Blood Cells E-Book

Barbara J. Bain

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1278

Veröffentlichungsjahr: 2014

Beschreibung

• Enables both the haematologist and laboratory scientist to identify blood cell features, from the most common to the more obscure
• Provides essential information on methods of collection, blood film preparation and staining, together with the principles of manual and automated blood counts
• Completely revised and updated, incorporating much newly published information: now includes advice on further tests when a specific diagnosis is suspected
• 400 high quality photographs to aid with blood cell identification
• Highlights the purpose and clinical relevance of haematology laboratory tests throughout

Leseprobe

Blood Cells

A Practical Guide

Barbara J. Bain MBBS, FRACP, FRCPath

Professor in Diagnostic Haematology St Mary's Hospital Campus of Imperial College Faculty of Medicine, London and Honorary Consultant Haematologist, St Mary's Hospital, London

FIFTH EDITION

This edition first published 2015 © 2015 by John Wiley & Sons Ltd. © 2006, 2002,1995 Barbara J. Bain

First published 1989 (published by Gower Medical Publishing); Second Edition published 1995; Third Edition published 1996; Reprinted 2003; Fourth Edition published 2006; Fifth Edition published 2015

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Cover images: Main (background) image: 3D red blood cells flowing in a vein. ©iStock.com/JoenStock. Other images: taken from within this book. For more details, see the figures captions for figures 2.16 (centre left), 8.19, 9.19 and 9.44(a).

Contents

Preface

Acknowledgements

List of abbreviations

About the companion website

1 Blood sampling and blood film preparation and examination

Obtaining a blood specimen

Specimen mixing

Making a blood film

Fixation, staining and mounting

Storage of slides

Setting up and using a microscope

Examining a blood film

Note

References

2 Performing a blood count

Basic techniques

Automated image analysis

Automated blood cell counters

Near-patient testing

References

3 Morphology of blood cells

Examining the blood film

Erythrocytes

Leucocytes

Granulocytes

Lymphocytes and plasma cells

Cells of monocyte lineage

Granulocyte precursors

Leucoerythroblastic blood films

The mast cell

Disintegrated cells

Platelets and circulating megakaryocytes

Platelets

Megakaryocytes

Blood film in healthy subjects

Non-haemopoietic cells

Micro-organisms in blood films

Further learning resources for blood film morphology

References

4 Detecting erroneous blood counts

The sources of errors in blood counts

The detection of errors in automated blood counts

Errors in automated WBC

Errors in haemoglobin concentration and red cell indices

Errors in platelet counts

Errors in automated differential counts

Errors in automated reticulocyte counts and other reticulocyte measurements

References

5 Normal ranges

Normal ranges for adults

Normal ranges for neonates and fetuses

Normal ranges in infants and children

Normal ranges in pregnancy

Normal ranges for platelet counts and other platelet variables

Normal ranges for reticulocyte counts

References

6 Quantitative changes in blood cells

Polycythaemia

Reticulocytosis

Leucocytosis

Lymphocytosis

Monocytosis

Plasmacytosis

Thrombocytosis

Anaemia

Reticulocytopenia

Leucopenia

Neutropenia

Eosinopenia

Basopenia

Monocytopenia

Lymphocytopenia (lymphopenia)

