Hematology

1. WBCs &PLT Abnormal
Morphology

2. 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).

3. 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

4. Giant Platelets
Morphology
Platelet larger than a normal
red cell.
Found in
 Increased platelet turnover
 Myeloproliferative disorders
 Myelodysplastic disorders

5. Micro Clots
Morphology
Fibrin strands, platelets and white
cells (in this case - neutrophils)
clumped together.
Found in
In vitro artifact caused by poor
venesection technique leads to
false low counts - can influence
white cell, red cell and platelet
counts

6. Platelet Clumping
Morphology
Small clumps of platelets.
Found in
 In vitro artifact caused
by EDTA or cold and
leads to false low
platelet count.
 Difficult venesection

7. Wiskott Aldrich Syndrome
Morphology
Small platelets.
Found in
 Wiskott Aldrich syndrome

8. 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)

9. Abnormal WBCs

10. Abnormalities other than leukemia and lymphoma
• SMUDGE CELL
- Nuclear remnants of
lymphoid cells
- “thumb prick”
appearance
- May be seen normally
due to forceful
smearing or in CLL

11. Hypersegmented neutrophils
- 5-10 nuclear lobes
- Macropolycytes or PA
cells
- Vitamin B12 or B9
def. (megaloblastic
anemia

12. Pelger-huet anomaly
- Inherited condition
characterized by
neutrophils with
dumb bell shape
nucleus or PINCE-
NEZ appearing
nucleus or
spectacle
appearing nucleus
- Has no pathologic
consequence;
normal function

13. LE cell
- Usually neutrophils that
has ingested round
globular nuclear mass of a
destroyed cell
- In vitro phenomenon
Rosettes form
L.E.Cell

14. Rieder cell
- Lymphocyte with a clover leaf-like nucleus
- Seen in chronic lymphocytic leukemia
Flame cell
• Thesaurocyte
• Abnormal plasma cell with intensely eosinophilic
cytoplasm
• Seen in IgA myelomas

15. Grape cell
• Morula cell/Mote cell
• Abnormal plasma cell whose cytoplasm is completely
filled with Russel bodies
• Seen in multiple myeloma
Alder-Reilly bodies
• Dense azurophilic granules which may be seen in all
types of leukocytes
• Abnormal deposition of mucopolysaccharide
• Seen in mucopolysaccharidoses

16. Russell bodies
Morphology
are eosinophilic, large,
homogenous immunoglobulin-
containing inclusions
Found in
a plasma cell undergoing excessive
synthesis of immunoglobulin; the
Russell body is characteristic of the
distended endoplasmic reticulum
This is one cell variation found
in multiple myeloma.

17. Chediak-Steinbrink-Higashi Anomaly
Chediak-Higashi syndrome
(CHS) is a rare autosomal
recessive disorder
characterized by recurrent
pyogenic infections, partial
oculocutaneous albinism,
progressive neurologic
abnormalities, mild coagulation
defects.

18. Gaucher disease
• With eccentric nucleus “Crumpled Tissue paper cytoplasm”
• Most common type class of lipidosis
• Defective in B-glucocerebrosidase
• Abnormal cell seen: Gaucher cell
Niemann-Pick Disease
• Deficient in acid sphingomyelinase
• FOAM CELLS: macrophage whose cytoplasm is swollen by
many small lipid droplet

19. Hairy cells
• Abnormal lymphocytes with little
cytoplasmic projections
• Seen in Hairy cell leukemia
• TRAP (+)
Tart cell
• Monocytes that has ingested a whole
lymphocyte or a nucleus which has
an identifiable nuclear chromatin
• Seen in “Drug sensitivity”

20. Toxic Granulation
Morphology
Increased granulation. Granulation more
basophilic and larger than normal.
• Stain dark blue-black after Wright
stain
Found in
 Lead Poisoning
 Severe bacterial infection.
 Non specific finding - seen in tissue
damage of various types.
 Normal pregnancy.
 Therapy with cytokines

21. Auer Rods
Morphology
Small azurophil rods in the
cytoplasm of myeloblasts and
promyelocytes. Sometimes found
in mature neutrophils.
• Linear projections of primary
granules
• FAGGOT CELLS: cells
containing bundles of Auer
rods
Found in
 Acute myelocytic leukemia.
 Myelodysplastic syndromes.

