ISSUE20

ISSUE

December
2021

This issue
Last Month’s Slides P.1
Monthly Case study P.1-2
Cell Quiz P.2
Red cell terminology P.2-3
Season’s Greetings P.3

Last
Month’sSlides
Slide 1
Monomorphic
hyperlymphocytosis composedof large lymphocytes, often
nucleolated nuclei and with
abundant cytoplasm(sometimes vacuolated).
Phenotyping result of
circulating lymphocytes:
Matutes scoring at 1/5. Expert
comment : Cytology suggestiveof lymphoma of the marginalzone.

Slide 2Anisocytosis (+).Echinocytes(+++).Hyposegmentation ofneutrophils / band cells(++).Discrete myelemia. Expert
comment: Döhle body?

Slide 3
Erythroblasts (2 to 3%).
Hyposegmented PMN (+).
Expert comment: Morphology"Elliptocytes" of red blood cells
not taken into account,because there is an underlying
iron deficiency.

Slide 4
Anisocytosis (++).Echinocytes(++).2 to 3% of Erythroblasts.
Vacuolated (+) andhypergranulated (+) PMNs.
Discrete myelemia.

Slide 510 to 12% eosinophils. Expert
comment: A cell classified inthe "Plasma Cells" column.

Slide 6
See Slide Review

Monthly Digital Case study
November 2021 Slide 6
Presentation
Male 49 years

FBC Results
WBC 3.83 (10^3/mm3)
RBC 3.27 * (10^6/mm3)
HGB 10.5(g/dL)
HCT 31.5 (%)
MCV 96 (fL)
MCH 32.3 (pg)
MCHC 33.4 (g/dL)
PLT
19* (10^3/mm3)
Neutrophils 97.2 %Lymphocytes 0.0 %Monocytes
0.9 %Eosinophils 0.0 %Basophils
0.0%
Metamyelocytes 1.9%

Neutrophils showing left shift(decrease in the number of lobes),
Toxic Granulation (increase ingranulation)
andnuclear
vacuolation

Analyser Alarms – WBC abn Matrix, Plt Abn histogram

Slide review
Anisocytosis (++).
Echinocytes (+).
Lymphopenia (0.1x10 ^ 9 / L).
Thrombocytopenia.
Expert comment:
Very vacuolated and hypergranulated atypical PMNs: Septicshock?

Cell Quiz:
What is the name of the cells
highlighted in red box:A) AcanthocyteB) DacrocyteC) SchistocyteD) Drepanocyte

Last Month’s Cell
Quiz:
What test would you perform if you
saw a number of these cells in ayoung adult presenting with swollen
lymph nodes, tiredness, sore throat:A) Ham’s testB) Infectious Mononucleosis test(Monospot)C) Malarial parasites
D) COVID-19 Lateral Flow test

Slide 6 Review continued
Neutro Toxic Granulation (NTG) - increase in azurophilic granules with the granules
being more visible than normal due to their increase in size and being morebasophilic. Although being characteristic of infection, NTG is not only seen in infection
as it can be seen in normal pregnancy and in patients receiving cytokine treatment(GM-CSF, G-CSF).
Neutrophil Left Shift – increase in less mature Neutrophils i.e. fewer number ofsegmented lobes. The term Left Shift is derived from the fact that on old fashioned
manual cell counting machines the more immature Neutrophils were on the left mostside of the counter. Left shift is indicative of the marrow’s response to infection byreleasing the more immature forms. Left Shift may also be seen in GM-CSF, G-CSF
treatment.
Follow up tests:
Due to the low platelet count, a full coagulation screen, including D-Dimer, is highly
recommended in order to check for the presence of Disseminated Intravascular
Coagulation (DIC). Sepsis is the most common underlying cause of DIC and thepresence of DIC in sepsis has a poor prognostic outcome.

Red Cell Morphology Terminology part 1
Normal red cells are biconcave cells with an average diameter of approx. 7.5um,
when a blood film is stained and then examined microscopically the red cells appear
as circular discs with a central area of parlour and with little variation on size andcolour in normal patients. The normal red cell is approximately the same diameter asthat of the nucleus of a Lymphocyte.
Numerous terms are used to describe the variation in size, shape and colour of the
red cell and is traditionally scored in severity as either +, ++, +++ and even ++++.

Variation in size
Anisocytosis - describes an increase in the variation in size. Anisocytosis in itself is nonspecific. An increase Red Cell Distribution Width as measured by automated analyser
is indicative of the presence of anisocytosis in the blood film.
Anisocytosis may be accompanied with the majority of the red cells being either
smaller or larger in size than normal red cell. Microcytosis describes the presence ofcell smaller than normal red cells, while Macrocytosis describes the presence of celllarger than normal red cells.
Microcytic (MCV 62fL)

Normal (MCV 90fL)

Macrocytic (MCV 114fL)

Answer:B) Infectious Mononucleosis test.
The cells displayed are classicalIf there are only a small number of Microcytic or Macrocytic red cells present the
Atypical Lymphocytes which are Mean Cell Volume (MCV) may still be within the reference range.
a feature of Infectious
Mononucleosis (most commonly Some causes of Microcytosis and Macrocytosis:
caused by Epstein-Barr Virus ) .
Microcytosis
Macrocytosis
Atypical Lymphocytes are large
with abundant basophillic
Iron Deficiency
Vitamin B12 deficiency
cytoplasm the nucleus can be
Anaemia of chronic disease
Folic acid deficiency
round, oval, reniform oroccasionally clover leaf
Beta Thalassaemia
Liver disease (including increased alcoholuptake)sometimes with a prominent
nucleoli.
Hb Constant Spring, Hb H disease, Hb
LeporeDrug interaction e.g Hydroxycarbamide,
doxorubicin, azathioprine

The importance of the blood film in patients with raised MCV is seen in patients who
present with cold agglutinin disease (agglutinating autoantibodies which operate at atemperature below 37°C) which causes the red cells to agglutinate (clump together) inlow temperatures and the measured MCV may be inappropriately raised. As theagglutinated cells are counted in the analyser, they cause the red cell count to be lessthan it should be and the MCV greater with agglutinated multiple cells being counted asa single cell. Warming the sample to 37°C and then re-analysing often, clears the red cell
agglutination. Fig below showing RBC autoagglutination (red box):QSP 2.0

RBC auto agglutination needs to be differentiated from Rouleaux formation which iswhere the red cells are in stacks resembling a pile of coins (see below):

Bibliography

Available as a single use
license and a site license
which allows up to 50
concurrent users.
To find out more, contactus.

Blood Cells – A Practical
Guide, Barbara J Bain

Editorial Team
Kelly Duffy
Rouleaux formation does not affect the measured MCV. Rouleaux formation is caused by Andrew Fisher
increased concentration of plasma proteins e.g. Immunoglobulins and Fibrinogen. The
Erythrocyte Sedimentation Rate (ESR) will also be elevated. Rouleaux formation is seen in
infections, myeloma (as in the case above) and Waldenström's macroglobulinemia. The
case above also displays a bluish background staining as a result of the excessive
concentration of the paraprotein present.

Variation in Colour
Polychromasia
As immature red cells are released from the bone marrow, they are larger than mature
red cells and also contain an amount of RNA which is lost as the cell matures in thecirculation. The RNA causes the red cell to appear more of a bluish colour than a redcolour and this leads to the term Polychromasia. In normal adults, only about 0.1 % of redcells are polychromatic since only the most immature red cells are polychromatic.
Examples of polychromatic red cells (red box):

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