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1. Specimen Collection
2. Peripheral Smear Preparation
3. Staining of Peripheral Blood Smear
4. Peripheral Smear Examination
 Venipuncture
◦ Should be collected in an EDTA (disodium or tripotassium
ethylene diamine tetra-acetic acid) tube
◦ Chelates calcium.
◦ 1.2 mg anhydrous EDTA salt/ml of blood used.
◦ EDTA effect
Peripheral Smear technique and reporting

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This document provides information about performing a peripheral blood smear examination, including the different types of blood smears, proper procedures for making blood smears, characteristics of a good smear, common causes of a poor smear, staining techniques, performing a manual differential count and assessing red blood cell morphology. Key steps include making wedge or spun smears from EDTA blood, allowing the smear to air dry before staining with Leishman's stain, examining under 10x, 40x and 100x magnification to perform white blood cell counts and differentials, and platelet and red blood cell morphology assessments. Causes of abnormal smears and signs of abnormal white blood cell morphology are also outlined.

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Peripheral blood smear examination plays an important role in the evaluation of various blood disorders. A good peripheral smear should be prepared using the wedge or coverslip technique to obtain an even distribution of red blood cells. The smear is then stained using the Romanowsky method which involves fixing the cells using methanol followed by staining with Giemsa stain. During examination, red blood cells, white blood cells, platelets and any abnormal cells or inclusions are evaluated under the microscope. Changes in the size, shape, color and structural features of red blood cells can provide clues to underlying hematological conditions.

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The document discusses different staining techniques used in hematology to differentiate blood cells. It describes routine stains like Leishman, Giemsa, Wright, and Jenner stains which use combinations of basic and acidic dyes to stain cell nuclei and cytoplasm. Proper preparation of thin and thick blood films, including fixation in methanol, is outlined. The principles, procedures, and interpretations of common Romanowsky stains are explained in detail.

 Wedge method
 Cover glass method
 Spinner method
Specific methods
 Buffy coat smear for WBC < 1.0 x10^9/L
 Thick blood smear for blood parasites
A. Hold spreader slide at correct
angle
B. Blood spread across width of
slide
C. Completed wedge smear
WEDGE METHOD
 Place a drop of blood in the centre of a clean
glass slide 1cm away from the end.
 Place the spreader in front of the drop at an
angle of 30 degrees to the slide and move it
back to make contact with the drop.
 The drop should spread quickly along the line
of contact, with a steady movement of the
hand spread the drop of blood along the
slide.
 Smear should be 3 cm in length,
smooth,tongue shaped.
 Air dry and stain.
COVER GLASS METHOD
 Take 22 mm clean cover glass,touch it on drop
of blood and place it on another cover glass in
cross wise direction with slide containing drop
of blood facing down.

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The blood smear document defines a blood smear, outlines its uses in diagnosing conditions like anemia and infections, and provides detailed instructions on preparing, staining, examining, and interpreting a blood smear slide. A well-prepared blood smear shows red and white blood cells with normal morphology, and is examined under microscopy to check for abnormalities and identify blood parasites or immature cells that can indicate conditions like infection or leukemia.

SPINNER METHOD
Automated method-place a drop of blood
in the centre of the glass slide and spin at a
high speed in a centrifuge cytospin.
Blood spread uniformly, dry it and stain.
 Does not cover the entire area of
slide.
 Should be tongue shaped, ie broad
at starting point (head.) & taper
towards end.
 Has both thick and thin areas with
gradual transition.
 Does not contain any lines or
holes. Smooth margins.
Tail
Head
 Labelling of PS-
 The film should be labelled immediately after
spreading with lab reference number or the
patients name.
 Fixing-
 To preserve the morphology of cells ,films must
be fixed without delay.
 Take methanol in a coplin jar ,give 4 to 6 dip to
the smear in methanol and air dry.
Methanol is used as a fixative & must be free from water.
Methanol precipitates the plasma proteins, which then acts
as a glue to fix the cells to the slide.
 Romanowsky stains –
 Differentially stain the blood cell components on the basis
of their pH.
 Standardized stain is composed of:
Azure B-trimethylthionine-cationic dye
Eosin Y-tetrabromofluoroscein-anionic dye
 Polychrome methylene blue and eosin are the outgrowths
of the original method.
 Methylene blue and azure B are basic dyes that stains
acidic components of the cell like nucleic acids, granules
of basophil.
 The eosin is acidic or anionic dye that stain basic
components like hemoglobin & granules of eosinophils .

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This document provides information on preparing, fixing, and staining blood smears or peripheral blood films. It describes how to make thin and thick blood films using different methods like the slide, cover glass, and spin methods. Films need to be fixed using methanol to preserve cell morphology before staining. Various Romanowsky stains are commonly used like Leishman, Giemsa, Wright, Field, and Jenner stains. Proper staining techniques and precautions are outlined to produce high quality blood films for microscopic examination and identification of blood cells and parasites.