22. Popcorn cells
• Seen in Nodular Lymphocyte Predominant Hogdkin’s
Lymphoma
Reed-Sternberg cells
• Owl’s eye appearance
• Seen in classical Hodgkin’s lymphoma
Lacunar Cells
• Characterized by lobated nucleus and artefactual
retraction of the cytoplasm
• Seen in Nodular Sclerosis

23. Sezary cells
• Are cells of lymphocytic origin characterized by
cerebriform nucleus
• Seen in Mycosis fungoides
Lazy Leukocyte syndrome
• Characterized by neutrophils that poorly respond to
chemotactic agents
Job Syndrome
• Characterized by neutrophils with poorly directional
motility but still respond to neutrophils

24. Jordan’s anomaly
• Characterized by granulocyte and monocyte with fat
containing vacuoles
• Seen in Muscle Dystrophy, Ichtiosis
Chronic granulomatous disease
• Phagocyte fail to produce superoxide and reactive
oxygen species
• Patient have frequent bacterial and fungal infections
• Tested through:
• Chemiluminescence
• Nitroblue tetrazolium test

25. 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

26. Ring shaped nuclei
Morphology
Nucleus ring or doughnut shaped.
Found in
 Acute myeloid leukemia
 Chronic granulocytic leukaemia
 Megaloblastic anaemia
 MDS

27. Hypogranulation
Morphology
Reduced granulation in neutrophil cytoplasm.
Found in
 Myelodysplastic syndromes

28. Dohle Bodies
Morphology
Small pale blue cytoplasmic
inclusions, often in the periphery of
the cell.
Consist of ribosomes and endoplasmic
reticulum
Found in
 Infective and inflammatory states.
 Severe burns
 Tuberculosis
 Post chemotherapy
 Pregnancy
 May-Hegglin Anomaly

29. May-Hegglin Anomaly
• Characterized by granulocytes with spindle-shaped
inclusion which are PAS negative
• Patients have giant hypogranular platelets

30. DOHLE
BODIES
MAY-
HEGGLIN
ANOMALY
INCLUSION
PAS rxn (+) (-)
Shape round Spindle
shape
Size Smaller Larger than
Dohle bodies
RNA type Ribosomal
RNA
Messenger
RNA

31. Phagocytosed Parasites
Morphology
Malaria - Plasmodium falciparum
Found in
 Severe malaria infection

32. Phagocytosed Platelet
Morphology
Platelet in vacuole in neutrophil cytoplasm
Found in
 Infection

33. Phagocytosed Red blood cell
Morphology
Red cell in vacuole in cytoplasm of neutrophil
Found in
 Infection
 Auto immune haemolytic anaemia
 Incompatible blood transfusion

34. 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

35. 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.

36. Pseudo Pelger Huet Anomaly
Morphology
Bilobed neutrophils with more condensed chromatin
Found in
 Inherited Myelodysplastic syndromes.
 Idiopathic myelofibrosis.
 Chronic granulocytic leukemia.
 Therapy with colchicine, ibuprofen.
 Infectious mononucleosis, malaria, myxedema.
 CLL

37. 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.

38. 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.

39. Mott cell
Morphology
Plasmacytoid lymphocyte with globular inclusions
composed of immunoglobulin.
Found in
 Reactive changes in peripheral
blood.

40. Large Granular Lymphocyte
Morphology
Small eosinophilic granules in the cytoplasm of large
lymphocytes.
Found in
 Natural killer cells.
 Lymphokine activated T cells.

41. Monocyte Vacuolization
Morphology
Vacuoles in the cytoplasm of monocytes.
Found in
 Infections

42. GENERAL OVERVIEW
OF LEUKEMIA AND
LYMPHOMA

43. Leukemia
• Malignant neoplasm of the blood-forming tissues of the
bone marrow, spleen, and lymph system
• General rule: more blasts  shorter, more fatal course
of disease
• Increase WBC count with shift to the left
• With M:E ratio of 10:1
• FAB Classification:
• Based on morphology of cells in Romanowsky-
stained smear
• Based on cytologic and histochemical characteristics
of cells involved

44. Lymphocytic leukemia
• ACUTE LYMPHOCYTIC LEUKEMIA (ALL)
• Classifications
• By French, American, British Cooperative Group
(FAB)
Type of ALL Comments
L1 Generally has the best prognosis
Reported to have a strongly positive
reaction with PAS
L2 Weakly positive with PAS
L3 Generally has the poor; Oil Red O
positive

45. •
Small lymphoblast
•
Nucleus~ Homogeneous
•
Nucleoli~ Not clear
•
Medium to large
lymphoblast
•
Nucleus~May found
not round
•
Large lymphoblast
•
Cytoplasm~Basophilia
& vacuoles

46. • By the use of immunologic markers
E rosettes Surface Ig Serum
Anti-ALL
T-ALL + - -
B-ALL - + -
Common
ALL
- - +
Null ALL - - -

47. Chronic Lymphocytic Leukemia (CLL)
• Disease primarily affecting old men greater than 50
years old
• In the peripheral blood smear: characterized by
persistent lymphocytosis, presence of large amounts of
Smudge cells and Rieder cell

