Peripheral Blood Smear Morphology

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Peripheral Blood Smear Morphology

• William F. Kern, MD
• Director, Laboratory Hematology

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None of the photographs, graphs or diagrams may
be downloaded from this presentation and used for
any purpose other than studying for the BHL
course.
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Evaluation of Peripheral Blood Smears

• Low power examination
• Medium power examination
• High power examination
• RBCs
• WBCs
• Platelets

Systematic approach critical
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Low Power Examination (10x)

• Assess quality of smear
• Estimate the hemoglobin
• Look for gross RBC abnormalities
• Rouleaux
• Aggutination
• Estimate the WBC count
• Look for WBCs in feathered edge
• Find best area for higher power exam

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Medium Power Examination20x or 40x

• Assess WBC types
• Look for abnormal WBCs
• Large cells with high n-c ratios
• Scan feathered edge and sides of smear
• Rough estimate of platelet count
• Look for platelet clumps

Blasts and other immature cells may float to
feathered edge or sides of smear
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High Power Examination50x or 100x oil

• RBCs
• Size Compare to nucleus of small lymph
• Shape Any abnormal shapes?
• Inclusions?
• WBCs
• Predominant cell type
• Differential
• Immature or abnormal cells

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High Power Examination50x or 100x oil

• Platelets
• Number
• Size
• Clumping or satellitism

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Evaluation of Peripheral Blood Smears

• Determine the major abnormality or abnormalities
• Evaluate the context

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Evaluation of Peripheral Blood SmearsDetermine
the Major Abnormality

• Anemia
• Abnormal RBCs
• Abnormal WBC number
• Immature or abnormal WBCs
• Decreased or increased platelet count
• Abnormalities in multiple cell lines

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Evaluate the Context
Example Possible blasts on blood smear

• What is the WBC count?
• Are there multiple abnormal cells, or just one?
• Are there any other abnormalities
• Immature granulocytes
• Nucleated RBCs

Continued...
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Evaluate the Context
Example Possible blasts on blood smear

• Is there anemia?
• Is there thrombocytopenia?

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Evaluate the Context
Example Lymphocytosis

• Absolute or relative lymphocytosis
• Child or adult
• What do the lymphs look like
• Reactive?
• Monomorphic or variable?
• What are the neutrophil platelet counts?

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Normal Blood Cells
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Erythrocytes
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Segmented Neutrophil(PMN Seg or Poly)

• Nucleus with distinct lobes separated by thin
  strands of chromatin
• Finely granular cytoplasm
• Weakly staining granules

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Band Neutrophil (Band)

• Horseshoe-shaped, non-segmented nucleus
• Less mature than segmented neutrophil
• Fully functional

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Eosinophils (Eos)

• Segmented nucleus- usually bilobed
• Large, uniform, reddish cytoplasmic granules

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Basophil (Basos)

• Large, purple granules
• Segmented nucleus

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Lymphocytes (Lymphs)

• Small, round, condensed nucleus
• Scanty pale blue cytoplasm
• Nucleus same size as erythrocyte

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Large Granular Lymphocyte

• More cytoplasm
• Large azurophilic (reddish) granules
• 10-15 of blood lymphs
• Associated with natural killer function

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Reactive (Atypical) Lymphocytes
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Monocytes (Monos)

• Folded nucleus
• Abundant, light grey cytoplasm
• Cytoplasmic vacuoles common
• Few, small cytoplasmic granules

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Platelets (Thrombocytes)
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Erythrocyte Abnormalities
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Rouleaux Increased Immunoglobulins
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Cold Agglutination IgM Antibodies to RBC Antigen
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Microcytic, Hypochromic Anemia Iron Deficiency
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Target Cells Thalassemia, Liver Disease
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Sickled Cells Sickle Cell Anemia
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Schistocytes (Fragments) Microangiopathic
Hemolysis
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Spherocytes (?), Nucleated RBC and
Polychromasia Immune Hemolysis
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Reticulocytes (new methylene blue stain)
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Echinocytes (Burr Cells) Uremia
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Teardrop Cells Space-Occupying Lesion in Marrow
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Leukocyte (WBC) Abnormalities
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Hypersegmented Neutrophil Megaloblastic Anemia
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Blood smear (100x)
Blasts Acute Leukemia
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Auer Rod
Bone Marrow Aspirate
Acute Myeloid Leukemia (with Auer Rod)
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Bone Marrow Aspirate Smear
Acute Promyelocytic Leukemia (APL)
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Blood smear (low)
See also next photograph
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Blood smear (100x)
Chronic Myeloid Leukemia (CML)
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Continued
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Blood smear (100x)
Chronic Lymphocytic Leukemia (CLL)
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Hairy Cell Leukemia (HCL)
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Platelet Abnormalities
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Platelet Clumping (EDTA artifact)
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Platelet Satellitism (EDTA artifact)
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Thrombocytosis
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Infectious Diseases
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Malaria
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Yeast (Histoplasma capsulatum)
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Ehrlichia
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Loa Loa (Microfilaria)