Thrombocytopenia

Pancytopenia

References

7 Important supplementary tests

Cytochemical techniques

Cytochemical stains used in the diagnosis and classification of leukaemias

Flow cytometric immunophenotyping

Immunocytochemistry

Cytogenetic analysis

Fluorescence

in situ

hybridisation

Molecular genetic analysis

Ultrastructural examination

References

8 Disorders of red cells and platelets

Disorders of red cells

Hypochromic and microcytic anaemias and thalassaemias

Congenital haemolytic anaemias

Other defects of the erythrocyte membrane

Acquired haemolytic anaemias

Polycythaemia

Disorders of platelets

References

9 Disorders of white cells

Reactive changes in white cells

T-lineage lymphoproliferative disorders

References

Index

End User License Agreement

List of Tables

Chapter 1

Table 1.1

Table 1.2

Chapter 2

Table 2.1

Table 2.2

Table 2.3

Table 2.4

Table 2.5

Table 2.6

Table 2.7

Chapter 3

Table 3.1

Table 3.2

Table 3.3

Table 3.4

Table 3.5

Table 3.6

Table 3.7

Table 3.8

Tablae 3.9

Table 3.10

Table 3.11

Table 3.12

Table 3.13

Table 3.14

Table 3.15

Chapter 4

Table 4.1

Table 4.2

Table 4.3

Table 4.4

Table 4.5

Table 4.6

Table 4.7

Table 4.8

Table 4.9

Table 4.10

Table 4.11

Table 4.12

Table 4.13

Table 4.14

Chapter 5

Table 5.1

Table 5.2

Table 5.3

Table 5.4

Table 5.5

Table 5.6

Table 5.7

Table 5.8

Table 5.9

Table 5.10

Table 5.11

Table 5.12

Table 5.13

Table 5.14

Table 5.15

Table 5.16

Table 5.17

Table 5.18

Table 5.19

Table 5.20

Table 5.21

Chapter 6

Table 6.1

Table 6.2

Table 6.3

Table 6.4

Table 6.5

Table 6.6

Table 6.7

Table 6.8

Table 6.9

Table 6.10

Table 6.11

Table 6.12

Table 6.13

Table 6.14

Table 6.15

Table 6.16

Table 6.17

Table 6.18

Table 6.19

Table 6.20

Table 6.21

Table 6.22

Table 6.23

Table 6.24

Table 6.25

Table 6.26

Table 6.27

Table 6.28

Table 6.29

Table 6.30

Chapter 7

Table 7.1

Table 7.2

Table 7.3

Table 7.4

Chapter 8

Table 8.1

Table 8.2

Table 8.3

Table 8.4

Table 8.5

Table 8.6

Table 8.7

Table 8.8

Table 8.9

Table 8.10

Table 8.11

Table 8.12

Table 8.13

Table 8.14

Chapter 9

Table 9.1

Table 9.2

Table 9.3

Table 9.4

Table 9.5

Table 9.6

Table 9.7

Table 9.8

Table 9.9

Table 9.10

Table 9.11

Table 9.12

Table 9.13

Table 9.14

Table 9.15

Table 9.16

List of Illustrations

Chapter 1

Fig. 1.1

 Anterior surface of the left arm showing veins most suitable for venepuncture.

Fig. 1.2

Venepuncture technique using needle and syringe.

Fig. 1.3

Venepuncture technique using an evacuated container; the distal end of the needle has been screwed into the holder and the proximal needle has then been unsheathed and inserted into a suitable vein.

Fig. 1.4

Venepuncture technique using an evacuated container; the evacuated container has been inserted into the holder and forced onto the sharp end of the needle.

Fig. 1.5

The areas of the foot of a baby or infant that are suitable for obtaining capillary blood.

Fig. 1.6

A blood film from ethylenediaminetetra-acetic acid (EDTA)-anticoagulated blood showing an even distribution of platelets.

Fig. 1.7

A blood film from non-anticoagulated capillary blood showing the aggregation of platelets that usually occurs.

Fig. 1.8

A blood film from non-anticoagulated venous blood showing the minor degree of platelet aggregation that usually occurs.

Fig. 1.9

The method of spreading a blood film.

Fig. 1.10

Blast cells from a patient with acute leukaemia that have been inadvertently transferred to the blood film of another patient by the use of an inadequately cleaned spreader.

Fig. 1.11

Unsatisfactory and satisfactory blood films: (a) uneven pressure has produced ridges; (b) too broad and too long — the edges and the tail of the film cannot be examined adequately; (c) too long and streaked by an uneven spreader; (d) too thick and short due to the wrong angle or speed of spreading; (e) even distribution of blood cells has been interrupted because the slide was greasy; (f) satisfactory.

Fig. 1.12

Thick films for examination for malarial parasites: (a) unstained film showing the correct thickness of the film of blood; and (b) film stained without fixation, causing lysis of red cells.

Fig. 1.13

A blood film that has been fixed before drying was complete. It is important not to confuse the apparent leaking of nuclear contents into the cytoplasm, which is an artefactual change, with dyserythropoiesis.

Fig. 1.14

Artefactual changes produced by 5% water in the methanol used for fixation.

Fig. 1.15

A drawing of a microscope showing the names of the individual parts.

Chapter 2

Fig. 2.1

 Absorbance spectrum of cyanmethaemoglobin.