48. Non-Lymphocytic Leukemias
• ACUTE MYELOGENOUS LEUKEMIAS
SUBGROUP ORIGIN REMARKS
M0 Myelocytic
M1 Myelocytic Acute Myelocytic Leukemia w/o maturation
M2 Myelocytic AML with maturation
M3
**M3V
Myelocytic
Myelocytic
M4
**M4E
Myelocytic
Monocytic

49. M5
**M5a
**M5b
Monocytic
M6 Erythrocytic
Myelocytic
M7 Megakaryocytic

50. Acute Myeloblastic Leukemia
(with Minimal Maturation)

51. Acute Myeloblastic
Leukemia (with Maturation)
Myeloblast with azurophilic granules

52. Acute Promyelocytic
Leukemia
•
Found hypergranular with
Auer rods (Faggot’s) in
promyelocytes
•
Promyelocytes > 50 %
Promyelocyte ~granules
•
Nucleus ~ bilobes or
multilobes like monoblast

53. Acute Myelomonocytic
Leukemia
•
Myeloblasts 30 - 80 %
•
Monoytic cells > 20 %
•
May found Auer rod
•
Blast cell found in form of
Increased marrow
eosinophils

54. Acute Monoblastic Leukemia
(without Maturation)
•
Found Monoblasts >80 %
•
May found pseudopods
& granules
•
Found Monoblasts <80 %
•
Folded nucleus
•
Gray blue cytoplasm
•
Fine azurophilic granules
Acute Monoblastic Leukemia
(with Maturation)

55. Erythroleukemia
> 50 % Megaloblastoid
erythroid precursors
•
Found multinucleus
giant form
•
Found Myeloblasts >30 %

56. Acute Megakaryoblastic
Leukemia
•
Found Megakaryoblasts 20-30 %
•
Found Megakaryocytic fragments
•
BM.~ Fibrosis

57. Chronic Myelogenous Leukemia
• Characterized by the presence of Philadelphia
Chromosome

58. Leukemoid Reaction
• Excessive leukocytic response in the peripheral blood
• WBC ct greater than 50 x 109/L
• Leukemoid reaction may be differentiated from CML by:
• LEUKOCYTE (NEUTROPHIL) ALKALINE
PHOSPHATASE TEST
• Principle: increase LAP activity can be observed in
neutrophils that have undergone normal growth
• A smear is made from a drop of capillary blood and
then stained immediately
• Result: red, brown to black precipitate of alkaline
phosphatase activity in the cytoplasm of neutrophils

59. • 100 seg. neutrophils and bands are scored from 0 to 4+
based on stain intensity”
• 0: no red/brown to black precipitate
• 1+: slightly diffused to red/brown to black precipitate
• 2+: moderately diffused red/brown to black precipitate
• 3+: heavily diffused red/brown to black precipitate
• 4+: very heavily diffused red/brown to black
precipitate

60. • Normal Kaplow’s Score: 20-100
• Disorders with INCREASED KAPLOW’S (LAP) SCORE:
• Leukemoid reaction
• 3rd trimester pregnancy
• Polycythemia vera
• Intoxications
• Infections
• Disorders with DECREASED KAPLOW’S (LAP)
SCORE:
• Chronic Myelogenous leukemia
• Paroxysmal Nocturnal Hemoglobinuria
• Sideroblastic anemia
• Myelodysplastic disorders

61. Sample Problem:
Score No. of
Neutrophils
LAP Score
0 32
1+ 24
2+ 21
3+ 15
4+ 8
TOTAL 

62. Other factors that differentiate CML from LR
CML LEUKEMOID
REACTION
Leukocyte in the
peripheral blood
Usually
promyelocyte &
Blasts
Myelocyte
Toxic granulation Absent Present
Eosinophils/Basophils Increase Decrease
LAP Decrease Increase
Philadelphia
chromosome
Present Absent
Splenomegaly Present If present-mild
Platelet count Prominent Normal

63. LYMPHOMA
• Hodgkin’s Disease/Lymphoma
a. Nodular Lymphocyte Predominant
Hodgkin’s Lymphoma
b. Classical Hodgkin’s Lymhoma
1. Nodular Sclerosis
2. Mixed Cellulary
3. Lymphocyte Rich
4. Lymphocyte Depleted

64. • Non-Hodgkin’s Lymphoma
a. Burkitt’s Lymphoma
b. Cutaneous T cell lymphoma
1. Mycosis fungoides

65. CYTOCHEMISTRY
• Study of chemical constituents of cells
• Useful for acute leukemias
• Specimens: bone marrow lymph nodes,
peripheral blood
• For enzymatic technique: fresh smears
• For nonenzymatic technique (like PAS/SBB):
may remain stable for months if stored at room
temp.