Stains include-
 AzureB EosinY stain-highly purified standard.
 May-Grunwald-Giemsa stain(used in Europe)
 Wright’s stain(used in N. America)
 Leishman’s stain
 Field stain( Rapid)- used in our department.
 Giemsa stain
 JSB stain- for malarial parasite
 Automated stains
MAY-GRUNWALD-GIEMSA METHOD
1. Air dry slides.
2. Fix in Methanol for 2-3 minutes at room temperature.
3. Stain for 15 mins in May-Grunwald stain freshly
diluted with an equal volume of buffered distilled
water, pH=6.8
4. Stain for 10 minutes in Giemsa stain freshly diluted
with buffered distilled water, pH=6.8 (1/9)
5. Wash in running tap-water and then leave for 3-4
minutes in buffered distilled water, pH 6.8
 It consists of methylene blue and eosin dissolved in absolute
methyl alcohol.
 Weigh 0.2 gm of powdered dye in conical flask & add 100 ml
methanol & warm the mixture to 50C for 15 min. Allow to
cool & filter.
METHOD:
1.Air dry the film & flood the slide with stain for 2 min.
2.Add double volume of water & stain the film for 5-7 min.
3.Wash in a stream of buffered water & dry it.
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RAPID STAINING METHOD: Field’s
method
(45 sec)
Tap
water
(3 sec)
(1 min 15 sec)
Wash gently to
remove excess stain,
under tap water. Drain
and dry.
Methanol Eosin
Polychromed
methylene
blue
Cell Component Staining Colour
Chromatin(including Howell-
Jolly body)
Purple
Promyelocyte granules & Auer
rods
Purplish-red
Cytoplasm of lymphocytes Blue
Cytoplasm of monocytes Blue-grey
Cytoplasm rich in RNA(i.e.
Basophilic cytoplasm)
Deep blue
Dohle bodies Blue-grey
Specific granules of neutrophils,
granules of lymphocytes,
granulomere of platelets
Light purple or pink
Specific granules of basophils Deep purple
Specific granules of eosinophils Orange
Red cells Pink
STAINING FEATURES OF CELL COMPONENTS WITH ROMANOWSKY STAIN
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TOO THICK
TOO
THIN
1. RBCs are uniformly and singly
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2. Few RBC are touching or overlapping
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1.Assess the overall quality of the smear.
2.Find an area where red cells are evenly distributed and not
distorted.
3.Check to see if there are good counting areas available free
of ragged edges and cell clumps.
4.Check the number,distribution and staining of leukocytes.
5.Assess whether red cell agglutination, platelet aggregation
or fibrin strands are present.
 WBC estimation
•Choose a portion of the peripheral smear where there
is only slight overlapping of the RBCs.
•Count 10 fields, take the total number of white cells
and divide by 10.
•To do a WBC estimate by taking the average number
of white cells and multiplying by 2000.
•WBC:RBC::1:500 (normal leucocrit approx.)
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Reporting results
•Absolute number of cells/µl = % of cell type in
differential x white cell count
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NORMAL HAEMATOPOEISIS
 RBC distribution
 Morphology
◦ Colour
◦ Size
◦ Shape
◦ Structure
◦ Inclusions
◦ Young rbcs
CAUSE RESULTANT ABNORMALITY
Abnormal Erythropoeisis-
Effective/Ineffective
Anisopoikilicytosis,Basophilic
stippling,dimorphism(sometime
s)
Inadequate Hb synthesis Hypochromia/Anisochromia/
Dimorphism
Damage to normal cells after
leaving bone marrow/
Hyposplenism/Splenectomy
Poikilocytosis- Specific/Non
specific;
Red cell inclusions
Compensatory increased
erythropoeisis by bone marrow
Less mature cell release:
Polychromasia,Erythroblastemia
MECHANISM OF RBC ABNORMALITY &
RESULTANT FEATURES
ABNORMAL ERYTHROPOEISIS
A) ANISOCYTOSIS & POIKILOCYTOSIS: Increased
RDW
•Non specific
•Seen in various disorders
of diverse etiology.

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With reticulocytosis
Megaloblastic
erythropoeisis
Associated with-
Megaloblastic OR
macronormoblastic
erythropoeisis
Macronormoblastic
erythropoeisis
Uncertain mechanism
C) MICROCYTOSIS- Decreased MCV
Inherited
Acquired
D) BASOPHILIC STIPPLING: Indicates disturbed rather than increased
erythropoeisis
Basophilic Inclusions; RNA
CAUSES
•Thalassemia trait and
major
•Haemolytic Anemia
•Myelodysplastic
syndrome/Sideroblastic
anemia
•Megaloblastic Anemia
•Pyrimidine 5’
nucleotidase deficiency
•Heavy metal
poisoning(Coarse
basophilic stippling)
o Lead, Zinc, Arsenic,
Silver, Mercury
INADEQUATE HAEMOGLOBIN
FORMATION
A) HYPOCHROMIA-

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B) ANISOCHROMASIA- Increased variation in degree of
haemoglobinization of RBC
Seen in development/resolution of iron
deficiency anaemia; anaemia of chronic disease
C) DIMORPHIC CELL
POPULATION
•Seen after
response to iron
therapy in iron
deficiency
anemia;
• macrocytic
anemia post
blood
transfusion;
• sideroblastic
anaemia;
•Post stem cell
transplantation
DAMAGE TO RED CELLS AFTER RELEASE FROM
MARROW
A) HYPERCHROMASIA
In presence
of
macrocytes
Abnormally
round cells
Seen in:
B) SPHEROCYTOSIS
CAUSES
•Warm autoimmune hemolytic
anaemia
•ABO hemolytic disease of
newborn/Rh hemolytic disease
of newborn
•Cold autoimmune hemolytic
anemia/paroxysmal cold
hemoglobinuria
•Hereditary Spherocytosis
•Clostridium sepsis
•IV water infusion or fresh
water drowning
•Bartonellosis
•Snake bite
•Hyposplenism
•Hypophosphatemia
•Rh-null phenotype