Fig. 2.2

Measurements of packed cell volume (PCV) by the microhaematocrit technique; paired tests from three patients are shown.

Fig. 2.3

Diagrams of blood films showing tracking patterns employed in a differential white blood cell count: (a) tracking along the length of the film; (b) battlement method; and (c) modified battlement method – two fields are counted close to the edge parallel to the edge of the film, then four fields at right angles, then two fields parallel to the edge and so on.

Fig. 2.4

Reticulocytes stained with new methylene blue. (a) A group I reticulocyte with a dense clump of reticulum, several group II reticulocytes with a wreath or network of reticulum and several group III reticulocytes with a disintegrated wreath of reticulum. (b) Group II, III and IV reticulocytes: the group IV reticulocyte has two granules of reticulum. There is also a cell with a single dot of reticulum. By some criteria this would also be classified as a reticulocyte. (c) Three reticulocytes and a Howell-Jolly body.

Fig. 2.5

 The appearance of a Miller ocular micrometer for use in counting reticulocytes.

Fig. 2.6

Semi-diagrammatic representation of part of Coulter Counter, model FN, showing the aperture tube and the manometer used for metering the volume of cell suspension counted. Right: diagrammatic representation of the cross-section of the aperture tube of an impedance counter.

Fig. 2.7

Histograms produced by a Coulter S Plus IV automated counter showing volume distribution of white cells, red cells and platelets.

Fig. 2.8

Printouts of Coulter STKS automated counter. (a) Scatter plot of white cell volume against discriminant function 1. There are four white cell populations: NEUT, neutrophils; EOS, eosinophils; MONO, monocytes; and LYMPH, lymphocytes. (b) Scatter plots of white cell volume against discriminant function 2 showing three white cell populations: GRAN, neutrophils, eosinophils and basophils; MONO, monocytes; and LYMPH, lymphocytes. (c) Scatter plots of white cell volume against discriminant function 3 showing three white cell populations; BASO, basophils; MONO, monocytes; and LYMPH, lymphocytes. (d) Histogram showing size distribution of red cells and platelets.

Fig. 2.9

Printouts from Beckman–Coulter DxH 800. (a) Scatter plots from the differential channel, five-part differential 1 (5PD1) and five-part differential 2 (5PD2), showing a plot of volume (v) against multi-angle rotated light scatter (RLSn) (left) and volume against opacity (right); in the corresponding three-dimensional representations (centre) the heights of the peaks reflect cell numbers; a composite three-dimensional plot (bottom left) can be rotated using a mouse to demonstrate different populations; histograms (bottom right)show the size of white blood cells (WBC), red blood cells (RBC) and platelets (PLT) in their respective channels; (b) Two-dimensional and three-dimensional plots in the nucleated red blood cell (NRBC) channel showing the separation of NRBC from leucocytes; two light scatter measurements, RLAS (NRBC1, left) and RUMALS (NRBC2, right) are plotted against axial light loss (AL2), which measures the light absorbed as the cell passes through the flow cell (an indicator of cell size but also influenced by cellular transparency). By courtesy of Beckman–Coulter.

Fig. 2.10

Scatterplot and histograms produced by Beckman–Coulter A

c

T 5diff counter: (a) normal; (b) sample with eosinophilia; (c) sample with monocytosis.

Fig. 2.11

Graphic output of Sysmex SE-9000 automated haematology analyser. (a) White cell scatter plots and red cell, platelet, eosinophil and basophil volume histograms on a normal sample. (b) White cell scatter plots – radiofrequency (RF) against direct current (DC) – of an abnormal sample with an increase of immature granulocytes. White cell populations shown are: GRAN, granulocytes; LYMPH, lymphocytes; MONO, monocytes (left); and immature granulocytes in a separate cluster from erythrocytes and residues of other leucocytes (right).

Fig. 2.12

Scatter plots and histograms of the Sysmex XE-2100 showing the leucocyte clusters (DIFF), the white cell count/basophil channel (WBC/BASO), immature granulocytes (IMI), nucleated red cell (NRBC), the reticulocyte channel (RET), the optical (fluorescent) platelet count (PLT-O) and red cell and platelet histograms (RBC and PLT).