66. Myeloperoxidase
• Enzyme found in primary granules of:
• Neutro and Eo
• Mono (to a certain extent)
• Used in differentiating blasts of AML from those of ALL
(+) peroxidase stain rules out ALL
• POSITIVE:
• Neutrophilic granuocytes (except normal blasts)
• Auer rods
• Leukemic blasts in FAB M1, M2 and M3
• WEAKLY POSITIVE OR NEGATIVE
• Monocytes
• NEGATIVE:
• Myeloblasts
• Basophils
• Lymphocytic cell series
• Erythrocytic cell series

67. Sudan Black B
• Reactions parallel to those of the MPOs
• Stains sterols, neutral fats, phospholipids (found in the primary and
secondary granules of neutrophils and lysosomal granules of
monocytes
• POSITIVE
• Promyelocyte, myelocyte
• Metamyelocytes, bands, and segmented neutrophils
• Leukemic blasts
• Auer rods
• Eosinophils
• WEAKLY POSITIVE OR NEGATIVE
• Myeloblasts
• Monocytic cells
• NEGATIVE
• Lymphocytes and its precursors
• Megakaryocytes and platelets
• Erythrocytes

68. Esterases
• Differentiate acute granulocytic leukemias
from monocytic leukemias
• SUBSTRATES:
• a-naphthyl acetate and a-naphthyl
butyrate (nonspecific)
• Naphthol AS-D Chloroacetate (specific)

69. a-naphthyl acetate esterase (NSE)
• POSITIVE:
• Monocytes (strong positive reaction)
• Positive for other certain cell types
• WEAKLY POSITIVE OR NEGATIVE
• Granulocytes
• Lymphoid cell (Lymphocytic cell lines)
• NEGATIVE
• Monocytes
• The nonspecific esterase enzymes alpha-naphthyl acetate
and butyrate esterase are used clinically to recognize cells of
monocytic origin. If the enzyme is of monocytic origin, it is
inhibited by sodium fluoride; however, no sodium fluoride
inhibition of enzyme occurs if the enzyme is of granulocytic
or lymphocytic origin.

70. a-naphthyl butyrate esterase (NSE)
• POSITIVE
• Monocytes
• Positive for other certain cell types
• WEAKLY POSITIVE OR NEGATIVE
• Granulocytes
• Lymphoid cells (Lymphocytes cell lines)
• NEGATIVE
• Monocytes (with NaF inhibition)

71. Naphthol AS-D Chloroacetate esterase
• POSITIVE:
• Promyelocyte, myelocyte, metamyelocyte, bands,
seg. Neutro
• Leukemic myeloblasts
• Auer rods
• WEAKLY POSITIVE OR NEGATIVE
• Monocytic cells
• NEGATIVE:
• Myeloblasts (variable)
• Monoblasts, promonocytes, and monocytes

72. Periodic Acid-Schiff (PAS) Reaction
• Stain for glycogen
• Useful in identifying FAB M6 leukemia
• RBCs in eythroleukemia are STRONGLY POSITIVE
• Normal erythroid precursors are PAS negative

73. Cytochemical Reactions of Certain Types of Leukemia
CONDITION MPO SBB NAPHTHOL
AS-D
CHLOROA
CETATE
(SE)
a-
NAPHTHYL
BUTYRATE
ESTERASE
(NSE)
a-
NAPHTHYL
ACETATE
ESTERASE
(NSE)
FACTOR VII
AML + + + - - -
AMML + + + + + -
AMoL - -/+ - + + -
Erythroleuke
mia
+myeloblast
-
normoblasts
+myeloblast
-
normoblasts
+myeloblast
-
normoblasts
- - -
Megakaryoc
ytic
Leukemia
- - - - + localized
reaction
+

74. Perl’s Prussian Blue
• Stain cellular free iron precipitate
• Iron inclusions are called siderotic granules or
Pappenheimer bodies when visible with Wright’s stain
• Sideroblasts are nucleated RBCs in bone marrow that
contain iron granules. These re normal. Ringed
sideroblast contain iron that encircles the nucleus. These
are abnormal.
• Increased percentage of siderocytes is seen in severe
hemolytic anemias, iron overload, sideroblastic anemia
and post splenectomy; ringed sideroblasts are seen in
bone marrow of myelodysplastic syndrome (refractory
anemia with ringed sideroblasts (RARS) and
sideroblastic anemias

75. Tartrate-Resistant Acid Phosphatase
stain (TRAP)
• Most blood cells contain the acid
phosphatase enzyme, however, once
tartrate is added, staining is inhibited in
most cells
• Hairy cells found in patients with leukemic
reticuloendotheliosis (hairy cell leukemia)
are resistant to inhibition with tartrate and
continue to stain positive.