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Practical of Clinical Hematology. RBC’s Morphology. Lab 2. RBCs Abnormal morphology. Peripheral Blood Morphology. Abnormal erythrocyte morphology. Is found in pathological states that may be abnormalities in Red cell distribution. Size (anisocytosis).

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Practical of clinical hematology

Practical of Clinical Hematology

RBC’s Morphology

Lab 2

Practical of clinical hematology

RBCs Abnormal morphology

Peripheral Blood Morphology

Abnormal erythrocyte morphology
Abnormal erythrocyte morphology

  • Is found in pathological states that may be abnormalities in

    • Red cell distribution.

    • Size (anisocytosis).

    • Hemoglobin content – Color Variation .

    • Shape (poikilocytosis).

    • The presence of inclusion bodies in erythrocyte.

Erythrocyte distribution abnormalities
Erythrocyte Distribution Abnormalities

  • Rouleaux formation

    Stacking of RBCs due to increased plasma proteins coating RBCs (resembling a stack of coins)

    Found in:- Hyperfibrinogenaemia- Hyperglobulinaemia

  • Agglutination

    Antibody-mediated Irregular clumping , temperature dependent

    Found in:- Cold agglutinins- Warm autoimmune hemolysis

Variation in erythrocyte size anisocytosis
Variation in erythrocyte size (anisocytosis)

  • Anisocytosis: Variations in size (Microcyte and Macrocyte)

  • Normocytic RBC’s

    Normal size of RBC (8 μm) with a range of 7 to 9 μm.

    The nucleus of a small lymphocyte (± 8 µm) is a useful guide to the size of a red blood cell).


  • RBC cell smaller than the normal RBC ( <7 μm), and is associated with a decrease in hemoglobin synthesis

    • Found in:

      • Iron deficiency anemia.

      • Thalassaemia.

      • Sideroblastic anemia.

      • Lead poisoning.

      • Anemia of chronic disease.


  • RBC larger than the normal (<9 μm) and is the result of a defect in nuclear maturation or stimulated erythropoiesis. May be round or oval in shape, the diagnostic significance being different.

    • Found in:

      • Folate and B12 deficiencies (oval)

      • Ethanol (round)

      • Liver disease (round)

      • Reticulocytosis (round)

Example film study
Example : Film Study

Most erythrocytes presented in the picture are microcytes (compare with the small lymphocyte). The degree of hemoglobinization is sufficient. Normal platelets and single ovalocytes are present.

1. microcyte   2. normocyte

Variation in erythrocyte color
Variation in erythrocyte color

  • A normal erythrocyte has a pinkish-red color with a slightly lighter-colored center (central pallor) when stained with a blood stain, such as Wright.

  • The color of the erythrocyte is representative of hemoglobinconcentration in the cell.

  • Under normal conditions, when the color, central pallor, and hemoglobin are proportional, the erythrocyte is referred to as Normochromic.


  • Increased central pallor and decreased hemoglobin concentration, the central pallor occupies more than the normal third of the red cell diameter.

    • Found in:

      • Iron deficiency

      • Thalassaemia

      • any of the conditions

        leading to Microcytosis


  • Red cells stain shades of blue-gray as a consequence of uptake of both eosin (by hemoglobin) and basic dyes (by residual ribosomal RNA). Often slightly larger than normal red cells and round in shape - round macrocytosis.

  • Found in:

    Any situation with reticulocytosis – for example bleeding, hemolysis or response to heamatinic factor replacement

Shape abnormalities of erythrocytes
Shape Abnormalities of Erythrocytes

  • Poikilocytosis is the general term for mature erythrocytes that have a shape other than the round, biconcave disk.

  • Poikilocytes can be seen in many shapes.(e.g. Acanthocyte, Spherocytosis,……)

Target cell
Target cell

Red cell with a “target” or bull’s-eye appearance. The cell appears with a central bull’s eye that is surrounded by a clear ring and then an outer red ring.

Found in:

  • Obstructive liver disease

  • Severe iron deficiency

  • Thalassaemia

  • Haemoglobinopathies (S and C)

  • Post splenectomy

    • Lipid disorders


Red cells are more spherical. Lack the central area of pallor on a stained blood film.

Found in:

  • Hereditary spherocytosis

  • Immune haemolytic anemia

  • Zieve's syndrome

  • Microangiopathic haemolytic


Red cells with a central linear slit or stoma. Seen as mouth-shaped form in peripheral smear.

Found in:- Alcohol excess- Alcoholic liver disease- Hereditary stomatocytosis

Ovalocyte :

  • An elongated oval cell. They are a result of a membrane defect.

    Found in:

    • Thalassaemia major.

    • Hereditary ovalocytosis.

    • Sickle cell anemia


The red cells are oval or elliptical in shape. Long axis is twice the short axis.

Found in:- Hereditary elliptocytosis- Megaloblastic anemia- Iron deficiency - Thalassaemia- Myelofibrosis


  • red cell fragments that are irregular in shape and size. They are usually half the size of the normal RBC; therefore, they have a deeper red color.

