http://sun025.sun.ac.za/portal/page/portal )Platelet Morphological abnormalities

	Platelet Satellitism Morphology: Platelets clumped around neutrophils. Found in: EDTA in vitro induced change of no clinical significance except false low platelet count (in vitro).
	Giant Platelets Morphology: Platelet larger than a normal red cell. Found in: Increased platelet turnover Myeloproliferative disorders Myelodysplastic disorders
	Large Platelets Morphology: Large platelets - larger than one third but less than the size of a red cell. Found in: Increased turnover of platelets Myeloproliferative disorders Myelodysplastic disorders May Hegglin anomaly Grey platelet syndrome Bernard Soulier
	Micro Clots Morphology: Fibrin strands, platelets and white cells (in this case - neutrophils) clumped together. Found in: In vitro artefact caused by poor venesection technique Leads to false low counts - can influence white cell, red cell and platelet counts
	Platelet Clumping Morphology: Small clumps of platelets. Found in: In vitro artefact caused by EDTA or cold and leads to false low platelet count Difficult venesection
	Wiskott Aldrich Syndrome Morphology: Small platelets. Found in: Wiskott Aldrich syndrome
	Grey Platelet Syndrome Morphology: Platelets appear degranulated. Found in: Grey platelet syndrome Discharge of platelet granules in vivo (cardiopulmonary bypass, hairy cell leukemia) Discharge of platelet granules in vitro (poor venesection technique)

WBC Morphology(http://sun025.sun.ac.za/portal/page/portal

		Drumstick Morphology: Drumstick shaped nuclear appendage. ± 1,5 µm in diameter and attached to the nucleus by a filament. Inactive X chromosome of the female. Found in: Neutrophils of females Males with Klinefelter syndrome
		Sessile Nodule Morphology: Inactive X chromosome found as nodule on neutrophils of females. Found in: Neutrophils of females
		Hypersegmentation or right shift of neutrophil nuclei Morphology: Average lobe count increased OR increased % of neutrophils with 5 - 6 lobes OR > 3% neutrophils with 5 lobes or more. Found in: Megaloblastic anaemia Iron deficiency Chronic infection Liver disease Uraemia Hereditary
		Ring shaped nuclei Morphology: Nucleus ring or doughnut shaped Found in: Acute myeloid leukemia Chronic granulocytic leukaemia Megaloblastic anaemia MDS
		Detached nuclear fragments Morphology: Detached nuclear material in cytoplasm. Found in: Dysgranulopoiesis Patients on anti cancer chemotherapy HIV
	<	MPO deficiency Morphology: Neutrophils appear normal on Romanowsky stain but are not counted as neutrophils by the cell counters employing a myeloperoxidase stain. Found in: Inherited Refractory anaemia Blast crisis of CML
		Toxic Granulation Morphology: Increased granulation. Granulation more basophilic and larger than normal. Found in: Severe bacterial infection Non specific finding - seen in tissue damage of various types. Normal pregnancy Therapy with cytokines
		Hypogranulation Morphology: Reduced granulation in neutrophil cytoplasm. Found in: Myelodysplastic syndromes
		Vacuoles Morphology: Vacuoles in the cytoplasm of granulocytes Found in: Infection Toxic effect of ethanol Jordan's anomaly
		Döhle Bodies Morphology: Small pale blue cytoplasmic inclusions, often in the periphery of the cell. Found in: Infective and inflammatory states Severe burns Tuberculosis Post chemotherapy Pregnancy
		Phagocytosed Parasites Morphology: Malaria - Plasmodium falciparum Found in: Severe malaria infection
		Phagocytosed Organisms Morphology: DF2 organism. Rod shaped organism in vacuoles in cytoplasm of neutrophils Found in: Dog bite
		Phagocytosed Platelet Morphology: Platelet in vacuole in neutrophil cytoplasm Found in Infection
		Phagocytosed Red blood cell Morphology: Red cell in vacuole in cytoplasm of neutrophil Found in: Infection Auto immune haemolytic anaemia Incompatible blood transfusion
		Auer Rods Morphology: Small azurophil rods in the cytoplasm of myeloblasts and promyelocytes. Sometimes found in mature neutrophils Found in: Acute myeloblastic leukemia Myelodysplastic syndromes
		Macro Neutrophils Morphology: Twice the size of a normal neutrophil with tetraploid DNA content. Found in: Occasionally in the blood of healthy subjects Inherited Administration of G-CSF Megaloblastic anaemia Chronic infection
		Necrobiotic / Apoptotic neutrophil Morphology: Dense homogenous nuclei (pyknotic) Found in: Occasionally in healthy subjects In vitro artefact AML
		Shift to the Left Morphology: Presence of precursor of granulocytes in the peripheral blood Found in: Normal in pregnancy or neonate Infections Bone marrow fibrosis Bone marrow infiltration by malignancies
		Pseudo Pelger Hüet Anomaly Morphology: Bilobed neutrophils with more condensed chromatin. Found in: Inherited Myelodysplastic syndromes Idiopathic myelofibrosis Chronic granulocytic leakaemia Therapy with colchicine, iboprofen Infectious mononucleosis, malaria, myxoedema CLL
		Neutrophil aggregation Morphology: Small clumps of neutrophils. Happens in vitro if EDTA anticoagulated blood is allowed to stand. May lead to incorrect WBC Found in: In vitro finding Infectious mononucleosis Bacterial infections Auto immune disease

