated phase
 Persistent thrombocytopenia ( 100 X 109/L)
 Persistent thrombocytosis ( 1000 X 109/L)
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172. CML
 Blast phase
 Blast crisis (≥20%)
 Conversion of CML to AML
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173. CML
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174. Leukemoid reaction
 Moderate or marked leukocytosis
Usually
o >30000 cell/µl
Absolute neutrophilia
Shift to the left
o Mostly neutrophilic metamyelocytes and band forms.
o Immaturity is similarly observed in the early stages of
CML
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175. Leukemoid reaction
 Not a result of a leukemic disease
Infectious disease
o Bacterial (most common)
o Toxoplasma and viral (less common)
Other inflammatory process
o Uremia, acute gout and burns
Drug and chemical intoxication
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176. Leukemoid reaction
 Reactive changes of neutrophils
 Usually appear as follow arrangement
1- Toxic granulation
o Nonspecific reactive changes
2- Döhle bodies
o Nonspecific reactive changes
3- Cytoplasmic vacuolization
o Strongly indicates a serious bacterial infection
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177. Leukemoid reaction
 Reactive changes of neutrophils
 Usually appear as follow arrangement
1- Toxic granulation
o Nonspecific reactive changes
2- Döhle bodies
o Nonspecific reactive changes
3- Cytoplasmic vacuolization
o Strongly indicates a serious bacterial infection
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178. Leukemoid reaction
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179.  Report as:
WBC immaturity.
Neutrophils reactive changes
Features in keeping with marked response to infectious
or inflammatory processes (Leukemoid reaction).
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Leukemoid reaction

180.  Slight leukocytosis with neutrophilia
With or without the shift to the left.
Toxic granulation
 Report as:
Features in keeping with mild response to infection
or inflammatory process.
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Mild infection

181.  Mild to severe normocytic normochromic anemia
 ↓ platelet counts
 WBC count is variable (↓ to ↑↑↑)
 Auer rods in blasts cytoplasm (for AML)
 The blood smear usually reveals blasts or other immature
cells
 Circulating NRBC are occasionally seen
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AML & ALL

182. Abu Jad Caesar
AML & ALL

183. Abu Jad Caesar
AML & ALL

184. Abu Jad Caesar
For AML
AML & ALL

185. Abu Jad Caesar
AML & ALL
For ALL

186. Abu Jad Caesar
AML & ALL

187. Abu Jad Caesar
AML & ALL

188. Abu Jad Caesar
AML & ALL

189. Abu Jad Caesar
AML & ALL

190. Abu Jad Caesar
AML & ALL

191. Abu Jad Caesar
AML & ALL

192. Abu Jad Caesar
AML & ALL

193. Abu Jad Caesar
AML & ALL

194. Abu Jad Caesar
AML & ALL

195. Abu Jad Caesar
AML & ALL

196. Abu Jad Caesar
AML & ALL

197.  Normochromic normocytic anemia
 ↑ Indirect serum bilirubin level
 Thrombocytopenia is not common.
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CLL

198.  Lymphocytic leukocytosis From mature appearing
lymphocytes to prolymphocytes (10%)
o Small lymphocytes or slightly larger than a normal
lymphocyte and have a hypercondensed nuclear
chromatin pattern
 Smudge cells are common
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CLL

199. Abu Jad Caesar
CLL
Smudge cells

200.  WBC Reporting
o Leukocytosis/Leukocytopenia.
o Maturation stage
o Smudge cell
o Chromatin (fine, coarse, clumped)
o Nucleolus ?? (for prolymphocyte)
o Amount of cytoplasm ??.
o For definitive diagnosis, recommend flow cytometry for
immunological markers.
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WBC Reporting for CLL

201.  WBC Reporting
o Mostly reported as: Mature-appearing lymphocyte with
hypercondensed nuclear chromatin pattern and few/many
prolymphocytes
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WBC Reporting for CLL

202. Abu Jad Caesar
CLL
 A lymphoblasts
 B lymphocytes
 C smudge cells

203. THANK YOU
A B U J A D C A E S A R