UNIT 7

PERIPHERAL BLOOD
SMEARS
What is a Blood Smear?
• A blood smear is a sample of blood that's spread on a glass
slide which is treated with a special stain. In the past, all
blood smears were examined under a microscope by
laboratory professionals. Now automated digital systems
may be used to help examine blood smears.
• The purpose of examining a blood smear is to check the
size, shape, and number of three types of blood cells:
• Other names: peripheral smear, peripheral blood film,
smear, blood film, manual differential, differential slide,
blood cell morphology, blood smear analysis
What is it used for?
• A blood smear is used to help diagnose and monitor many
conditions, such as blood disorders, sudden kidney failure,
and treatment for certain cancers.
What's the role of PBS
• Evaluation of anemia
• Thrombocytopenia/cytosis
• Diagnosis of abnormal cells like blasts, lymphoma cells
• Infections like malaria, microfilaria
• Others, fragmented RBCs, Howell-Jolly bodies etc
• Gives vital clues for further workup
• In some situations where analyzers fails
Normal Red cell morphology
• Normal red cells are said to be normocytic and
normochromic.
• In well spread and stained films the great majorities of the
cells have round smooth contours and Pink cytoplasm with
an area of central pallor.
• Size varies from 7-8um in diameter.
• As a rough guide, normal red cell size appears to be about
the same as that of the nucleus of a small lymphocyte.
• The hemoglobin stains with the eosin component of
Romanowsky dyes and owing to the biconcavity of the cell,
stains more palely at the center and quite deeply at the
periphery.
• This depth and distribution of staining in normal red cells is
described as normochromic.
Variation in size of Red blood cells (Anisocytosis)
The size of the red blood cells increases or decreases
in various conditions:
1. Microcytes
Microcytes are the RBC of small size and are present
in the blood in the following conditions:
i. Iron deficiency anemia
ii. Prolonged forced breathing
iii. Increased osmotic pressure in blood
2. Macrocytes
• Macrocytes have diameter greater than 8.0µm and the mean
cell volume is also increased. Because of their increased
hemoglobin content they stain darker than normal RBC.
• Macrocytosis is seen in stress erythropoiesis as seen in
hemolytic anemia and also during recovery from acute blood
loss.
3. Megalocytes
• Large cells, diameter may measure 12µm), often oval
shaped cells with increased hemoglobin content.
• True megalocytes are identified only if megaloblasts have
been identified in bone marrow aspirates.
• Megalocytes are seen in vitamin B12 and/ or folic acid
deficiency, in association with some leukemias.
Variation in Shape (Poikilocytosis)
Acanthocytes (spiny cells)
• Spheroidal cells with 3-12 spicules of uneven length
irregularly distributed over the cell surface.
• It is seen in disorders of lipid metabolism, alcoholic liver
cirrhosis and rarely in hepatitis.
Dacrocytes (Tear drop cells)
• These are tear drop or pear shaped red cells which could be
considered to be discocytes with a single drawn out spicule.
• It is thought that stretching of the cell membrane beyond a
certain limit results in loss of deformability and ability to
revert to normal discoid shape.
• It is seen in myelofibrosis, myeloid metaplasia, tumor
metastases to the bone marrow, tuberculosis and drug-
induced Heinz body formation
Drepanocytes (sickle cells)
• These are crescent shaped red cells because of the formation
of rod-like polymers of Hb S or some other rare hemoglobins.
• They have an increased surface area and increased
mechanical fragility which leads to hemolysis and hence
severe anemia.
• They are primarily seen in sickle cell anemia.
Echinocytes (crenated cells)
• Red cells showing numerous, short, evenly distributed
spicules of equal length.
• These are probably the most common artefacts in a blood film
consistently found in blood samples that have been stored for
some time room temperature.
• Invivo they are seen in uremia, pyruvate kinase deficiency and
neonatal liver diseases.
Elliptocytes/ ovalocytes
• They are elliptical or oval shaped red cells. Normally less
than 1% of the red cells are elliptical/oval shaped.
• They are found in almost all anemias where approximately
10% of the red cells may assume elliptical/oval shape and in
hereditary elliptocytosis where almost all the red cells are
elliptical
Variation in structure of RBC
1. Punctate Basophilism
2. Ring
3. Howel Jolly bodies
Abnormalities in White Blood Cells and their clinical
significance
• Most of the abnormalities in white blood cells are seen in
neutrophils. They are discussed below:
1. Toxic granulation
• In many severe bacterial infections neutrophils contain
prominent granules which take up an intensely pulrple
black colour in the cytoplasm.
• These may also appear in some hereditary disorders
(chediak Higashi)
2. Vacuoles
• In conditions such as severe infections, burns, chemical
poisoning, malignancy and others, cytotoxic injury may
result in the occurrence of vacuoles in the cytoplasm and
nucleus.
3. Dohle bodies
• These are small round or oval discrete light blue stained
inclusion bodies (1-5µm) that occasionally appear in the
cytoplasm of the neutroohils in severe infections, burns and
on exposure to the toxic agents.
• They are also associated with May-Hegglin anomaly.
4. Hypersegmentation
• When too many lobes (more than 3 to4) lobes are seen in
segmented neutrophils, they are classified as
hypersegmented neutrolphis (technically called shift to the
right) which may be due to an inherited disorders or may
occur in megaloblastic anemia.
5. Hyposegmentation
• This anomaly is characterised by failure of normal lobe
development ( less than 3) in neutrophils.
• The nucleus may take up a dumbell shape or may appear as a
band neutrophil.
• It occurs in the acute myelocytic leukemia, severe infections,
toxic states and heriditary disorders (Pelger Huet anomaly).
• Non heriditary dumb bell shaped neutrophils are also known
as Pseudo Pelger Huet anomaly.
6.Auer bodies
• These are cytoplasmic inclusions found in myeloblasts with
Romanowasky stains in case of acute myelogenous leukemia.
• Their detection can markedly be improved by modified
peroxidase staining technique, when they are referred to as
Phi bodies.
• They are needle like in shape with intense red or purple red
colour, usually found as a single inclusion.
7. Smudge cells
• These are degenerated lymphocytes that look like baskets
(often called basket cells) with no cellular wall.
• Their presence may be associated with chronic lymphocytic
leukemia.
• The presence of a few smudge cells in the smear is considered
as normaal and is probably due to faulty technique.