EOSINOPHILS:

	Eosinophilia Morphology: Increase in number of eosinophils in peripheral blood Found in: Parasitic infections Allergic reactions Drug hypersensitivity Hodgkin's disease
	Left shift: Eosinophil Morphology: Eosinophil metamyelocyte in peripheral blood Found in: Reactive eosinophila Myeloproliferative disorders AML

BASOPHILS:

Basophilia Morphology Increase in the neumber of basophils in the peripheral blood. Found in: Myeloproliferative disorders Myxoedema Ulcerative colitis Hyperlipidaemia

LYMPHOCYTES:

	Atypical Lymphocytes Morphology: Pleomorphic. Large with diameter of 15 - 30 µm. Abundant, strongly basophilic cytoplasm. Basophilia may be confined to the cytoplasmic margins. Found in: Viral infections - EBV, CMV, Hep A, Measles Bacterial infections - brucella, tuberculosis Protozoa - malaria Immunization SLE
	Plasmacytoid Lymphocyte Morphology: Lymphocyte with basophilic cytoplasm and eccentric nucleus. Found in: Reactive phenomenon
	Mott cell Morphology: Plasmacytoid lymphocyte with globular inclusions composed of immunoglobulin. Found in: Reactive changes in peripheral blood
	Large Granular Lymphocyte Morphology: Small eosinophilic granules in the cytoplasm of large lymphocytes Found in: Natural killer cells Lymphokine activated T cells

MONOCYTES:

Monocyte Vacuolization Morphology: Vacuoles in the cytoplasm of monocytes Found in: Infections

RBC Morphology (http://sun025.sun.ac.za/portal/page

Hypochromasia Morphology: Increase in the red cells' central pallor which occupies more than the normal third of the red cell diameter. Found in: Iron deficiency Thalassaemia And any of the conditions leading to microcytosis

 