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ELLIPTOCYTOSIS and OVALOCYTOSIS
Large number of elliptocytes
Hereditary Elliptocytosis
Small number of elliptocytes
•Iron deficiency
•Thalassemia trait and major
•Megaloblastic anaemia
•Myelodysplastic syndrome
•Myelofibrosis
C) IRREGULARLY CONTRACTED CELLS
CAUSES
• Oxidative hemolysis
(Glucose-6-phosphate
deficiency, glutathione
synthetase deficiency,
drugs, toxins)
•Unstable
haemoglobins
•Hb C homozygous
•Hb SC disease
•Wilson’s disease
•Zieve’s syndrome
D)SPICULATED CELLS and RED CELL FRAGMENTATION
SCHISTOCYTE
ECHINOCYTE
ACANTHOCYT
E
KERATOCYT
E
On basis of electron
microscopy [ Bessis]
SCHISTOCYTE
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CAUSES
•Artifact
•Uremia and chronic
renal disease
•Hypophosphatemia
•Disseminated
malignancy
•Liver disease
•Vitamin E deficiency
•Pyruvate kinase
deficiency
•Phosphoglycerate
kinase deficiency
•Early post transfusion
of RBC
•Hyperlipidemia
•Myeloproliferative
disorders
ECHINOCYTE
ACANTHOCYTES
Large numbers of acanthocytes
•Advanced liver disease
•Spur cell hemolytic anaemia
•Abetalipoproteinemia
•Hypobetalipoproteinemia, homozygous
•McLeod phenotype
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•Choreoacanthycytosis
Small numbers of acanthocytes
•Post splenectomy
•Hypothyroidism
•Panhypopituitarism
•Vitamin E deficiency
•Malnutrition
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•Iron deficiency
•Psoriasis
Glucose-6 Phosphate
Dehydrogenase deficiency
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Dapsone
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deficiency, glutathione
synthetase deficiency,
drugs, toxins)
•Unstable
haemoglobins
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Seen in severe iron deficiency anaemia, thalessemia,
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CAUSES
•Artifact
•Alcoholism
•Alcoholic liver disease
•Obstructive liver disease
•Hereditary stomatocytosis
•Hereditary xerocytosis
•South east Asian ovalocytosis
•Tangier disease
•Rh-null phenotype
•Drugs (hydroxy urea)
TARGET CELLS
CAUSES
Microcytic
•Hb E heterozygous+
homozygous
•B-thalassemia trait+major
•Alpha-Thalassemia trait
•Hb H disease
•Hb C trait+ disease
•Hb Lepore heterozygous
+homozygous
•Hb O Arab disease
•Hb D disease
•Iron deficiency
•Hb Lepore trait
Normocytic or Macrocytic
•Obstructive jaundice
•Liver disease
•Lecithin Cholesterol Acyl
Transferase deficiency
•Hb SC disease
•Hyposplenic disease
•Hb O Arab disease
Primary Myelofibrosis
DACRYOCYTES
Megaloblastic Anaemia
Also seen in bone marrow infiltration, Thalessemia major, some cases of
hemolytic anemia
SICKLE CELLS (DREPANOCYTE)
Sickle cell anaemia:homozygous
for HbS

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ERYTHROCYTE INCLUSIONS
Pappenheimer Body
Cabot Ring
Howell Jolly Body
Heinz Body
Howell Jolly body DNA
Basophilic Stippling RNA
Pappenheimer body Iron containing inclusions
Heinz body Denatured Haemoglobin
Hb H disease beta-globin tetramer
Fessus body Alpha-globin tetramer
Crystal Hb C
Cabot Ring Mitotic Spindle
RED CELL INCLUSIONS CONTENT
ROULEAUX and AUTOAGGLUTINATION
ROULEAUX- due to-
Increased plasma proteins
(polyclonal or other proteins)
•Inflammatory state
•Infection
Increased plasma proteins
(monoclonal)
•MGUS
•Myeloma
•Amyloidosis
•Lymphoma
RED BLOOD CELL
AGGLUTINATION
•Cold agglutinins
•Cold autoimmune hemolytic
anaemia
•Paroxysmal cold hemoglobinuria
•Ig M paraproteinemia
CHANGES WITH COMPENSATORY
INCREASE IN ERYTHROPOESIS
Polychromasia
Nucleated RBCs
Leukoerythroblastic blood
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Peripheral Smear technique and reporting
RETICULOCYTOSIS
o They are juvenile red cells containing remnants of
ribosomal ribonucleic acid.
o They react with a basic dye to form a blue or purple
precipitate of granule or filaments.
o This reaction needs supravital staining and unfixed
preparation.
o Dye used-brilliant brilliant cresyl blue, new
methylene blue, azure B.
o Normal count—in adults and children-0.5%-2.0%.
o In infants(cordblood)-2%-5%
Most immature:Grade I
Most mature:Grade IV
Peripheral Smear technique and reporting

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Peripheral Smear technique and reporting
Peripheral Smear technique and reporting
A. Granules
B. Vacuoles
C. Bacteria
D. Nuclei
E. Hypersegmentation
F. Pyknotic Neutrophils
(Apoptosis)
B. Toxic Neutrophilia with toxic
vacuolation
A. Toxic granulation
IN SEVERE SEPSIS~
Azurophilic
cytoplasmic granules
seen in severe infections,
other toxic and reactive
conditions
Seen in infections,
indicating phagocytosis

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C.Overwhelming
Septicemia:Bacterial inclusion
Dohle Body in a
neutrophil
Pale blue, oval
cytoplasmic remnants of
ribosomes seen in
infection and other toxic
condition.
Alder-Reilly anomaly
FEW INHERITED ANOMALIES~
May –Hegglin anomaly
Chediak-Higashi syndrome
Autosomal recessive disorder
with giant granules,likely
representing giant fused
lysosomes& abnormal
leukocyte function
Inherited Pelger-Huet anomaly
Bilobed or rounded
nuclei with pince-nez
shape nucleus
Pseudo Pelger-Huet anomaly
Hypogranular
neutrophils with
irregular nuclear
pattern
D. NUCLEI

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E.Hypersegmented Neutrophil
Segmentation Index=Number of neutrophils with 5-more lobes
___________________________________
Number of neutrophils with 4 lobes
F. Pyknotic neutrophils : Undergoing apoptosis.
◦ May normally be found in infection.
◦ Cells have round, dense, featureless nuclei and
cytoplasm is dark pink.
EOSINOPHILIC GRANULOCYTE
MATURE EOSINOPHIL
HYPEREOSINOPHILIC SYNDROME
MATURE BASOPHIL
Marked BASOPHILIA in case with
Philadelphia chromosome positivity
BASOPHILIC GRANULOCYTE

