Terminology in Interpretation of

Red Blood Cell Morphology

Mag. Ljuba Krnjak, spec.med.biokem.,

Majda Piskar, univ.dipl.biol.
University Medical Centre Ljubljana
University Institute for Clinical Chemistry and
Biochemistry
Diagnostic technology in haematological
laboratory

• Evaluation of morphology of red blood cells

• Examination of peripheral blood film
• Prescribed terminology
• Understanding of results interpretation
 Erythrocytes

The total mass of erythropoietic cells and circulating erythrocytes

has been termed the ERYTHRON.
It may be viewed as a functional, though dispersed organ. Any
alteration in the synchronized sequence of maturation and
amplification gives rise to a defective erythrocyte.
 Characteristics of the erythrocyte
- red blood cell
• erythrocyte is non nucleated
cell, without endoplasmatic
reticulum, ribosomes and
mitochondries
• it contains haemoglobin
• life span is from 100 to 120
days
• erythrocytes in blood of
healthy people have fairly
uniform size with variation
approximately 5 %
 Structure of the erythrocyte membrane

Erythrocyte membrane has a high resistance and flexibility.

Erythrocyte can easily change his own shape and accommodate
to all barriers on his way over circulation of blood.
 The metabolism of the erythrocyte

Glucose is the normal energy source of the erythrocyte. The mature

red cell contents itself with extracting energy from glucose almost
solely by anaerobic glycolysis. In direct glycolytic pathway glucose
is catabolised anaerobically to pyruvate or lactate.
For erythrocytes we describe changes in

• size
• shape
• colour
• distribution
• presence of various inclusions
 Variation in size of erythrocytes
- anisocytosis
• the grade of anisocytosis is
determined by RDW – red
cell distribution width
• anisocytosis is frequent in
microcytic anaemias, iron
deficiency anaemia, aplastic
anaemia, sideroblastic and
megaloblastic anaemia,
thalassaemia major and minor,
acute leukaemias, polycythemias,
idiopathic myelofibrosis with
myeloid metaplasia (MMM)
 Normocytes

• normal adult red cells

• normal resting forms of
erythrocytes is a biconcave
disc, with diameter 7 - 8 µm
• on a stained blood film they
have a circular outline and
2-3 µm a central pale area
• Pappenheim stain - pink
colour
• Wright stain – reddish-
brown colour
 Microcytes
• red cells which are smaller than
normocytes, with diameter below
7 µm, round or spherical shape
• haemoglobin concentration is
normal or lower

• Associated disease states:

diminished synthesis of haemoglobin
because of iron deficiency,
changeable synthesis of globin in
thalassaemias, haemoglobinophatias,
unsufficient synthesis of porphyrins in
sideroblastic anaemia
 Macrocytes
• red cells which are bigger than
normocytes, with diameter above
8 µm and round or abnormal shape
• haemoglobin concentration is
normal or decreased, his distribution
can be abnormal

• Associated disease states:

liver disease, alcohol disease,
hypothyroidism, myelodysplasia,
aquired sideroblastic anaemia,
aplastic anaemia, raised reticulocyt
count, hypoxia, myeloma, cytotoxic
drugs
 Megalocytes
• red cells which are bigger than
normocytes, with diameter
12–15 µm and oval shape
• normal or increased filling with
haemoglobin, all surface is
normal coloured
• developed from megaloblast

• Associated disease states:

changeable synthesis of DNK
because of vitamin B12 or
folate deficiency –
megaloblastic anaemias
 Interpretation of the laboratory results

• Anisocytosis is described as:

mild (+)
well defined (++)
very well defined (+++)

• Presence of microcytes, macrocytes or megalocytes

is described as single, numerous and very numerous.
Variation in shape of erythrocytes
- poikilocytosis
 Variation in shape of erythrocytes
- poikilocytosis

• Echinocytes or burr cells

• Spherostomatocytes or spherocytes
• Codocytes or target cells
• Ovalocytes or elliptocytes
• Schizocytes or schistocytes or fragmented cells
• Acanthocytes or spur cells
• Dacryocytes or teardrops cells
• Stomatocytes or mouth cells
• Drepanocytes or sickle cells
 Echinocytes or burr cells
• spiculated RBC with 10 - 30
short, equally spaced
projections over entire surface

• Associated disease states:

uraemia, chronic kidney
disease, chronic kidney
destruction, liver carcinoma,
bleeding ulcer, pyruvate kinase
deficiency, low potassium,
post transfusion
• like artefact in coarse blood
smears and in smears with aged
blood
 Spherostomatocytes or spherocytes
• spherical RBC with dense
haemoglobin, without
a central pale area and
diminished diameter

