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Red Cell Morphology
Basic Introduction
Reference: Color Atlas of Hematology by Eric Glassy, M.D.
RBC Classification- - - - - - SIZE - - - - - - • Normocyte• Microcyte• Macrocyte• Anisocytosis
- - - - - - SHAPE - - - - - - • Acanthocytes• Burr Cells• Ovalocytes• Tear Drops• Stomatocytes• Spherocytes• Schistocytes• Target Cells• Sickle Cells
- - - - - - PALLOR - - - - - - • Normochromic• Hypochromic• Hyperchromic• Polychromasia
- - - - INCLUSIONS - - - - • NRBC’s• Howell-Jolly bodies• Basophilic Stippling• Pappenheimer bodies• Hemoglobin crystals
RBC Parameters
• MCV = X 10 80 – 100 fL
• MCH = X 10 27 – 31 pg/cell
• MCHC = X 100 32 – 36 g/dL
Hct_ RBC
Hgb_ RBC
Hgb_ Hct
Microcytic < 80 fL Macrocytic > 100 fL
Hypochromic < 32 g/dL Hyperchromic > 36 g/dL
Normal RBC
Normal RBC50x Objective
Normal RBC100x Objective
Microcytes
• SYNONYMS: microcytic RBCs
• KEY FEATURES:
– Size: MCV < 80 fL; diameter < 6 m
– Cytoplasm: normochromic or often hypochromic with increased central pallor
MicrocyticCompare RBC and Lymph sizes
Macrocytes
• SYNONYMS: macrocytic RBCs; macro-ovalocyte (oval form)
• KEY FEATURES:
– Size: MCV > 100 fL; diameter > 8 m
– Shape: round or oval
– Cytoplasm: normochromic, but may sometimes be hypochromic; no polychromasia
MacrocytesCompare RBC and Lymph sizes
AnisocytosisSize Variation
RDW Guide (g/dL)• Slight = 16-20• Moderate = 20-26• Marked = > 26
• Only use RDW as a guide
Hypochromia
• SYNONYMS: hypochromic RBCs
• KEY FEATURES:
– Size: microcytic or macrocytic cells
– Cytoplasm: central pallor > 1/3 of RBC diameter (increased central pallor); some cells contain so little hemoglobin that they are “ghost cells”
Microcytic – HypochromicCompare RBC and Lymph sizes
Polychromasia
• SYNONYMS: polychromatophil; reticulocyte (presumptive)
• KEY FEATURES:
– size: slightly larger than erythrocyte
– shape: round to slightly oval
– cytoplasm: little or no central pallor; color is slightly more gray-blue or purple than that of an erythrocyte
Polychromic
Acanthocytes
• SYNONYMS: spur, spike or horn cell
• APPEARANCE: Crenated RBC with very spiny, irregular projections
• KEY FEATURES:
– Size: diameter smaller than normal cells (like spherocytes)
– Shape: 3 – 20 irregular membrane spikes, unevenly distributed
– Cytoplasm: no central pallor
Acanthocytes
Burr Cells
• SYNONYMS: Echinocyte , crenated cell
• APPEARANCE: Similar to crenated RBCs but projections are less pointed and more regular than acanthocytes
• KEY FEATURES:
– Size: normocytic
– Shape: 10-30 evenly distributed short, blunt or pointed spicules; projections uniformly sized
– Cytoplasm: normochromic; retains central pallor (unlike acanthocytes)
Burr Cells
Elliptocytes
• SYNONYMS: ovalocyte, pencil cell
• APPEARANCE: elongate with round ends (cigar, egg, pencil shapes)
• KEY FEATURES:
– Size: variable; usually longer than normal red cell and much more narrow
– Shape: uniform, symmetrical rod shape; sides nearly parallel
– Cytoplasm: often retain central pallor
Elliptocytes
Teardrop Cells
• SYNONYMS: dacrycocyte
• APPEARANCE: Round cells with elongated tail or point; resembles a teardrop
• KEY FEATURES:
– Size: microcytic to normocytic
– Shape: teardrop or pear-shaped RBC with single tapered end (tail) that is blunt or round
– Cytoplasm: normochromic to hypochromic
Teardrop Cells
Stomatocytes
• SYNONYMS: hydrocyte
• APPEARANCE: RBC with a slit-like central pallor
• KEY FEATURES:
– Size: normocytic
– Shape: round; uniconcave disc
– Cytoplasm: normochromic; central pallor appears slit-like, straight, fish mouth, or curved rod-shaped; a few cells may have tri-polar pallor creating cells that resemble sleigh bells
Stomatocytes
Spherocytes
• SYNONYMS: none
• APPEARANCE: Cells appear perfectly round and have no central pallor; often smaller than normal RBCs
• KEY FEATURES:
