HEMATOLOGY| RBC MORPHOLOGY DATE: 08 / 21 / 24

LESSON 3 | PRELIM

RED BLOOD CELL - associated with decreased hemoglobin

synthesis
• Also known as erythrocytes
- can be seen in ATIS (Anemia of chronic
• Mature RBCs measure 6.8 – 7.5 micrometers disease, Thalassemia, Iron deficiency
(average: 7.2 um diameter) anemia, Sideroblastic anemia)
• Thickness: 1.5 – 2.5 micrometers (average: 2 um)
• Shape: round, biconcave disc; discocyte
• Salmon pink with central pallor (1/3 diameter of the
cell)

RBC VARIATION 3. MACROCYTIC

- larger than normal RBCs
• The variation from normal red blood cell can be
- resulted from a defect in either nuclear
classified as:
maturation or stimulated erythropoiesis
o Variation in size
- can be seen in Megaloblastic anemia
o Variation in shape
o Variation in hemoglobin content
o Inclusion bodies
o Alteration in RBC distribution on PBS (peripheral
blood smear)

VARIATION IN SIZE VARIATION IN SHAPE

• Anisocytosis – a general term used in hematology to • Poikilocytosis – general term for mature
denote an increased variation in the size of the erythrocyte that have a shape other than the
RBCs normal round, biconcave appearance on a
o Normocytic – normal size stained blood smear
o Microcytic – smaller; lower MCV o Spherocyte
o Macrocytic – larger; higher MCV o Elliptocyte
▪ evaluate size variation using PBS, RBC o Codocyte
indices results (MCV (average: 80 – 100 o Echinocyte
fL), MCH, MCHC), RDW o Drepanocyte
o Schistocyte
1. NORMOCYTIC o Dacrocyte
- discocyte o Stomatocyte
- normal size of RBC o Acanthocyte
- same size as the nucleus of a small
lymphocyte 1. SPHEROCYTE
- Lacks central pallor
- Caused by a problem in the RBC
membrane protein (deficient in spectrin
protein)
2. MICROCYTIC - Associated with hereditary spherocytosis,
- smaller than normal size of RBC G6PD

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▪ Decreased surface volume ratio (how - seen in Liver disease, Uremia (high levels
much surface area is available of urea in blood, which is toxic), Pyruvate
compared to the cell size) Kinase deficiency
▪ can also be seen with artificially drying
of smears or overly dried smears

2. ELLIPTOCYTE
- aka ovalocyte
- appears cigar to egg shaped
- caused by defects of red cell membrane 5. DREPANOCYTE
- aka sickle cell
proteins
- seen in Hereditary Elliptocytosis, - thin, elongated, pointed ends or has a
Megaloblastic anemia, Thalassemia crescent shape
- polymerization of hemoglobin S (abnormal
hemoglobin)
- caused by cell membrane alteration due to
amino acid substitution
- seen in Hemoglobinopathies, Sickle cell
anemia
▪ prone to low oxygen levels and
decreased blood pH because these are
3. CODOCYTE
non-functional RBCs
- aka target cells, leptocytes
- darkly stained at the center with light
outer rim
- surface volume to ratio is excessive;
increased
- seen in Liver disease, Hemoglobinopathies,
Thalassemias
6. SCHISTOCYTE
- fragmented RBC with pointed projections
(due to ruptures)
- can be seen in MAHA (microangiopathic
hemolytic anemia), Uremia, DIC
(disseminated intravascular coagulation)

4. ECHINOCYTE
- aka crenated cell/sea urchin cell
- has regular spicules (consistent)
- caused by imbalance in the osmotic
pressure within the cell

