RED BLOOD CELL INDICES “WINTROBE INDICES”

MCV (Mean Cell Volume)

MCH (Mean cell Hemoglobin)
MCHC ( Mean cell Hemoglobin concentration)

I. Purpose:
-calculation of average volume and hemoglobin content and concentration of RBCs
-often needed for initial classification of anemias
A. MCV
-Average volume of a single red blood cell, expressed in femtoliters (fL) or 10-15 L

MCV = Hct(%) x 10
RBC count (x 1012/L)

Example: Hct value= 42 %

RBC count= 5 x 1012/L

Final result: 84 fL

REFERENCE VALUE: 80-100 fL

INTERPRETATION:
<80 fL = microcytic RBC
80-100 = normocytic RBC
>100 fL = Macrocytic RBC

B. MCH
- Average weight of hemoglobin in a single red blood cell, expressed in picograms (pg) or 10-12 g
-should correlate with the MCV

MCH = hb (g/dL) x 10
RBC count (x1012/L)

Example: Hb value: 15 g/dL

RBC count: 5 x 1012/L

Final result: 30 pg
REFERENCE VALUE: 26-34 pg
<26 pg, decreased hemoglobin
>34 pg, increased hemoglobin

C. MCHC
- Indicates the average concentration of Hb in each individual red blood cell.
- Expressed in g/dL

MCHC = hb(g/dL) x 100

Hct (%)

Example: Hb value: 15 g/dL

Hct value: 45%

Final result: 33.33 g/dL

REFERNCE VALUES: 32-36 g/dL

INTERPRETATION:
<32g/dL = hypochromic
32-36 g/dL = normochromic
>36 g/dL = “hyperchromic”
NOTE:
a. A cell does not really contain more than 37 g/dL of hemoglobin- but it’s shape may have become
spherocytic, making the cell appear full.
b.between 37 -38 g/dL of hemoglobin per cell( MCHC), check for the presence of spherocytes
c. Cold agglutinins can falsely increase MCV, MCH & MCHC
remedy: warm sample for 15 min at 37 deg Celsius

Example
MCV (fL) MCHC (g/dL) Red blood cell morphology Diseases

<80 <32 Microcytic, hypochromic Iron deficiency anemia

Thalassemia
Sideroblastic anemia
Anemia of inflammation
Hb E disease and trait
80-100 32-37 Normocytic, normochromic Hemolytic anemia
Bone marrow failure
Chronic renal disease
Myelopththisic anemia

>100 32-37 Macrocytic, normochromic Megaloblastic anemia

Chronic liver disease
Bone marrow failure
Myelodysplastic syndrome

HEMATOCRIT

HCT or PCV: denotes the % of RBC in a known volume of whole blood

GENERAL PRINCIPLE:
Whole Blood is packed by centrifugation and the packed RBC’s is measured.

I. Normal values:
Men: 40-55 %
Women: 37-47%
NEWBORNS: 45-60%

II. METHODS:
A. MICROHEMATOCRIT METHOD
Priciple:
A small amount of whole blood is centrifuged to determine maximum packing of RBC,
expressed as Hematocrit

Specimen requirements:
EDTA, or Heparinated blood
 COMMENTS/SOURCES OF ERROR:

**TECHNICAL ERRORS:
INCREASE DECREASE INCREASE/DECREASE
• Including the buffy coat • Excess • Improper use of
• Inadequate Anticoagulant reader
centrifugation =shrinkage of RBCs • Insufficient mixing
• Improper sealing of blood sample
of capillary tubes
= leakage of
specimen
• Allowing tubes to
stand too long
after
centrifugation/
delay in reading
results

**PHYSIOLOGIC ERROSS:
INCREASE hematocrit DECREASE hematocrit
• trapped plasma = remains in RBCs • Immediately after blood loss
during = plasma volume is replaced faster
than RBCs
centrifugation • Hemolysis
• abnormal RBC: • Difficulty in venipuncture/probing
sickle cells, spherocytes too long
• hemoconcentration: due to = introduces interstitial fluid
overapplication • Patients under intravenous therapy
of • Excessive hydration
tourniquet • Physiologic hydremias of pregnancy
• Dehydration= fluid loss= low
plasma volume
• Polycythemias