– Size: slightly microcytic
– Shape: round to spherical
– Cytoplasm: no central pallor
Spherocytes50x Objective
Spherocyte100x Objective
Schistocytes
• SYNONYMS: helmet cell, triangulocyte, keratocyte, horn cell, fragmented RBCs
• APPEARANCE: Pieces of RBCs that can have a vast variety of shapes and sizes
• KEY FEATURES:
– Size: irregular cell sizes; usually microcytic
– Shape: shapes vary from helmet to triangular to unclassified fragments
– Cytoplasm: small fragments lack central pallor; horn cells can be normochromic
SchistocytesFragmented RBCs
Target Cells
• SYNONYMS: codocyte
• APPEARANCE: RBCs have a bullseye appearance
• KEY FEATURES:
– Size: normocytic to slightly macrocytic
– Shape: round
– Cytoplasm: increased surface membrane to volume ratio results in a central, darker hemoglobin region within the area of central pallor creating the appearance of a target or bullseye
Target Cells
Sickle Cells
• SYNONYMS: drepanocyte
• APPEARANCE: Usually a thin, crescent shaped cell
• KEY FEATURES:
– Shape: sickle shaped with at least one pointed end; may also be crescent-shaped, boat-shaped, filament shaped, holly-leaf form (rarely) and envelope shaped
– Cytoplasm: no central pallor; very dense hemoglobin concentration (normochromic to hyperchromic)
Sickle Cells50x Objective
Sickle Cells100x Objective
RBC Inclusions
• NRBCs
• Howell-Jolly Bodies
• Basophilic Stippling
• Pappenheimer Bodies
• Hemoglobin Crystals
Nucleated Red Blood Cells
• SYNONYMS: NRBCs
• APPEARANCE: RBC with a small, pyknotic nucleus with dense chromatin
• KEY FEATURES:
– Size: 8-10 m size; slightly larger than a mature RBC
– Cytoplasm: varies depending on stage of maturation; usually more blue-gray
NRBCsNucleated RBC
NRBCs
Howell-Jolly Bodies
• SYNONYMS: nuclear fragment, HJ bodies, Ho-Jo’s
• APPEARANCE: Large, singular dark purple inclusion
• KEY FEATURES:
– Size: 1 m; sometimes as small as 0.5 m
– Shape: spherical or oblong blue-purple or blue-black inclusion
– Cytoplasm: normochromic or hypochromic
– Location: eccentrically located (off center); usually a single inclusion, but multiple can be present
Howell-Jolly Bodies
Howell-Jolly Bodies
PappenheimerBodies (Iron)
Basophilic Stippling
• SYNONYMS: punctuated basophilia
• APPEARANCE: Medium-sized, blue-black dots (granules) evenly distributed throughout the RBC
• KEY FEATURES:
– Size of granules: numerous small coarse or fine granules; uniform in size and shape ; 0.5 m in diameter
– Cytoplasm: uniformly filled with deep blue or blue-gray dots
Basophilic Stippling
Pappenheimer Bodies
• SYNONYMS: none
• APPEARANCE: Small dark blue-purple staining hemoglobin iron granules; seen on Wright stained smear and confirmed with iron (Prussian blue) stain
• KEY FEATURES:
– Size: usually less than 1 m (sometimes <0.5 m)
– Shape: blue-purple granules with irregular, sharp edges (not round)
– Location: usually found along the periphery of the cell; one or two irregular, small blue-purple-green granules; if present in multiples, they form irregular closely aggregated clusters
Pappenheimer BodiesWright Stain
Pappenheimer BodiesIron Stain
Hemoglobin Crystals
• SYNONYMS: none
• APPEARANCE: dense staining, angular crystalline forms that vary in shape; may be rectangular, rod-shaped, tetragonal, octahedral (Washington monument, gold bar), spherocytic, rhomboid, or hexagonal
• KEY FEATURES:
– Size: variable since crystals may markedly distort the cell
– Shape: a normal disc shape is distorted by the crystal; cytoplasm contains the crystal, which is a precipitate of hemoglobin C or SC
– Cytoplasm: often pale or colorless; there is generally a clear area around the crystal
Hemoglobin SC Crystalsglove cells
Typical RBC Abnormal MorphologyPolychromasia Acanthocyte
Teardrop
Schistocyte
MicrocyteSpherocyte
Burr Cell
Elliptocyte
Target Cell
Hypochromic
Any Questions?