• Associated disease states:

hereditary spherocytosis,
immune haemolytic anaemia,
Heinz body haemolytic
anaemia, post transfusion,
effect of bacterial toxins,
water dilution haemolysis,
splenectomia, fragmentation
haemolysis
 Codocytes or target cells

• contain a bright white centre,

encircled by a dark ring that
makes it look like a target

• Associated disease states:

obstructive liver disease,
obstructive hepatitis, chronic
liver disease, iron deficiency
anaemia, haemoglobinopathies
S,C, thalassemia, sideroblastic
anaemia, postsplenectomy
 Ovalocytes or elliptocytes

• oval to elongated ellipsoid cells

• normal is 1 % in blood of
healthy people

• Associated disease states:

hereditary elliptocytosis,
thalassemia, iron deficiency,
myelophthisic anaemias,
megaloblastic anaemias
 Schizocytes or schistocytes or fragmented
cells
• split RBC, helmet cell, half disc
shape with two or three pointed
extremities

• Associated disease states:

microangiopathic haemolytic
anaemia (TTP, DIC, vasculitis,
glomerulonephritis, renal graft
rejection), malignant arterial
hypertension, uraemia, heart
valve haemolysis, severe burns,
march haemoglobinuria
 Acanthocytes or spur cells
• irregular spiculated RBC
with projections of varying
lenght and position,
without a central pale area

• Associated disease states:

alcoholic liver disease,
hereditary abetalipoproteinemia,
haemolytic anaemia,
postsplenectomy, malabsorptive
states, anorexia nervosa,
starvation
 Dacryocytes or teardrops cells

• teardrops or a pear shape,

with a single, elongated or
pointed end
• Associated disease states:
MMM, perniciosus anaemia,
anaemia of renal disease,
myelophthisic anaemia,
thallasemia, some haemolitic
anaemias
• they may also be seen as an
artefact in slide preparation
 Stomatocytes or mouth cells
• single concavity with small
dimple, seen as smiling face
or mouth shaped cells

• Associated disease states:

hereditary spherocytosis,
hereditary stomatocytosis,
alcoholism, liver cirrhosis,
obstructive liver disease,
erythrocyte sodium
potassium pump defect
 Drepanocytes or sickle cells

• varying shapes from bipolar

spiculated forms to holly-
leaf and irregular forms
• cells containing polymerized
haemoglobin S

• Associated disease states:

sickle cell disorders (SS,
S, SC, SD, S- thalassemia),
haemoglobinopathy C -
Harlem, Memphis/S
 Interpretation of the laboratory results
• Poikilocytosis is decribed as:
mild
well defined
very well defined.

• Various shape of erythrocytes is described as single,

numerous and very numerous.
The reliability of the result is higher if the number of cells
counted is higher.
• Various shape of erythrocytes can be counted as well and
given as a number per 1000 of erythrocytes.
 Changes in the colour of erythrocytes

• Normochromia
• Hypochromia
• Hyperchromia
• Anisochromasia
• Polychromasia or polychromatophilia
 Hypochromia
• in the blood film we can find
hypochromic erythrocytes
which have a central pale
area more than a third of the
diameter
• Associated disease states:
iron deficiency anaemia
(anulocytes), thalassemias
(leptocytes), sideroblastic
anaemia, anaemias related to
chronic diseases, lead
poisoning anaemia
 Hyperchromia
• in the blood film we can find
hyperchromic erythrocytes which
lack a central pale area
• cells are more intensive stained
because of thickness of the red
cells
• Associated disease states:
macrocytosis in blood in
megaloblastic anaemias or
in a newborn
 Anysochromasia

• in the blood film we can find

cells which show a greater
than normal variation in the
degree of haemoglobin
concentration
• Associated disease states:
development of iron
deficiency anaemia and
chronic diseases related
anaemia
 Polychromasia or polychromatophilia

• in the blood film we can find

cells which have a blue or lilac
tinge
• they are strongly coloured with
eosin, but haemoglobin
concentration is normal
• Associated disease states:
megaloblastic anaemia,
haemolytic anaemia,
thallasemia major,
postsplenectomia
Interpretation of the laboratory results

• Hypochromia is described as:

mild, well defined, very well defined
• Hyperchromia is descibed as:
mild, well defined, very well defined
• Anysochromasia is described as:
mild, well defined, very well defined
• Polychromasia is described as:
mild, well defined, very well defined
 Dimorphic population of erythrocytes

• two very distinct populations of

erythrocytes might be noticed,
both can be normal althought
different in colour and size
• a distinction should be made
between anysochromasia and
dimorphic picture
• Interpretation of the laboratory
results :
dimorphic population of
erythrocytes
 Abnormality of distribution of red cells
in blood film
• Rouleaux formation
red blood cells sediment rapidly in
form into stacks or a linear fashion
• true rouleaux formation is due to
hyperproteinemia, primarily
fibrinogen and globulins