B. MACROHEMATOCRIT METHOD

Principle: Large amount of whole blood is centrifuged to determine the maximum

packing of RBCs

METHOD:
1. Venous blood is extracted placed in anticoagulated tube (HEPARIN, EDTA, Oxalated)
2. Filling in the Wintrobe tube with blood (100mm long tube)
3. Centrifuged at 3000rpm for 30 min.
4. Results read directly from the millimeter mark of the wintrobe tube.
 FORMULA:
Packed RBC in mm______ X 100 = % PCV
Whole blood in 100mm tube

III. RULE OF THREE

Hb x 3 = Hct
Rbc ct. x 3 = Hb

_________________________________________________________________________________
_______________

BLOOD CELL COUNT

HEMOCYTOMETERS
Number of Volume of 1
Ruled-areas ruled area
Depth of 1
present in each 1 ruled area
ruled area
type of (depth x
hemocytometer Area)
1. Improved 2 1. mm 3mm x 3mm = 9mm2 0.9 mm3
Neubauer
q
2. Fuchs-Rosenthal 2 2. mm 4mm x 4mm = 16 3.2 mm3
mm2
3. Speirs-Levy 4 0.2 mm 2 mm3
2mm x 5mm = 10
mm2
 INCREASE DECREASE
WBC Bacterial infection Viral infection
Leukemia Parasitic infection
Asthma Hypersplenism
tonsillitis Congenital marrow aplasia

Strenuous Exercise overhydration

Severe emotional or physical stress
Dehydration

RBC Increased production of Hemolytic anemia

Erythropoietin Aplastic anemia
Polycythemia vera Iron deficiency
Vit. B12 Deficiency
Kidney failure
Thalassemia
hemoglobinopathies

Overhydration
dehydration Low Altitude
High Altitude trauma

RBC ANOMALIES
I. Cell Size
- Indicators of normal cell size:
i. Cell diameter: 6-8 μm 


ii. Mean Corpuscular Volume (MCV): 80-100 fL 


iii. Red Cell Distribution Width: 11-14% 


- Variation: Anisosytocis
a. Normocyte 

- Normal MCV

- Associated conditions 

Normal status Pathological conditions 

Acute blood loss Hemolytic anemia Aplastic anemia 


b. Microcyte

- Smaller RBCs, < 6 μm

- MCV <80 fL

- Defect: Abnormal size due to the failure of hemoglobin synthesis

- Associated Conditions: 


o Anemia of Chronic disease o Thalassemia


o Iron DeUiciency anemia

o Sideroblastic anemia
c. Macrocyte

- MCV > 100 fL - Defect:
o Impaired DNA synthesis o Stress erythropoiesis

o Excess surface membrane
- Associated Conditions:

o Megaloblastic anemia o Liver diseases

II. Hemoglobin Content (Cell Color)

- Mean Corpuscular Hemoglobin Content: 31-36% - Variation: Anisochromia
a. Normochromic

- Normal MCHC

- Normal color

- Central pallor 1/3 of the total cell diameter

b. Hypochromic

- Decreased MCHC

- Central pallor > 1/3 of the total cell diameter - Hypochromic grading:
1+: Area of central pallor is 1⁄2 of cell diameter 2+: Area of pallor is 2/3 of cell diameter

3+: Area of pallor is 3⁄4 of cell diameter

4+: Thin rim of hemoglobin
- Associated Conditions: o Iron deUiciency o Thalassemia
c. Polychromasia

- Blue-gray coloration

- Polychromasia grading
Slight: 1% of total RBC are polychromatophilic
. 1+: 3% of total RBC are polychromatophilic 


. 2+: 5% of total RBC are polychromatophilic 


. 3+: 10% of total RBC are polychromatophilic 


. 4+: >11% of total RBC are polychromatophilic 


- Indicates:

o Increased erythropoietic activity

o Presence of young erythrocytic cells & precursors

III. Cell Shape


- Normal: Biconcave disc-shaped - Variation: Poikilocytosis

A. Poikilocytosis secondary to developmental macrocytosis

a. Oval Macrocytes

- Oval shaped; Slightly larger than normal size - Mature cytoplasm, immature nucleus