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Myeloblast :
◦ Large cell 10-18um.
◦ Round oval nucleus
occupying most cell
area.
-- Nucleoli are typically
prominent (2-5)
-- Deep blue scanty
cytoplasm no
granules.
Promyelocyte
 Slightly larger 12-20um
 Shares same features with
myeloblast .
 Less prominent nucleoli.
 Cytoplasm contains blue purple
primary azurophilic granules.
Myelocyte :
 Size 12-18 um
 Nucleus is oval or slightly
indented, fine chromatin.
 No nucleoli are seen or very rare.
 Cytoplasmic granules now acquire
specific characters. Both primary
and secondary granules seen.
Metamyelocyte :
◦ Size 10-18m
◦ Indentation less than ½ diameter
of nucleus
◦ Condensed chromatin.No
nucleoli.
◦ Cytoplasm is abundant with
secondary granules only.
Band cells :
◦ 10-16 micron.
◦ Indentation more than ½ diameter
of nucleus.
◦ Cytoplasm is abundant with
secondary granules only.
Lymphoblast Myeloblast
Nuclear
chromatin
Coarse Fine
Nucleoli 1-2 3-5
N:C ratio High High
Auer rod Absent Present
Accompanyin
g cells
Lymphocytes Myeloid
precursors

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SMALL LYMPHOCYTES
•Size-6-10 microns
•High nucleocytoplasmic
ratio
•Scant amount of
slightly basophilic
cytoplasm.
•Smooth contour with
mature “closed”
chromatin and absent
nucleoli.
LARGE LYMPHOCYTE
•Size- 12-15 micron
•Moderate nuclear-
cytoplasmic ratio
•Oval nucleus
•Slightly open
chromatin
•Pale cytoplasm
•About 1/3rd may
contain azurophilic
granules; larger than
neutrophilic
granules
NORMAL
CLL
ALL L1 type of
lymphoblast
shown here
usually has a high
nuclear:cytoplasmi
c (N:C) ratio with
an immature or
“open”
chromatin
CLL cells appear as slightly
larger versions of normal
small lymphocytes.
CLL cells can display
clumped or “soccer ball”
chromatin.
Small lymphocyte
•Large size,
abundant basophilic
cytoplasm at
periphery
•Often vacuolated.
•Nucleus- Large;
irregular
•Partially condensed
chromatin
•Nucleoli present
ACTIVATED LYMPHOCYTES
‘Atypical mononuclear cell’

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‘TURK CELL’; IMMUNOBLAST
•10-15 um size.
•Round nucleus,
abundant deeply
basophilic cytoplasm
•Seen in severe
bacterial and viral
infection
PLASMA CELL
•Larger than small
lymphocyte
•Oval in shape with
eccentric round nucleus
with clumped nuclear
chromatin.
•Moderate amount of
basophilic cytoplasm with
prominent nuclear hof
Plasma cell
MATURE MONOCYTE
•Size : 14-20 um
•Irregular, lobulated
nucleus
•Has the most delicate
nuclear chromatin
pattern.
• Abundant light gray
cytoplasm with fine
granularity and
vacuolation seen
Deeply indented
nucleus
Figure 33-24 Promonocyte (center) shows immature
chromatin and finely convoluted nuclear folds in
comparison with monoblasts.

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 Degenerative changes
 Broken cells
 Contracted cells
 Endothelial cells
 Radial segmentation of the nuclei
 Vacuolation
 Pseudophagocytosis
Ruptured Leukocyte Basket Cell
Broken cell of myeloid
series
Smudge cell
◦ Normal platelets are 2-4 um in diameter.
◦ Irregular outline with fine red granules .
◦ Normal peripheral count 1.0 -5 lac/mm3
◦ Remain viable in circulation for 10 days.
◦ Large Platelets seen in–hyposplenism, Bernard-Soulier
syndrome, May-Hegglin anomaly.
PLATELET
AGGREGATES
PLATELET SATTELITISM
False Thrombocytopenia:

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Hyposplenism in coeliac
disease: GIANT
PLATELETS
GRAY PLATELET SYNDROME
ESSENTIAL THROMBOCYTOSIS
MISCELLANEOUS PLATELET ABNORMALITIES
1. MALARIA PARASITE :Plasmodium
◦ Blood is collected at or just after the height of a
febrile paroxysm.
◦ One thick & one thin smear should be prepared .
◦ Procedure-Take a large of drop of blood in the
centre of a clean glass slide & spread it in an area
of 1.5 cm with a slide.
◦ Dry and stain by any Romanowsky combination.
Leishman, Giemsa method are suitable.
 In P. falciparum often only early trophozoite (ring
form) +/- gametocytes are found.
 In P. vivax, all stages of life cycle usually present.
Male gametocyte:
P.falciparum
Ring form trophozoite: P.
falciparum
Ring form:
P.vivax
Early
schizont
2.MICROFILARIA:W.bancrofti
 Blood is collected at midnight
between 10 p.m.-4a.m.
 Blood concentration of
microfilaria is higher in capillary
blood than in venous blood.
Morphology:
When stained with
Romanowsky stain:
•A hyaline sheath seen
projecting beyond the
body.
•Nuclei appear as granules
in central axis of body
extend from head to tail,
but not to the tip of tail.