• Red cell agglutination

is caused by an antibody against a red
cell antigen
• the antibody coated red cells become
sticky and form into irregularly
shaped clumps or agglutinates
 Various pathological inclusion in red
blood cells
• Basophilic stippling
• Howell – Jolly bodies
• Cabot rings
• Nuclear dust
• Heinz bodies
• Pappenheimer bodies
• HbC crystal
 Basophilic stippling
• presence of small basophilic
inclusion distributed
throughout the red cell
• they represent abnormally
staining precipitates of RNA
in ribosomes
• Associated disease states:
thalassemia, aquired
sideroblastic anaemia,
megaloblastic anaemia,
lead poisoning,
pyrimidine 5-nucleotidase
deficiency
 Howell – Jolly bodies

• larger, round, densely staining

inclusion with diameter
0,5 - 1µm
• they are nuclear fragment
containing chromosomes
• Associated disease states:
postsplenectomia,
hemolytic anaemia,
hyposplenism,
megaloblastic anaemia
 Cabot rings

• the ring like figure, sometimes

twisted into a figure eight
• the origin of Cabot rings is not
known
• Associated disease states:
in erythrocytes and
reticulocytes in
megaloblastic anaemia
 Heinz bodies
• refractive inclusion of
denaturated haemoglobin in
erythrocytes and occasionally in
reticulocytes
• they appear as large, single or
multiple inclusion often
attached to the inner surface of
the membrane
• blood film must be stain with
Nile blue dyes
• Associated disease states:
hereditary haemolytic anaemia,
unstable haemoglobin,
defective glycolytic sistem
 Pappenheimer bodies

• small basophilic inclusion,

occurring in small numbers
towards the periphery of the
erythrocytes, reticulocytes
or occasionally within
orthochromic normoblasts

• they contain iron in “iron

bodies” or siderosomes.
Pappenheimer bodies are
siderosomes stained with
Wright stain
 Nuclear dust
• it breaks out after fragmentation
of the nucleus of a cell
undergoing programmed cell
death (karyorrhexis)
• it is usually preceded by
pyknosis (clumping and
condensation of chromatin in
the nucleus
• Associated disease states:
it reflects in severe anaemias
 HbC crystals

• crystals mostly have

rhomboid, tetragon or
stick shape

• Associated disease states:

post - splenectomia in
patients with haemoglobin
CC or SC
Interpretation of the laboratory results

• The number of erythrocytes with pathological inclusion

is described as: single, numerous and very numerous.

• Erythrocytes with basophilic stippling can be counted as

well and given as a number per 1000 of erythrocytes.
 Parasites in erythrocytes
• Malaria – genus Plasmodium
Plasmodium vivax,
Plasmodium falciparum
Plasmodium malariae,
Plasmodium ovale
• Babesiosis – genus Babesia
• Bartonellosis - Bartonella bacilliformis

Interpretation of the laboratory results:

• Result is given as: 1 (positive) and type of parasite or
0 (negative).
Babesiosis – Bartonellosis –
genus Babesia Bartonella bacilliformis
 Erythroblasts
• single erythroblast can be found in
a blood of healthy people, except
in a newborn
• Associated disease states:
haemolytic anaemias, haemolytic
uraemia syndrome, TTP, strong
bleeding, anaemias caused by
cancer diseases, chronic myeloid
leukaemia, myelofibrosis,
thallasemias
• erythroblasts have to be counted
beside leucocytes and are given as
a number per 100 of differentiated
leucocytes
 Reticulocytes
• cells without nucleus and central pale, round or oval shape
with size 8–10 µm
• larger and less dense than mature red cells
• content ribosomal RNA, golgi apparatus, mitochondria,
centrioles, ferritin molecules
• standard dye for microscopy reference measurement
procedures is “New Methylene blue”
• ↑ number is indicator for increased erythropoiesis – lose
of a blood, haemolyses, treatment of anaemias caused by
deficiency of iron, vitamin B12 or folate
• ↓ number is typical for diminish erythropoiesis in
anaemias without treatment and after bone marrow damage
Interpretation of the laboratory results
• the number of reticulocytes per 1000 erythrocytes is
counted
• in the frame of CBC number of erythrocytes is
determined, reticulocytes are counted and calculated per
concentration of erythrocytes in liter of blood

Pappenheim New Methylene blue

 Conclusion
• morphology of red blood cells can only be interpreted by a
laboratory expert with a lot of experience in preparation of
blood films as well as in evaluation and recognition of all
cells present in blood film
• result of haematological analysis must give exact data on all
normal and abnormal cells
• for correct interpretation of the results close collaboration
of laboratory specialist in medical biochemistry and medical
doctor is essential
• only in this way a patient can receive appropriate help by
diagnosis of his disease and by continuous control of the
result of his therapy
Thank you for your attention