HEMATOPATHOLOGY

THE POST SPLENECTOMY BLOOD

PICTURE by Craig E. Litz, M.D.
In our consult experience misinterpretation of the blood smear findings in the splenectomized patient is a cause of significant misdiagnosis. The blood changes following splenectomy are relatively predictable and knowing these changes can obviate a wrong diagnosis
and therapy in your patient.
The diagnosis of a post-splenectomy/hyposplenic blood picture can be made reliably by identifying Howell Jolly bodies in routine
Wright-Giemsa stained blood. These are round basophilic bodies
in red blood cells that represent residual nuclear material from
marrow nucleated red cell precursors that is usually culled out
Figure 1- Red blood cell with Howell-Jolly
by the spleen (Fig 1, Table 1). These do not occur in individuals
body (large arrow) and target cells (small
arrow) indicating functional asplenia. The
with normally functioning splenic tissue and their presence
Howell-Jolly body represents the residual
nucleus of a red cell that has not been
indicates either 1) an asplenic state or 2) hypofunctioning
culled out by the spleen. Its presence in the
splenic tissue as might be seen in a patient with late stage sickle
blood indicates a hypofunctional or absent
spleen.
cell anemia. Their presence in an individual with splenomegaly
leads to a narrow differential diagnosis (Table 2) and their
absence in a splenectomized individual indicates accessory splenic
tissue.
TABLE 1. CHANGES FOLLOWING SPLENECTOMY 1-3
RBC

% WITH FINDING

DEGREE OF CHANGE

Howell Jolly Bodies

100%

Siderocytes

25%

Heinz bodies

Increased2

MCV, Hgb

No change

Poikilocytosis

~100% (Target cells)

WBC

Increased in 35%

Usually 10,000-15,000/ ul

Lymphocytes

Increased in 55%

Usually >40% of differential

NK cells

Mild increase

13% (normal 9%) of differential

Monocytes

Increased in 30%

Moderate, 7.5 to 17% of differential

Eosinophils

Increased in 26%

Moderate, 3.5 to 15% of differential

Basophils

Increased in 20%

Mild, usually <3% of differential

PLT

Marked increases in most patients

immediately post-splenectomy

Persists >400,000/ ul in 40-50% of cases

PROPATH

THE POST SPLENECTOMY BLOOD PICTURE

HEMATOPATHOLOGY

by Craig E. Litz, M.D.

TABLE 2. CAUSES OF HYPOSPLENISM IN INDIVIDUALS WITH SPLENOMEGALY 4

SPLENIC TUMORS AND CYSTS
AMYLOIDOSIS
MALARIA

Heinz bodies and poikilocytosis typically increase in a splenectomized individual and care must be taken not to overdiagnose hemolysis
in such an individual. Benign poikilocytosis can be quite dramatic in an asplenic individual with renal insufficiency. Mean corpuscular
volume (MCV) and hemoglobin levels do not change with splenectomy.
Changes in white blood cells include a mild leukocytosis with an increase in large granular lymphocytes and NK cells. Monocytes are
frequently increased occasionally leading to a mistaken diagnosis of chronic myelomonocytic leukemia (CMML).
Virtually all individuals undergoing splenectomy experience a thrombocytosis acutely; some may reach levels of greater than
1,000,000/ul. 5 Platelet counts persist above 500,000/ul in up to 40% of splenectomized individuals. 6 It is important to exclude
asplenia in all individuals in whom a diagnosis of a myeloproliferative disorder, in particular essential thrombocythemia, is being
entertained.
References

Craig E. Litz, M.D.

1) Lipson RL, Bayrd ED, Watkins CH: The postsplenectomy blood

picture. Am J Clin Pathol 32:526-532, 1959.

Dr. Craig Litz is board certified in Anatomic

and Clinical Pathology with subspecialty
board certification in Hematopathology. Dr.
Litz joined PROPATH in 1997. He is the
Director of Hematopathology and a Clinical
Professor of Pathology at the University of
Texas Southwestern School of Medicine in
Dallas, Texas. He graduated from the Medical
College of Virginia (AOA) in Richmond, Virginia and completed his
residency at the University of Minnesota in Minneapolis, Minnesota,
where he was named Chief Resident. Dr. Litz continued at the
University of Minnesota as a Hematopathology Fellow. He joined the
University of Minnesota Division of Hematopathology in 1989 becoming
a tenured associate professor in1995. For direct inquiries to Dr. Litz,
contact him at Craig.Litz@propath.com.

2) Personal communication with Dr. R. Brunning of the University of

Minnesota Medical School, Minneapolis, MN, regarding the subject
presented in an honors thesis by Mary Schmalz.
3) Theodorou GL, Mouzaki A, Tsiftsis D et al: Effect of non-operative
management (NOM) of splenic rupture versus splenectomy on the
distribution of peripheral blood lymphocyte populations and cytokine
production by T-cells. Clin Exp Immunol 150:429-436, 2007.
4) Steinberg MH, Gatling RR, Tavassoli M: Evidence of hyposplenism in the presence of splenomegaly. Scand J Haematol 31:437,
1983.
5) Hirsh J, Dacie JV: Persistent post splenectomy thrombocytosis and
thrombo-embolism: a consequence of continuing anaemia. Br J
Haematol 12:44, 1966.
6) Slater PP, Sherlock EC: Splenectomy, thrombocytosis, and venous
thrombosis. Am Surg 23:549, 1957.
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Revised 021312

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