- Often seen in megaloblastic anemia

B. Poikilocytosis secondary to membrane abnormalities

a. Acanthocyte

- Aka: Spur Cell/ Thorn Cell

- Spheroid with 3-12 irregular spikes/ spicules

-Defect: Abnormal ratios of membrane lecithins and sphingomyelin; Increased ratio of cholesterol to
lecithin - Associated Conditions:
o End-stage liver disease

o Alcoholic cirrhosis with hemolytic anemia o Severe hemolytic anemia associated with cirrhosis
and metastatic liver disease o Hepatitis of the newborn
o Malabsorption states

o Postsplenectomy states

o Pyruvate kinase deUiciency
o Abetalipoproteinemia

b. Echinocyte

- Aka: Burr Cell/ Crenated Cell/ Sea Urchin Cell - Regular 10-30 scalloped short projections

- Defects:
o Depletion of ATP

o Exposure to hypertonic salt solution; Artifact in air drying -Associated Conditions:
o Uremia

o Chronic renal disease o Cirrhosis

o Hepatitis

c. Codocyte

- Aka: Target Cell/ Mexican Hat Cell

- Bell or tall hat shape on scanning electron microscope

- Peripheral rim of hemoglobin surrounded by a clear area and central hemoglobinized area (bull’s
eye)

- Defect:
o Excess surface membrane to volume ratio
o Increased cholesterol and phospholipid - Associated Conditions:
o Hemoglobinopathies SS, CC, DD, EE o Thalassemias

o Obstructive liver disease

o Post-splenectomy states
o Iron deUiciency anemia
d. Elliptocyte

- Rod or cigar shape, narrower than ovalocytes - Defect: Polymerization of hemoglobin

- Associated Conditions:
o Hereditary Elliptocytosis

o Defect in the cytoskeleton

e. Ovalocyte
o Decreased membrane protein band 4.1 - Egg like or oval shaped cell, wider than elliptocytes
- Defect:

o Bipolar arrangement of hemoglobin o Reduction in membrane cholesterol
- Associated Conditions:

o Megaloblastic anemia
- o Myelodysplasia

o Sickle cell anemia

f. Spherocyte

- Smaller in diameter than normal RBC with concentrated hemoglobin

- No visible central pallor

- Defects:
o Lowest surface area to volume ratio
o Defective membrane - Associated Conditions:
o Hereditary spherocytosis

o Isoimmune and autoimmune hemolytic anemia o Severe burns

o Banked blood stored for a long time
NOTE: After splenectomy in a patient with HS, spherocyte persists, indicating that the abnormality
involves the membrane itself rather than splenic damage to the cells

g. Stomatocyte

- Mouth or slit-like pallor area, bowl-shaped

- Defect: Increased permeability of the membrane to sodium

- Associated Conditions:
o Hereditary stomatocytosis o Rh null disease

o Alcoholism

o Cirrhosis
o Obstructive liver disease

C. Poikilocytosis secondary to trauma

a. Schistocyte/ Schizocyte (Gr. Schistos: cloven, Gr. Schizo: split)
- Fragments in RBC varying in size and shape - Variants

a1. Keratocyte’/ Helmet cells
-Schistocyte with hornlike projections
a2. Knizocyte
-Triangular-shaped with 2 pallor areas
- Defect: Extreme fragmentation of RBC produced by damage of RBC by Uibrin, altered vessel walls,
prosthetic heart valves

- Associated conditions:
o Disseminated Intravascular Coagulation (DIC)
o Thrombocytopenic purpura

o Burns

o Microangiopathic hemolytic anemia

b. Dacryocytes

- Aka Tear drop cells

- Teardrop or pear-shaped with single elongated point or tail

- Defect: Squeezing and fragmentation during splenic passage

- Associated Conditions:
o Myeloid metaplasia o Hypersplenism

c. Microspherocytes/ Pyropoikilocytes

- RBCs with small diameter and is known for its incapability to withstand high temperatures
0
- Fragments at 45 C which is relatively lower to the temperature where normal red blood cells start
0
to fragment (49 C)

- Associated Conditions:
o Severe burns

o Hereditary pyropoikilocytosis

d. Semilunar bodies

- Aka Half-moon cell/ Crescent cell

- Large, pale pink staining ghost of the red cell

- Defect: Membrane is disrupted and red cell contents have been released