Fig. 2.13

Scatter plots of the Sysmex XE-2100 on a blood sample from a patient with acute myeloid leukaemia showing the leucocyte clusters (DIFF), the white cell count/basophil channel (WBC/BASO), immature myeloid information (IMI) and nucleated red cell (NRBC) scatter plots. The WBC was 38.2 × 10

9

/l with flags for suspected blast cells and suspected immature granulocytes. The IMI scatter plot shows an abnormal population of blast cells and granulocyte precursors (red) and another population that represents mature granulocytes and the ghosts or erythrocytes (blue).

Fig. 2.14

Histograms and scatter plots of red cell volume and red cell haemoglobin concentration and white cell scatter plots produced by a Bayer-Technicon H.2 counter. In the peroxidase channel forward light scatter, largely determined by cell volume, is plotted against light absorbance, largely determined by the intensity of the peroxidase reaction. There are five white cell populations: NEUT, neutrophils; MONO, monocytes; LYMPH, lymphocytes; EOS, eosinophils; and LUC, large unstained cells, which are large, peroxidase-negative cells. In the basophil/lobularity channel forward light scatter, representing cell volume following differential cytoplasmic stripping, is plotted against high-angle light scatter, which is determined largely by cellular structure. There are three cell clusters, two of which overlap: BASO, basophils; MONONUC, mononuclear cells (lymphocytes and monocytes); and GRAN, granulocytes (neutrophils and eosinophils).

Fig. 2.15

Scatter plots produced by the Siemens Advia 120 on a normal blood sample, showing the peroxidase channel (top left, Perox), the basophil channel (top right, Baso), a plot of red cell size versus haemoglobin concentration (bottom left, RBC V/HC) and the reticulocyte channel scatter plot (bottom right, Retic Scatter Abs). In the Perox channel, the bottom left area is occupied by NRBC (on the left) and noise (on the right), platelet clumps appear in the area to the right of the lymphocyte box; in this channel basophils are located in the lymphocyte box. In comparison with H.1 series instruments, the Baso channel now has an area of noise (bottom) and a blast box (above and to the left of the noise box); the previous basophil box is divided into basophils (left) and ‘Baso suspect’ (right); on the extreme right, a narrow box is ‘signals in saturation’.

Fig. 2.16

Scatter plots and histograms produced by the Siemens Advia 120 on a blood sample from a patient with hereditary spherocytosis, showing the peroxidase channel (top left, Perox), the basophil channel (top right, Baso), a plot of red cell size versus haemoglobin concentration (centre left, RBC V/HC) and a plot of platelet size against platelet component (centre right, PLT volume PC). The y-axis in the PLT volume PC plot is the refraction index, proportional to the ‘platelet component’ (PC). At the bottom are histograms of red cell volume, red cell haemoglobin concentration (HC) and platelet volume. Note that there is a population of hyperdense cells representing spherocytes, apparent in the red cell cytogram and in the histogram of red cell haemoglobin concentration (RBC HC), crossing the right-hand haemoglobin concentration threshold in both plots. Red cell indices were RBC 3.55 × 10

12

/l, Hb 109 g/l, Hct 0.32, MCV 89.2 fl, MCH 30.8 pg, MCHC 346 g/l and CHCM 396 g/l. By courtesy of Professor Gina Zini, Rome.

Fig. 2.17

Graphic output of Cell-Dyn 3500 automated counter, showing histograms of volume distribution of RBC, platelets (PLT) and white cells (WIC) derived from the impedance channel.

Fig. 2.18

Graphic output of a Cell-Dyn 3500 counter, showing white cell scatter plots derived from the white cell optical channel. (a) A plot of 90° scatter (indicating lobularity) against 10° scatter (indicating complexity) separates a granulocyte cluster from a mononuclear cluster. (b) 90°D (depolarised) scatter against 90° scatter separates the granulocyte cluster into eosinophils (which depolarise light) and neutrophils (which do not). (c) 0° scatter (related to size) against 10° scatter (related to complexity) separates the mononuclear cell cluster into lymphocytes, monocytes and degranulated basophils. (d) The five populations thus identified are shown on a plot of 90° scatter (related to lobularity) against 0° scatter (related to size). GRAN, granulocytes; MONONUC, mononuclear cells; NEUT, neutrophils; MONO, monocytes; LYMPH, lymphocytes; and EOS, eosinophils.

Fig. 2.19

Histograms of red cell (RBC) and platelet (PLT) size distribution and scatter plots of the differential white cell channel (DDM) and the reticulocyte channel (RET) of the Horiba ABX Pentra 120 analyser.