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3.TRYPANOSOMA
BRUCEI
(African sleeping sickness)
 Trypomastigotes can be found
in peripheral blood,lymph node
aspirate and CSF.
 When stained with Leishman
stain, cytoplasm & the
undulating membrane appear
pale blue and the nucleus
reddish purple or red.
 Kinetoplast & flagellum dark
red.
4. TRYPANOSOMA CRUZI
– (Chagas disease)
 Two forms are found
a. Trypomastigote form can only
be found in blood in acute form
of Chagas disease.
b. Amastigote form (in striated
muscles)
Trypomastigote form appear as
C or U shaped.
5. LEISHMANIA DONOVANI
◦ Diagnosed by direct visualization of
amastigote (LD bodies)
◦ Causes kala azar .
◦ In aspirate smears amastigote forms
are seen in groups inside
macrophages or lying free between
the cells.
◦ In buffy coat smears they are seen
within monocytes or neutrophils in
peripheral blood.
◦ Small round bodies 2-4 micron in
diameter, indistinct cytoplasm, a
nucleus, a small rod shaped
kinetoplast .
Red Blood Cells, Examine for :
1.Size and shape ( Anisocytosis, Poikilocytosis)
2.Relative hemoglobin content.
3.Polychromatophilia.
4.Inclusions.
5. Rouleaux formation or agglutination
White Blood Cells
1.Check for even distribution and estimate the number present (also, look for any
gross abnormalities present on the smear).
2.Perform the differential count.
3.Examine for morphologic abnormalities and immature cells.
Platelets.
1.Estimate number present.
2. Examine for morphologic abnormalities, aggregates.
 Comment on any haemoparasites, if present.

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THANK YOU!~

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Peripheral Smear technique and reporting

