Peripheral Smear

Daniel McFarland
 Peripheral Blood Smear
• With the use of automated blood-cell
analyzers, the proportion of blood count
samples that require a blood smear has
steadily diminished
• Nevertheless remain a crucial diagnostic
aid
• In comparison with the procedure for an
automated blood count, the PBS is labor
intensive and must be used judiciously
 Peripheral Blood Smear
• Physician-indicated request
• Laboratory might have apolicy of always
examining a smear if clinical details
indicate lymphadenopathy or
splenomegaly. www.islh.org
 Consensus Guidelines: Positive
Smear findings
• Below is the listing of criteria used to determine a positive smear finding for the study
of suggested criteria for action following automated CBC and WBC differential
analysis.
1. Morphology
a. RBC morphology at either 2+ / Moderate or greater. The only exception is
Malaria, where any finding will be considered a positive finding.
b. PLT morphology (giant platelets) at either 2+ / Moderate or greater.
c. Platelet Clumps at > rare / occasional
d. Dohle bodies at either 2+ / Moderate or greater
e. Toxic granulation at either 2+ / Moderate or greater
f. Vacuoles at either 2+ / Moderate or greater
2. Abnormal Cell Types
a. Blast > 1
b. Meta >2
c. Myelo / Promyelocyte > 1
d. Atypical Lymphs > 5
e. NRBC > 1
f. Plasma Cells > 1
 Delta Definitions
• Delta limits: The delta limit for a particular test is the
amount by which the most recent automated analyzer
test result may differ from a previous test result before
triggering smear review or some other action to validate
the analyzer result. Delta limits should be established for
each laboratory by taking into account physiological
considerations as well as the characteristics of the
automated analyzer used in that laboratory.
Delta pass and delta fail: Delta pass occurs when the
result of the most recent automated analyzer test does
not differ by more than the delta limit from the result of
the previous test. Delta fail is when the result of the
most recent test differs by more than the predefined
delta limit from the previous test result.
Clinical Indications for Examination
of a Blood Smear
• Features suggestive of anemia, unexplained
jaundice, or both
• Features suggestive of sickle cell disease –
dactylitis or sudden splenic enlargement and
pallor in a young child or an older child or adult
with limb, abdominal or chest pain
• Features suggestive of lymphomaor other
lymphoproliferative d/o. LAD, Splenomegaly,
enlargement of thymus
• Features suggestive of myeloproliferative
disease-splenomegaly, plethora, weight loss
Clinical Indications for Examination
of a Blood Smear
• Suspicion of DIC
• Acute or recent onset renal failure or unexplained renal
enlargement
• Suspicion of bacterial or parasitic disease that can be
diagnosed from smear
• Features suggestive of disseminated nonhematopoietic
cancer-weight loss, malaise, bone pain
• General ill health with malaise and fever, suggesting
infectious mononucleosis or other viral infection or
inflammatory or malignant disease
 Anemia-characteristic seen on
automated counts
• Automated instruments impart valuable
information. Red-cell count, mean cell volume,
mean cell hemoglobin (average amount of
hemoglobin per cell) and mean hemoglobin
concentration.
• Previous could only be derived from manual
smear: RDW, (correlates on a cell smear with
anisocytosis), hemoglobin-distribution width and
percentages of hypochromic and hyperchromic
cells which correlate with anisochromasia,
hyper/hypochromasia etc..
Morphologic characteristics that are
critical in DDx of anemia
• Detection of variations in cell shape and
red-cell inclusions such as Howell-Jolly
bodies (nuclear fragments), Pappenheimer
bodies (hemosiderin-containing granules)
and basophilic stippling or punctate
basophilia (altered ribosomes)
 Hemolytic Anemia
• Red cell shape is important
• All you need in hereditary elliptocytosis
because its so distinctive
• Presence of spherocytes is not
diagnostically specific, could be from
AIHA, or alloimmune hemolytic anemia
(hemolytic disease of the newborn or
delayed transfusion rxn)-together with DAT
and clinical scenario reveal diagnosis
 Hemolytic Anemia
• Microspherocytes (reduced size and diameter)
are present in spherocytic hemolytic anemai but
also characteristic of burns and
microangiopathic hemolytic anemia
• Importance of microangiopathic hemolytic
anemia may indicate pregnancy –associated
HTN, disseminated cancer, chronic DIC, the
hemolytic uremic syndromeor TTP (later 2
require urgent dx)
• Need PBS to validate platelet count
 Hemolytic anemia from oxidant
damage
• Keratocytes or “bite” cells, “blister” cells
• Most often seen in G6PD deficiency but
can also occur in defects in the pentose
shunt or glutathione synthesis
• Exogenous oxidant damage as in
exposure to chemicals or drugs (dapsone)
or endogenous (Wilsons Disease)
• PBS suggest diagnosis of G6PD even if
assay is normal
Bite cell
 Hemolytic anemia
• Red-cell agglutinates –indicates presence
of cold agglutinin
• Erythrophagocytosis is often a feature of
paroxysmal cold hemoglobinuria
erythrophagocyte(also seen in
hemophagocytic syndrome)
 Macrocytic Anemia
• B12 or folate deficiency: macrocytes and also
oval macrocytes and hypersegmented
neutrophils.