Fig. 2.20

Scatter plot of the reticulocyte count of the Sysmex R.3000. Cell volume is plotted against fluorescence intensity. A threshold separates red cells from platelets. Reticulocytes are divided into high fluorescence (HFR) representing the most immature reticulocytes, intermediate fluorescence (MFR) and low fluorescence (LFR) representing late reticulocytes.

Fig. 2.21

Printout of a Bayer H.3 counter showing the scatter plot of the reticulocyte counting channel. The volume and haemoglobin content of reticulocytes and other red cells are determined by high- and low-angle light scattering and light absorbance is measured following uptake of a nucleic acid dye, oxazine 750. Six variables of potential clinical usefulness are measured for reticulocytes as well as for total red cells: MCV, CHCM (= MCHC), RDW, HDW (in g/dl), CH (= MCH) and CHDW (HDW in pg). Cell volume is plotted against light absorbance. Reticulocytes are divided into high absorbance (H RETIC) representing early reticulocytes, intermediate absorbance (M RETIC) and low absorbance (L RETIC) representing late reticulocytes.

Fig. 2.22

Photograph of the colour monitor of a Bayer H.3 automated counter. The scattergram shows volume and haemoglobin content of reticulocytes (blue) in relation to size and haemoglobin content of other red cells (red) on both a Mie map and a red cell cytogram. This sample had a greatly increased reticulocyte count as a consequence of a haemolytic transfusion reaction.

Fig. 2.23

Scatter plots and histograms produced by the Siemens Advia 120 on a blood sample from a patient with pure red cell aplasia showing reticulocytopenia. The red cell cytogram (RBC V/HC) shows that there is macrocytosis (increased signals above the upper volume threshold). Note that, in comparison with the increased reticulocytes seen in Fig. 2.21, there are virtually no reticulocytes (blue dots) in the bottom right plot of light absorption in the reticulocyte channel. The absolute reticulocyte count was very low, 9.2 × 10

9

/l, with a reticulocyte percentage of 0.43. Red cells indices were RBC 2.14 × 10

12

/l, Hb 68 g/l, Hct 0.21, MCV 99 fl, MCH 31.8 pg, MCHC 321 g/l, CHCM 325 g/l, RDW 21%. Note that because of heterogeneity of red cell size, the MCV at the upper limit of normal does not reflect the presence of the significant number of macrocytes that are seen in the red cell histogram and cytogram; instrument flags included macrocytosis +++ and anisocytosis ++. By courtesy of Professor Gina Zini.

Fig. 2.24

Reticulocyte scatter plots and three-dimensional representations from Beckman–Coulter DxH 800 instrument on a sample of normal blood. In the plot of volume (v) against log of light scatter (LLSn) the reticulocyte and immature reticulocytes form clusters distinct from mature red cells and white cells (RETIC1, left). In the plot of volume against opacity (OP) the reticulocytes do not appear to separate (RETIC2, right), but in fact the software identifies them in three-dimensional analysis. By courtesy of Beckman–Coulter.

Chapter 3

Fig. 3.1

Blood film of a patient with multiple myeloma (left) compared with another blood film stained in the same batch (right). The deeper blue staining occurs because the high concentration of immunoglobulin leads to increased uptake of the basic component of the stain.

Fig. 3.2

Blood films from a patient with a potent cold agglutinin. The left-hand film, which shows marked agglutination, was prepared from ethylenediaminetetra-acetic acid (EDTA)-anticoagulated blood that had been standing at room temperature. The right-hand film, which shows no macroscopic agglutination, was prepared from blood warmed to 37°C.

Fig. 3.3

Blood film from a patient with multiple myeloma showing cryoglobulin precipitates. Courtesy of Dr Sue Fairhead, London.

Fig. 3.4

Blood film showing visible aggregates of tumour cells: (a) macroscopic photograph of slide; (b) photomicrograph, low power, showing that the visible masses are clumps of tumour cells. Courtesy of Dr Sue Fairhead.

Fig. 3.5

Platelet aggregate in a blood film. Following aggregation, some of the platelets have discharged their granule contents and thus appear grey.