  • 1. Moderator- Dr. Meena Mittal Speaker: Dr. Upma Gupta
  • 2. 1. Specimen Collection 2. Peripheral Smear Preparation 3. Staining of Peripheral Blood Smear 4. Peripheral Smear Examination
  • 3.  Venipuncture ◦ Should be collected in an EDTA (disodium or tripotassium ethylene diamine tetra-acetic acid) tube ◦ Chelates calcium. ◦ 1.2 mg anhydrous EDTA salt/ml of blood used. ◦ EDTA effect
  • 5.  Wedge method  Cover glass method  Spinner method Specific methods  Buffy coat smear for WBC < 1.0 x10^9/L  Thick blood smear for blood parasites
  • 6. A. Hold spreader slide at correct angle B. Blood spread across width of slide C. Completed wedge smear
  • 7. WEDGE METHOD  Place a drop of blood in the centre of a clean glass slide 1cm away from the end.  Place the spreader in front of the drop at an angle of 30 degrees to the slide and move it back to make contact with the drop.  The drop should spread quickly along the line of contact, with a steady movement of the hand spread the drop of blood along the slide.  Smear should be 3 cm in length, smooth,tongue shaped.  Air dry and stain.
  • 8. COVER GLASS METHOD  Take 22 mm clean cover glass,touch it on drop of blood and place it on another cover glass in cross wise direction with slide containing drop of blood facing down.
  • 9. SPINNER METHOD Automated method-place a drop of blood in the centre of the glass slide and spin at a high speed in a centrifuge cytospin. Blood spread uniformly, dry it and stain.
  • 10.  Does not cover the entire area of slide.  Should be tongue shaped, ie broad at starting point (head.) & taper towards end.  Has both thick and thin areas with gradual transition.  Does not contain any lines or holes. Smooth margins. Tail Head
  • 11.  Labelling of PS-  The film should be labelled immediately after spreading with lab reference number or the patients name.  Fixing-  To preserve the morphology of cells ,films must be fixed without delay.  Take methanol in a coplin jar ,give 4 to 6 dip to the smear in methanol and air dry. Methanol is used as a fixative & must be free from water. Methanol precipitates the plasma proteins, which then acts as a glue to fix the cells to the slide.
  • 12.  Romanowsky stains –  Differentially stain the blood cell components on the basis of their pH.  Standardized stain is composed of: Azure B-trimethylthionine-cationic dye Eosin Y-tetrabromofluoroscein-anionic dye  Polychrome methylene blue and eosin are the outgrowths of the original method.  Methylene blue and azure B are basic dyes that stains acidic components of the cell like nucleic acids, granules of basophil.  The eosin is acidic or anionic dye that stain basic components like hemoglobin & granules of eosinophils .
  • 13. Stains include-  AzureB EosinY stain-highly purified standard.  May-Grunwald-Giemsa stain(used in Europe)  Wright’s stain(used in N. America)  Leishman’s stain  Field stain( Rapid)- used in our department.  Giemsa stain  JSB stain- for malarial parasite  Automated stains
  • 14. MAY-GRUNWALD-GIEMSA METHOD 1. Air dry slides. 2. Fix in Methanol for 2-3 minutes at room temperature. 3. Stain for 15 mins in May-Grunwald stain freshly diluted with an equal volume of buffered distilled water, pH=6.8 4. Stain for 10 minutes in Giemsa stain freshly diluted with buffered distilled water, pH=6.8 (1/9) 5. Wash in running tap-water and then leave for 3-4 minutes in buffered distilled water, pH 6.8
  • 15.  It consists of methylene blue and eosin dissolved in absolute methyl alcohol.  Weigh 0.2 gm of powdered dye in conical flask & add 100 ml methanol & warm the mixture to 50C for 15 min. Allow to cool & filter. METHOD: 1.Air dry the film & flood the slide with stain for 2 min. 2.Add double volume of water & stain the film for 5-7 min. 3.Wash in a stream of buffered water & dry it. LEISHMAN METHOD
  • 17. RAPID STAINING METHOD: Field’s method (45 sec) Tap water (3 sec) (1 min 15 sec) Wash gently to remove excess stain, under tap water. Drain and dry. Methanol Eosin Polychromed methylene blue
  • 18. Cell Component Staining Colour Chromatin(including Howell- Jolly body) Purple Promyelocyte granules & Auer rods Purplish-red Cytoplasm of lymphocytes Blue Cytoplasm of monocytes Blue-grey Cytoplasm rich in RNA(i.e. Basophilic cytoplasm) Deep blue Dohle bodies Blue-grey Specific granules of neutrophils, granules of lymphocytes, granulomere of platelets Light purple or pink Specific granules of basophils Deep purple Specific granules of eosinophils Orange Red cells Pink STAINING FEATURES OF CELL COMPONENTS WITH ROMANOWSKY STAIN
  • 20. OPTIMAL ASSESSMENT AREA TOO THICK TOO THIN 1. RBCs are uniformly and singly distributed 2. Few RBC are touching or overlapping 3. Normal biconcave appearance
  • 21. 1.Assess the overall quality of the smear. 2.Find an area where red cells are evenly distributed and not distorted. 3.Check to see if there are good counting areas available free of ragged edges and cell clumps. 4.Check the number,distribution and staining of leukocytes. 5.Assess whether red cell agglutination, platelet aggregation or fibrin strands are present.
  • 22.  WBC estimation •Choose a portion of the peripheral smear where there is only slight overlapping of the RBCs. •Count 10 fields, take the total number of white cells and divide by 10. •To do a WBC estimate by taking the average number of white cells and multiplying by 2000. •WBC:RBC::1:500 (normal leucocrit approx.)
  • 24. Reporting results •Absolute number of cells/µl = % of cell type in differential x white cell count •If 10 or more nucleated RBC's (nRBC) are seen, correct the leucocyte Count using this formula: Corrected WBC Count = WBC x 100/( nRBC + 100) B) Platelet estimation
  • 26.  RBC distribution  Morphology ◦ Colour ◦ Size ◦ Shape ◦ Structure ◦ Inclusions ◦ Young rbcs
  • 27. CAUSE RESULTANT ABNORMALITY Abnormal Erythropoeisis- Effective/Ineffective Anisopoikilicytosis,Basophilic stippling,dimorphism(sometime s) Inadequate Hb synthesis Hypochromia/Anisochromia/ Dimorphism Damage to normal cells after leaving bone marrow/ Hyposplenism/Splenectomy Poikilocytosis- Specific/Non specific; Red cell inclusions Compensatory increased erythropoeisis by bone marrow Less mature cell release: Polychromasia,Erythroblastemia MECHANISM OF RBC ABNORMALITY & RESULTANT FEATURES