		Hypochromasia Morphology: Increase in the red cells' central pallor which occupies more than the normal third of the red cell diameter. Found in: Iron deficiency Thalassaemia And any of the conditions leading to microcytosis
		Polychromasia Morphology: Red cells stain shades of blue-gray as a consequence of uptake of both eosin (by haemoglobin) 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, haemolysis or response to haematinic factor replacement.
l		Anisocytosis Morphology: An increase in the variability of red cell size.Variation in erythrocyte size is now measured by the red cell distribution width (RDW). Always take the RDW into acount when interpreting the mean corpuscular volume (MCV).
		Microcytosis Morphology: Decrease in the red cell size. Red cells are smaller than ± 7µm in diameter. The nucleus of a small lymphocyte (± 8,µm) is a useful guide to the size of a red cell. Found in: Iron deficiency anaemia Thalassaemia Sideroblastic anaemia Lead poisoning Anaemia of chronic disease
		Macrocytosis Morphology: Increase in the size of a red cell. Red cells are larger than 9µm in diameter. 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)
		Dimorphic Blood Picture Morphology: Two distinct populations of red cells.The populations may differ in size, shape or haemoglobin content. Found in: Anaemic patient after transfusion Iron deficiency patient's taking supplements Combined B12 / folate and iron deficiency Sideroblastic anaemia
		Spherocytosis Morphology: Red cells are more spherical. Lack the central area of pallor on a stained blood film. Found in: Hereditary spherocytosis Immune haemolytic anaemia Zieve's syndrome Microangiopathic haemolytic anaemia.
		Stomatocytosis Morphology: 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 Hereditary spherocytosis
		Acanthocytosis Morphology: Spherical cells with 2 - 20 spicules of unequal length and distributed unevenly over the red cell surface. Found in: Liver disease Post splenectomy Anorexia nervosa and starvation
		Target Cells Morphology: Red cells have an area of increased staining which appears in the area of central pallor. Found in: Obstructive liver disease Severe iron deficiency Thalassaemia Haemoglobinopathies (S and C) Post splenectomy
		Elliptocytosis Morphology: The red cells are oval or elliptical in shape. Long axis is twice the short axis. Found in: Hereditary elliptocytosis Megaloblastic anaemia Iron deficiency Thalassaemia Myelofibrosis
		Cigar Cells Morphology: Red cells shaped like a cigar or pencil Found in: Iron deficiency
		Schistocytosis Morphology: Fragmentation of the red cells. Found in: DIC Micro angiopathic haemolytic anaemia Mechanical haemolytic anaemaia
		Echinocytes Morphology: Red cells are covered with 10 - 30 short spicules of regular form. Found in: Uraemia Severe burns EDTA artefact Liver disease
		Sickle Cells Morphology: Sickle shaped red cells Found in: Hb-S disease
		Tear Drop Cells Morphology: Red cells shaped like a tear drop or pear Found in: Bone marrow fibrosis Megaloblastic anaemia Iron deficiency Thalassaemia
		Rouleaux Formation Morphology: Stacks of RBC's resembling a stack of coins Found in: Hyperfibrinogenaemia Hyperglobulinaemia
		Red cell-agglutination Morphology: Irregular clumps of red cells Found in: Cold agglutinins Warm auto immune haemolysis
		Howell-Jolly Bodies Morphology: Small round cytoplasmic red cell inclusion with same staining characteristics as nucleus. Found in: Haemolytic anaemias Post splenectomy Megaloblastic anaemia
		Malaria Parasities Plasmodium falciparum Morphology: Ring form of Pl falciparum in red cells. Delicate rings with 1 or 2 chromatin dots. Often more than one ring in a red cell. Accolé forms are found. Found in: Malaria
		Basophilic stippling Morphology: Considerable numbers of small basophilic inclusions in red cells. Found in: Thalassaemia Megaloblastic anaemia Haemolytic anaemia Liver disease Heavy metal poisoning

Leucoerythroblastic blood film due to metastatic malignant melanoma in the bone marrow

From ^1William Gordon, ^2Mark McColl and ^2Julie Gillies, Departments of Haematology, ^1South Glasgow University Hospitals NHS Trust and ^2Crosshouse Hospital, Kilmarnock, Ayrshire, [e-mail]