• Smear is important as it provides provisional
diagnosis while assay is being performed, also
occasionally there are patients with a clinically
significant B12 deficiency despite a normal
assay result. (much of B12 is bound to
haptocorrin whereas the functional B12 is bound
to transcobalamin contributes much less to the
assay
 Macrocytic Anemia
• Liver disease and excess ethanol consumptiom
• MDS-hypogranular or hypolobulated neutrophils,
blast cells, giant or hypogranular platelets,
Pappeinheimer bodies
• When macrocytosis is the result of hemolysis or
recent blood loss the blood smear show
polychromasia (from increased retic count)
Hypersegmented neutrophil
Oval Macrocyte
 Microcytic Anemia
• Less important here, red cell indices and
serum ferritin
• Presence of Pappenheimer bodies and
red cell dimorphism in the sideroblastic
anemia and of basophilic stippling in cases
of lead poisoning
Pappenheimer bodies
Ringed sideroblast
 Hemoglobinopathy and
Thalassemia
• Differentiate between sickle cell anemia and SC
disease. The compound of S and C have a
normal hemoglobin level (can be confused with
trait)
• Consideration of the smear, hemoglobin level
and the results of a sickle cell solubility test
usually permits an accurate diagnosis
• Smear of a compound heterozygote usually
shows target cells, irregularly contracted cells,
boat shaped cells, few sickled cells
• SC poikilocytes
 Thrombocytopenia,
Thrombocytosis
• To confirm and look for underlying cause
• Small clots, platelet clumping, platelet satellitism,
abnormally large platelets
• Smear may reveal May-Hegglin abnormality,
microangiopathic thrombopathies, leukemias
and lymphomas
• Confirm high platelet counts (r/o red cell
fragments, fungi, fragments of leukocytes)
• Look for evidence of myeloproliferative disorder
(giant platelets, increase in basophil count)
May-Hegglin Abnormality
 Leukemia, Lymphoma or Bone
Marrow Failure
• Should always be examined with these
phenomena
• Low counts-acute leukemia, aplastic anemia,
hairy cell leukemia, infiltration of
nonhematopoietic malignant cells into the bone
marrow
• For Burkitts Lymphoma and acute promyelocytic
leukemia a blood smear is of particular
importance as it diagnoses rapidly and facilitates
treatment
Acute Lymphoblastic Leukemia
(ALL)/Lymphoma
L3 subtype (Burkitt's)
 Acute Lymphoblastic Leukemia
(ALL)/Lymphoma
L3 subtype (Burkitt's)
• The morphologic appearance of the malignant cells in L3
ALL/lymphoma (Burkitt's leukemia/lymphoma) on a Wright-Giemsa
stain is essentially diagnostic, especially in the classic subtype. The
cells are of medium size, about 1 1/2 to 2 times larger than L1 ALL
cells, and they are rather uniform in size. The cytoplasm is very
basophilic (blue) and contains a variable number of lipid-laden
vacuoles that stain positive with oil red 0 (neutral fat). The
vacuoles frequently cluster in a Golgi distribution. The nucleus is
round to slightly oval, and the nuclear chromatin is coarse but evenly
dispersed with some clumping. Nucleoli are prominant and usually
multiple in number. On fixed paraffin sections of bone marrow and
lymph node specimens the pattern of infiltration is diffuse with a
"starry sky" appearance due to histiocytic engulfment of apoptotic
Burkitt tumor cells. Mitotic figures are frequent reflecting the very
high proliferative rate. Resting cells are essentially non-existent.
Acute Promyelocytic Leukemia
 Probable Factitious Results
• Pseudo-neutropenia caused by
myeloperoxidase deficiency (automated
system deploys a peroxidase reaction for
the identification of neutrophils,
eosinophils and momocytes
Serendipity