  • 28. ABNORMAL ERYTHROPOEISIS A) ANISOCYTOSIS & POIKILOCYTOSIS: Increased RDW •Non specific •Seen in various disorders of diverse etiology.
  • 29. B) MACROCYTOSIS With reticulocytosis Megaloblastic erythropoeisis Associated with- Megaloblastic OR macronormoblastic erythropoeisis Macronormoblastic erythropoeisis Uncertain mechanism
  • 30. C) MICROCYTOSIS- Decreased MCV Inherited Acquired
  • 31. D) BASOPHILIC STIPPLING: Indicates disturbed rather than increased erythropoeisis Basophilic Inclusions; RNA CAUSES •Thalassemia trait and major •Haemolytic Anemia •Myelodysplastic syndrome/Sideroblastic anemia •Megaloblastic Anemia •Pyrimidine 5’ nucleotidase deficiency •Heavy metal poisoning(Coarse basophilic stippling) o Lead, Zinc, Arsenic, Silver, Mercury
  • 33. B) ANISOCHROMASIA- Increased variation in degree of haemoglobinization of RBC Seen in development/resolution of iron deficiency anaemia; anaemia of chronic disease
  • 34. C) DIMORPHIC CELL POPULATION •Seen after response to iron therapy in iron deficiency anemia; • macrocytic anemia post blood transfusion; • sideroblastic anaemia; •Post stem cell transplantation
  • 35. DAMAGE TO RED CELLS AFTER RELEASE FROM MARROW A) HYPERCHROMASIA In presence of macrocytes Abnormally round cells Seen in:
  • 36. B) SPHEROCYTOSIS CAUSES •Warm autoimmune hemolytic anaemia •ABO hemolytic disease of newborn/Rh hemolytic disease of newborn •Cold autoimmune hemolytic anemia/paroxysmal cold hemoglobinuria •Hereditary Spherocytosis •Clostridium sepsis •IV water infusion or fresh water drowning •Bartonellosis •Snake bite •Hyposplenism •Hypophosphatemia •Rh-null phenotype
  • 37. ELLIPTOCYTOSIS and OVALOCYTOSIS Large number of elliptocytes Hereditary Elliptocytosis Small number of elliptocytes •Iron deficiency •Thalassemia trait and major •Megaloblastic anaemia •Myelodysplastic syndrome •Myelofibrosis
  • 38. C) IRREGULARLY CONTRACTED CELLS CAUSES • Oxidative hemolysis (Glucose-6-phosphate deficiency, glutathione synthetase deficiency, drugs, toxins) •Unstable haemoglobins •Hb C homozygous •Hb SC disease •Wilson’s disease •Zieve’s syndrome
  • 39. D)SPICULATED CELLS and RED CELL FRAGMENTATION SCHISTOCYTE ECHINOCYTE ACANTHOCYT E KERATOCYT E On basis of electron microscopy [ Bessis] SCHISTOCYTE
  • 41. CAUSES •Artifact •Uremia and chronic renal disease •Hypophosphatemia •Disseminated malignancy •Liver disease •Vitamin E deficiency •Pyruvate kinase deficiency •Phosphoglycerate kinase deficiency •Early post transfusion of RBC •Hyperlipidemia •Myeloproliferative disorders ECHINOCYTE
  • 42. ACANTHOCYTES Large numbers of acanthocytes •Advanced liver disease •Spur cell hemolytic anaemia •Abetalipoproteinemia •Hypobetalipoproteinemia, homozygous •McLeod phenotype •In(Lu phenotype) •Choreoacanthycytosis Small numbers of acanthocytes •Post splenectomy •Hypothyroidism •Panhypopituitarism •Vitamin E deficiency •Malnutrition •Thalassemia •Iron deficiency •Psoriasis
  • 43. Glucose-6 Phosphate Dehydrogenase deficiency KERATOCYTE: ‘Helmet’/Bite cell’ Haemolytic Anemia by Dapsone CAUSES •Oxidative hemolysis (Glucose-6-phosphate deficiency, glutathione synthetase deficiency, drugs, toxins) •Unstable haemoglobins
  • 44. MISCELLANOUS ERYTHROCYTE ABNORMALITIES LEPTOCYTES: Unsually thin RBCs Seen in severe iron deficiency anaemia, thalessemia, liver disease
  • 45. STOMATOCYTES CAUSES •Artifact •Alcoholism •Alcoholic liver disease •Obstructive liver disease •Hereditary stomatocytosis •Hereditary xerocytosis •South east Asian ovalocytosis •Tangier disease •Rh-null phenotype •Drugs (hydroxy urea)
  • 46. TARGET CELLS CAUSES Microcytic •Hb E heterozygous+ homozygous •B-thalassemia trait+major •Alpha-Thalassemia trait •Hb H disease •Hb C trait+ disease •Hb Lepore heterozygous +homozygous •Hb O Arab disease •Hb D disease •Iron deficiency •Hb Lepore trait Normocytic or Macrocytic •Obstructive jaundice •Liver disease •Lecithin Cholesterol Acyl Transferase deficiency •Hb SC disease •Hyposplenic disease •Hb O Arab disease
  • 47. Primary Myelofibrosis DACRYOCYTES Megaloblastic Anaemia Also seen in bone marrow infiltration, Thalessemia major, some cases of hemolytic anemia
  • 48. SICKLE CELLS (DREPANOCYTE) Sickle cell anaemia:homozygous for HbS
  • 49. ERYTHROCYTE INCLUSIONS Pappenheimer Body Cabot Ring Howell Jolly Body Heinz Body
  • 50. Howell Jolly body DNA Basophilic Stippling RNA Pappenheimer body Iron containing inclusions Heinz body Denatured Haemoglobin Hb H disease beta-globin tetramer Fessus body Alpha-globin tetramer Crystal Hb C Cabot Ring Mitotic Spindle RED CELL INCLUSIONS CONTENT
  • 51. ROULEAUX and AUTOAGGLUTINATION ROULEAUX- due to- Increased plasma proteins (polyclonal or other proteins) •Inflammatory state •Infection Increased plasma proteins (monoclonal) •MGUS •Myeloma •Amyloidosis •Lymphoma RED BLOOD CELL AGGLUTINATION •Cold agglutinins •Cold autoimmune hemolytic anaemia •Paroxysmal cold hemoglobinuria •Ig M paraproteinemia
  • 52. CHANGES WITH COMPENSATORY INCREASE IN ERYTHROPOESIS Polychromasia Nucleated RBCs Leukoerythroblastic blood picture
  • 54. RETICULOCYTOSIS o They are juvenile red cells containing remnants of ribosomal ribonucleic acid. o They react with a basic dye to form a blue or purple precipitate of granule or filaments. o This reaction needs supravital staining and unfixed preparation. o Dye used-brilliant brilliant cresyl blue, new methylene blue, azure B. o Normal count—in adults and children-0.5%-2.0%. o In infants(cordblood)-2%-5%
  • 55. Most immature:Grade I Most mature:Grade IV
  • 59. A. Granules B. Vacuoles C. Bacteria D. Nuclei E. Hypersegmentation F. Pyknotic Neutrophils (Apoptosis)
  • 60. B. Toxic Neutrophilia with toxic vacuolation A. Toxic granulation IN SEVERE SEPSIS~ Azurophilic cytoplasmic granules seen in severe infections, other toxic and reactive conditions Seen in infections, indicating phagocytosis
  • 61. C.Overwhelming Septicemia:Bacterial inclusion Dohle Body in a neutrophil Pale blue, oval cytoplasmic remnants of ribosomes seen in infection and other toxic condition.
  • 62. Alder-Reilly anomaly FEW INHERITED ANOMALIES~ May –Hegglin anomaly Chediak-Higashi syndrome Autosomal recessive disorder with giant granules,likely representing giant fused lysosomes& abnormal leukocyte function
  • 63. Inherited Pelger-Huet anomaly Bilobed or rounded nuclei with pince-nez shape nucleus Pseudo Pelger-Huet anomaly Hypogranular neutrophils with irregular nuclear pattern