A 40-year-old female presented with weight loss and fatigue. A widespread rash consisting of black palpable nodules was noted. One year previously a localised nodular malignant melanoma had been excised (Breslow thickness < 1 mm). Six weeks previously two further lesions were excised. FBC showed Hb 100 g/l, WBC 5 x 10^9/l, platelets 8 x 10^9/l. A blood film was leucoerythroblastic. Bone marrow aspiration confirmed >95% infiltration with apparently undifferentiated blast cells. Immunophenotyping using APAAP on marrow and peripheral blood with monoclonal antibodies hmb45, S100, and tyrosinase confirmed marrow infiltration and involvement of peripheral blood. Malignant melanoma accounts for 2% of all cancers and results in 65% of all skin cancer deaths. Patients with metastatic malignant melanoma have a poor prognosis, (median survival 4-12 months). Circulating malignant cells are thought to be precursors of distant metastases and hence markers of a poor clinical outcome. Reverse transcription-polymerase chain reaction (RT-PCR) for the measurement of specific mRNAs has made it possible to detect very small amounts of mRNA from malignant melanoma cells in the peripheral blood. However, it is highly unusual to detect circulating melanoma cells in sufficient numbers to be detectable by immunocytochemistry

Three step cytogenetic evolution in paediatric acute lymphoblastic leukaemia with t(12;21)

A 6-year-old girl presented with pancytopenia, hepatomegaly and raised lactate dehydrogenase to 821 iu/l in January 2010. Flow cytometric analysis of the bone marrow demonstrated 95% blast cells expressing CD10, CD19, CD34 and terminal deoxynucleotidyl transferase and a diagnosis of precursor-B-cell acute lymphoblastic leukaemia (ALL) was thus made. Interphase fluorescence in situ hybridization (i-FISH) on bone marrow cells revealed t(12;21)(p13;q22) translocation (ETV6-RUNX1 gene fusion). The ALL IC BFM 2002 protocol was administered; the patient achieved complete remission at day 15 and she has remained in remission.
Various abnormal signal patterns of FISH probe for t(12;21) were observed in interphase nuclei at diagnosis indicating additional chromosomal aberrations affecting ETV6 and RUNX1 genes and revealing a three-step clonal evolution process.

Fig. 1 FISH labelling created 2 green (ETV6, 12p13) and 2 red (RUNX1, 21q22) signals in normal nuclei (A). Balanced translocation resulted in a 1F2R1G (1 fusion, 2 red, 1 green) signal pattern (B), furthermore a third red signal (full pattern: 1F3R1G) proved the presence of an extra copy of RUNX1 allele in some translocation-positive cells (C). Loss of a single green spot showed that the unaffected ETV6 allele has been deleted in the last step of process (D). The proportion of cell populations from A to D were 2%, 42%, 3% and 53%, respectively.

Coexisting beta thalassaemia trait and acute haemolysis due to glucose-6-phosphate (G6PD) deficiency
Dr Abbas Hashim Abdulsalam and Dr Nafila Sabeeh, Pathology Laboratory, Al-Yarmouk Teaching Hospital, Bagdad, Iraq, [e-mail], edited by Barbara Bain.

Case reports and images

An 18-month-old Iraqi boy present with the acute onset of anaemia. He had a family history of beta thalassaemia trait. WBC and platelet count were normal, Hb was 60 g/l and haematocrit 0.17 l/l. His blood film showed hypochromic microcytes, target cells, irregularly contracted cells (Figure 1), keratocytes (Figure 2), polychromatic macrocytes, nucleated red blood cells, basophilic stippling and occasional Howell-Jolly bodies. The reticulocyte count was 25% (Figure 3) and some Heinz bodies were present. A methaemoglobin reduction test showed G6PD deficiency. Haemoglobin A₂ was 5.4%.

Fig. 1 Blood film showing irregularly contracted cells, hypochromia, microcytosis and polychromatic cells

Fig. 2 Blood film showing (in the centre from above down) a keratocyte, a polychromatic macrocyte and an irregularly contracted cell.  Hypochromia and microcytosis are also apparent.

Fig. 3 Reticulocyte preparation showing marked reticulocytosis.

ISLH congress 2011 Marriott New Orleans

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XXIst Regional Congress of the ISBT

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