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7. DACRYOCYTE VARIATION IN HEMOGLOBIN CONTENT
- Teardrop cell/pear-shaped with one blunt
• a normal RBC has a moderately pinkish-red
projection
appearance with a lighter-colored center
- Seen in Primary Myelofibrosis,
when stained
Thalassemia, Megaloblastic anemia
• The color in the middle reflects the
hemoglobin present in the cell
• Bigger central pallor: lower hemoglobin
content
• Smaller central pallor: higher hemoglobin
content
• Anisochromia – general term for a variation
8. STOMATOCYTE in the normal coloration of RBCs
- aka mouth cell o Normochromasia – normal
- slit-like central pallor o Hypochromasia – low hemoglobin
- caused by osmotic changes due to cation o Hyperchromasia – high hemoglobin
imbalance (Na+, K+)
▪ Hereditary Stomatocytosis (two types:
overhydrated, dehydrated)
▪ Overhydrated: increased Na+ inside the
cell (should be PISO)
▪ Dehydrated: decreased intracellular K+
▪ Blue-colored: polychromasia (RBC
- associated with Rh null (patients without
contains residuals of RNA; is
Rh antigen), Alcoholism, Severe liver
somehow immature; reticulocytosis)
disease
1. HYPOCHROMIA
- Central pallor exceeds 1/3 of the cell
diameter
- Associated with Iron deficiency anemia,
Thalassemia, Sideroblastic anemia)
- Low MCH, MCHC, and decreased red cell
size, low hemoglobin
9. ACANTHOCYTE
- aka thorny cells/spur cells
- irregular spicules (opposed to echinocytes)
- caused by excessive cholesterol in the
membrane
- associated with Abetalipoproteinemia, 2. HYPERCHROMIA
McLeod Syndrome, Alcoholic liver disease, - A condition wherein the red cells are
post-splenectomy deeply stained to abnormal thickness of
cells
- Can be seen in Macrocytosis,
Spherocytosis, Megaloblastic anemia

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3. HEINZ BODIES
- represent denatured and precipitated
hemoglobin
- must use supravital stain to visualize
- associated with G6PD deficiency,
Hemoglobinopathies, Beta thalassemia
major
ERYTHROCYTE INCLUSION BODIES
o Basophilic stippling
o Cabot rings
o Heinz bodies
o Howell Jolly bodies
o Pappenheimer bodies
o Parasitic inclusion in erythrocytes
▪ pitted golf ball appearance
▪ irregular granules (opposed to solid
1. BASOPHILIC STIPPLING
granules of Howell Jolly bodies)
- red cells have fine to coarse granular
4. HOWELL JOLLY BODIES
inclusion bodies evenly dispersed
- they are nuclear remnants predominantly
throughout the cell
compared of Heinz bodies
- visualized by Wright stain and Supravital
- round, solid staining, dark-blue to purple
stain (dark blue)
inclusion with Wright/Supravital stain
- can be seen in Lead Poisoning, Severe
- due to overstimulation of erythropoiesis
anemia
- can be seen in Hemolytic anemia,
megaloblastic anemia, Splenectomy,
Alcoholism

▪ blueberry-bagel appearance
2. CABOT RINGS
- appear as figure of eight, ringed shape,
loop shaped
- probably microtubules remaining from
mitosis (spindle remnants) ▪ remnants predominantly composed
- abnormal histone biosynthesis of DNA
- visualized by Wright/Supravital stain 5. PAPPENHEIMER BODIES
- can be seen in Pernicious anemia, Lead - aka siderotic granules
poisoning, Abnormal erythropoiesis - are dark-stained particles of iron,
visualized by means of Prussia blue (iron
stain)
- aggregates of iron, mitochondria, and
ribosomes
- associated with hemoglobinopathies, seen
after splenectomy, Sideroblastic anemia

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- normal in size of infected RBCs (young and
old)
- Maurer’s dots

CRYSTAL (addtl. lang daw)

• Hb C crystals - Plasmodium ovale

- Appear as rod-shaped, angular opaque - benign tertian malaria
structure within some RBCs - normal to slightly enlarged infected RBCs
- Associated with Hemoglobin C disease (young)
• Hb H bodies - Schuffner’s dots
- Precipitated bodies of polymers of beta
chain of Hb A

- Plasmodium vivax
- benign tertian malaria
- enlarged infected RBCs
- Schuffner’s dots

- Plasmodium malariae
- quartan malaria
- normal in size of infected RBCs (old)
- Ziemann’s dots
▪ Fuelgen only stains structure with
DNA content
6. PARASITIC INCLUSIONS
- Plasmodium falciparum
- malignant tertian malaria

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- Babesia microti 2. AGGLUTINATION
- infected RBCs are normal in size - no pattern of RBC clumping
- Maltese cross - due to reaction of red cells when coated
with antibodies

**NUCLEATED RBCs **Additional Notes (might be included sa

boards)
- Indicate bone marrow stimulation or
increased erythropoiesis
- Associated with Thalassemia major, Sickle
cell anemia, and other hemolytic anemias,
erythroleukemia, and myeloproliferative
disorders

ALTERATION IN RBC DISTRIBUTION

o Rouleaux formation
o Agglutination

1. ROULEAUX FORMATION
- stacked RBCs
- true rouleaux formation: even if washed
with saline and it keeps it’s stacked
formations
- associated with high protein levels
- pseudo rouleaux: can be washed with NSS

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