  • 65. E.Hypersegmented Neutrophil Segmentation Index=Number of neutrophils with 5-more lobes ___________________________________ Number of neutrophils with 4 lobes
  • 66. F. Pyknotic neutrophils : Undergoing apoptosis. ◦ May normally be found in infection. ◦ Cells have round, dense, featureless nuclei and cytoplasm is dark pink.
  • 68. MATURE BASOPHIL Marked BASOPHILIA in case with Philadelphia chromosome positivity BASOPHILIC GRANULOCYTE
  • 69. Myeloblast : ◦ Large cell 10-18um. ◦ Round oval nucleus occupying most cell area. -- Nucleoli are typically prominent (2-5) -- Deep blue scanty cytoplasm no granules.
  • 70. Promyelocyte  Slightly larger 12-20um  Shares same features with myeloblast .  Less prominent nucleoli.  Cytoplasm contains blue purple primary azurophilic granules. Myelocyte :  Size 12-18 um  Nucleus is oval or slightly indented, fine chromatin.  No nucleoli are seen or very rare.  Cytoplasmic granules now acquire specific characters. Both primary and secondary granules seen.
  • 71. Metamyelocyte : ◦ Size 10-18m ◦ Indentation less than ½ diameter of nucleus ◦ Condensed chromatin.No nucleoli. ◦ Cytoplasm is abundant with secondary granules only. Band cells : ◦ 10-16 micron. ◦ Indentation more than ½ diameter of nucleus. ◦ Cytoplasm is abundant with secondary granules only.
  • 72. Lymphoblast Myeloblast Nuclear chromatin Coarse Fine Nucleoli 1-2 3-5 N:C ratio High High Auer rod Absent Present Accompanyin g cells Lymphocytes Myeloid precursors
  • 73. SMALL LYMPHOCYTES •Size-6-10 microns •High nucleocytoplasmic ratio •Scant amount of slightly basophilic cytoplasm. •Smooth contour with mature “closed” chromatin and absent nucleoli.
  • 74. LARGE LYMPHOCYTE •Size- 12-15 micron •Moderate nuclear- cytoplasmic ratio •Oval nucleus •Slightly open chromatin •Pale cytoplasm •About 1/3rd may contain azurophilic granules; larger than neutrophilic granules
  • 75. NORMAL CLL ALL L1 type of lymphoblast shown here usually has a high nuclear:cytoplasmi c (N:C) ratio with an immature or “open” chromatin CLL cells appear as slightly larger versions of normal small lymphocytes. CLL cells can display clumped or “soccer ball” chromatin. Small lymphocyte
  • 76. •Large size, abundant basophilic cytoplasm at periphery •Often vacuolated. •Nucleus- Large; irregular •Partially condensed chromatin •Nucleoli present ACTIVATED LYMPHOCYTES ‘Atypical mononuclear cell’
  • 77. ‘TURK CELL’; IMMUNOBLAST •10-15 um size. •Round nucleus, abundant deeply basophilic cytoplasm •Seen in severe bacterial and viral infection
  • 78. PLASMA CELL •Larger than small lymphocyte •Oval in shape with eccentric round nucleus with clumped nuclear chromatin. •Moderate amount of basophilic cytoplasm with prominent nuclear hof Plasma cell
  • 79. MATURE MONOCYTE •Size : 14-20 um •Irregular, lobulated nucleus •Has the most delicate nuclear chromatin pattern. • Abundant light gray cytoplasm with fine granularity and vacuolation seen Deeply indented nucleus
  • 80. Figure 33-24 Promonocyte (center) shows immature chromatin and finely convoluted nuclear folds in comparison with monoblasts.
  • 81.  Degenerative changes  Broken cells  Contracted cells  Endothelial cells  Radial segmentation of the nuclei  Vacuolation  Pseudophagocytosis
  • 82. Ruptured Leukocyte Basket Cell Broken cell of myeloid series Smudge cell
  • 83. ◦ Normal platelets are 2-4 um in diameter. ◦ Irregular outline with fine red granules . ◦ Normal peripheral count 1.0 -5 lac/mm3 ◦ Remain viable in circulation for 10 days. ◦ Large Platelets seen in–hyposplenism, Bernard-Soulier syndrome, May-Hegglin anomaly.
  • 85. Hyposplenism in coeliac disease: GIANT PLATELETS GRAY PLATELET SYNDROME ESSENTIAL THROMBOCYTOSIS MISCELLANEOUS PLATELET ABNORMALITIES
  • 86. 1. MALARIA PARASITE :Plasmodium ◦ Blood is collected at or just after the height of a febrile paroxysm. ◦ One thick & one thin smear should be prepared . ◦ Procedure-Take a large of drop of blood in the centre of a clean glass slide & spread it in an area of 1.5 cm with a slide. ◦ Dry and stain by any Romanowsky combination. Leishman, Giemsa method are suitable.  In P. falciparum often only early trophozoite (ring form) +/- gametocytes are found.  In P. vivax, all stages of life cycle usually present.
  • 87. Male gametocyte: P.falciparum Ring form trophozoite: P. falciparum Ring form: P.vivax Early schizont
  • 88. 2.MICROFILARIA:W.bancrofti  Blood is collected at midnight between 10 p.m.-4a.m.  Blood concentration of microfilaria is higher in capillary blood than in venous blood. Morphology: When stained with Romanowsky stain: •A hyaline sheath seen projecting beyond the body. •Nuclei appear as granules in central axis of body extend from head to tail, but not to the tip of tail.
  • 89. 3.TRYPANOSOMA BRUCEI (African sleeping sickness)  Trypomastigotes can be found in peripheral blood,lymph node aspirate and CSF.  When stained with Leishman stain, cytoplasm & the undulating membrane appear pale blue and the nucleus reddish purple or red.  Kinetoplast & flagellum dark red.
  • 90. 4. TRYPANOSOMA CRUZI – (Chagas disease)  Two forms are found a. Trypomastigote form can only be found in blood in acute form of Chagas disease. b. Amastigote form (in striated muscles) Trypomastigote form appear as C or U shaped.
  • 91. 5. LEISHMANIA DONOVANI ◦ Diagnosed by direct visualization of amastigote (LD bodies) ◦ Causes kala azar . ◦ In aspirate smears amastigote forms are seen in groups inside macrophages or lying free between the cells. ◦ In buffy coat smears they are seen within monocytes or neutrophils in peripheral blood. ◦ Small round bodies 2-4 micron in diameter, indistinct cytoplasm, a nucleus, a small rod shaped kinetoplast .
  • 92. Red Blood Cells, Examine for : 1.Size and shape ( Anisocytosis, Poikilocytosis) 2.Relative hemoglobin content. 3.Polychromatophilia. 4.Inclusions. 5. Rouleaux formation or agglutination White Blood Cells 1.Check for even distribution and estimate the number present (also, look for any gross abnormalities present on the smear). 2.Perform the differential count. 3.Examine for morphologic abnormalities and immature cells. Platelets. 1.Estimate number present. 2. Examine for morphologic abnormalities, aggregates.  Comment on any haemoparasites, if present.