  • Found in:

    • DIC

    • Micro angiopathic haemolytic anemia

    • Mechanical haemolytic anemia

Blister cell pre keratocyte
Blister cell: pre keratocyte

Have accentric hallow area. Resemble a women's handbag and may be called pocket-book cell.

Found in:

Microangiopathic hemolytic anemia

Keratocytes horn cell
Keratocytes (horn cell)

Part of the cell fuses back leaving two or three horn-like projections. The keratocyte is a fragile cell and remains in circulation for only a few hours.

Found in:- Uraemia- Severe burns- EDTA artifact- Liver disease

Also called helmet cells

Degmacyte bite cell
Degmacyte "bite cell"

  • An abnormally shaped red blood cell with one or more semicircular portions removed from the cell margin.

  • These "bites" result from the removal of denatured hemoglobin by macrophages in the spleen.

  • Found In:

    • G-6-PD deficiency, in which uncontrolled oxidative stress causes hemoglobin to denature and form Heinz bodies, is a common disorder that leads to the formation of bite cells

Sickle cells
Sickle Cells:

Sickle shaped red cells

Found in:

Hb-S disease and trait

Echinocyte burr crenation cell
Echinocyte“Burr” (crenation ) cell:

Red cell with 30 or more, short blunt projections which are regularly distributed on their surface

Found in:

Usually artifactual— the result of slow drying under humid conditions.

Sometimes are non - artifactual, indicating uremia or pyruvatekinase deficiency.

  • Hemolytic anemia

  • Uremia.

  • Megaloblastic anemia

    Cells retain the central pallor.

Acanthocytosis spur cells
Acanthocytosis (Spur Cells):

Red blood cells with irregularly spaced projections, these projections very in width but usually contain a rounded end

Found in:- Liver disease - Post splenectomy- Anorexia nervosa and starvation

Dacryocytes teardrop
Dacryocytes (Teardrop):

  • Resembles a tear and usually smaller than the normal RBC.

    Found in:

  • Bone marrow fibrosis

  • Megaloblastic anemia

  • Iron deficiency

  • Thalassaemia

Envelope form cell
Envelope form cell

  • Found in

    • Thalassaemia

    • Sickle cell anemia

Howell jolly bodies
Howell-Jolly Bodies:

Small round cytoplasmic red cell inclusion with same staining characteristics as nuclei

  • Found in:

    • Post splenectomy

    • Megaloblastic anemia

Siderotic granules pappenheimer bodies
Siderotic Granules (Pappenheimer Bodies)

These are iron containing granules in red blood cells that are seen because the iron is aggregated with mitochondria and ribosomes. They appear as faint violet or magenta specks, often in small clusters, due to staining of the associated protein.

They are associated with severe anemias and thalassemias. Pappenheimer bodies can be increased in hemolytic anemia, infections and post-splenectomy.

Basophilic stippling
Basophilic stippling:

Considerable numbers of small basophilic inclusions in red cells.

Found in:- Thalassaemia- Megaloblastic anemia- Hemolytic anemia - Liver disease- Heavy metal poisoning.

Heinz bodies
Heinz Bodies:

Represent denatured hemoglobin (methemoglobin - Fe+++) within a cell.

With a supravital stain like crystal violet, Heinz bodies appear as round blue precipitates.

Presence of Heinz bodies indicates red cell injury and is usually associated with G6PD-deficiency.

Practical of clinical hematology

Heinz Body Preparation. RBC are incubated supravitally in new Methylene blue to identify precipitates of oxidatively denatured hemoglobin.

Cabot rings
Cabot Rings:

Reddish-blue threadlike rings in RBCs of severe anemia's. These are remnants of the nuclear membrane or remnants of microtubules and appear as a ring or figure 8 pattern.

  • Very rare finding in patients with

  • Megaloblastic anemia.

  • severe anemia's.

  • lead poisoning.

  • Dyserythropoiesis.

A - Cabot ringB - Howell-Jolly body

Parasites of red cell
Parasites of Red Cell:

  • Two organisms are have a tendency to invade the RBCs.

  • All 4 species of the malaria parasite will invade RBCs. We will see the Plasmodium of different species in RBCs.

  • Theileriamicroti (Bebesiamicroti)

Rbcs abnormal morphology
RBCs Abnormal morphology

Depiction of red blood cell morphologies that may appear on a peripheral smear, showing:

  • basophilic stippling,

  • Howell-Jolly bodies,

  • Cabot's ring bodies and

  • Heinz's bodies.

Iron deficiency anemia
Iron Deficiency Anemia

Severe Hypochromia

Alpha thalassaemia a
Alpha Thalassaemia (a-/--)

Microcytic Hypochromia

Morphologic changes in liver disease
Morphologic Changes in Liver Disease

Target Cells

Spur Cells

Hepatorenal syndrome
Hepatorenal Syndrome

Burr + Spur Cells