Fig. 3.6

Fibrin strands in a blood film from a patient with a hypercoagulable state. The fibrin strands are very weakly basophilic and cause deformation of the red cells between which they pass. Fibrin strands can also form when there has been partial clotting of a blood specimen because of difficulty in venepuncture.

Fig. 3.7

Blood film showing storage artefact – crenation (echinocytosis), a disintegrated cell and a neutrophil with a rounded pyknotic nucleus.

Fig. 3.8

Blood film showing storage artefact – mild crenation and lobulation of a lymphocyte nucleus.

Fig. 3.9

Blood film from a blood specimen that has been transported in a hot motor vehicle, showing red cell budding and fragmentation.

Fig. 3.10

Low power view of a blood film showing large cryoglobulin crystals.

Fig. 3.11

Blood film showing crystals of cryoglobulin. By courtesy of Dr Poormina Kumar, London.

Fig. 3.12

Blood film showing an amorphous deposit of cryoglobulin; there is also phagocytosed cryoglobulin within the neutrophil.

Fig. 3.13

Blood film from a patient with hyperlipidaemia showing misshapen red cells with fuzzy outlines and blurring of the outline of the lobes of a neutrophil resulting from the high concentration of lipids.

Fig. 3.14

Red cell agglutinates in the peripheral blood film of a patient with a high titre cold agglutinin.

Fig. 3.15

Scanning electron micrograph of a normal red cell (discocyte). Courtesy of Professor Aaron Polliack, Jerusalem, from Hoffbrand and Pettit [8].

Fig. 3.16

Blood film of a healthy subject showing normal red cells and platelets. The red cells show little variation in size and shape. Some of the platelets show granules dispersed through the cytoplasm, while others have a granulomere and a hyalomere.

Fig. 3.17

Microcytosis in a patient with β thalassaemia trait; the MCV was 62 f1. The blood film also shows mild hypochromia, anisocytosis and poikilocytosis.

Fig. 3.18

Macrocytosis associated with liver disease; the MCV was 105 fl. Several target cells are also present.

Fig. 3.19

Hypochromic red cells in a patient with iron deficiency anaemia. The film also shows anisochromasia.

Fig. 3.20

A dimorphic peripheral blood film from a patient with sideroblastic anaemia as a feature of a myelodysplastic syndrome (MDS). One population of cells is normocytic and normochromic while the other is microcytic and hypochromic. One of the poorly haemoglobinised red cells contains some Pappenheimer bodies.

Fig. 3.21

Scanning electron microscopy of a reticulocyte. Courtesy of Professor Aaron Polliack, from Hoffbrand and Pettit [8].

Fig. 3.22

A polychromatic cell that is also larger than a normal cell; it may be designated a polychromatic macrocyte. The film also shows anisocytosis and poikilocytosis.

Fig. 3.23

Blood film showing polychromatic macrocytes in a patient with sickle cell anaemia, illustrating the highly irregular shape of reticulocytes.

Fig. 3.24

Blood film showing striking poikilocytosis in a patient with hereditary pyropoikilocytosis. With thanks to Dr Mike Leach, Glasgow.

Fig. 3.25

Blood film showing striking poikilocytosis in a patient who has co-inherited hereditary elliptocytosis and the genotype of haemoglobin H disease (α

TSaudi

α/ α

TSaudi

α). Elliptocytes are prominent among the numerous poikilocytes.

Fig. 3.26

Blood film showing deformation of red cells by a precipitated cryoglobulin.

Fig. 3.27

Scanning electron micrography of spherocytes and forms intermediate between discocytes and spherocytes. From Bessis [64].

Fig. 3.28

Blood film of a patient with severe burns showing spherocytes, microspherocytes and red cells that appear to be budding off very small spherocytic fragments.

Fig. 3.29

Blood film of a patient with clostridial septicaemia showing many spherocytes. Courtesy of the late Professor Harry Smith.

Fig. 3.30

Spherocytes in the peripheral blood film of an iron deficient patient who suffered a delayed transfusion reaction due to an anti-Rh D antibody; the film is dimorphic, showing a mixture of the recipient’s hypochromic microcytic cells and the donor cells, which have become spherocytic.

Fig. 3.31

Blood film of a patient with haemoglobin C disease showing irregularly contracted cells and several target cells.

Fig. 3.32

Scanning electron micrograph showing a hemi-ghost cell containing Heinz bodies. Courtesy of Dr T.K. Chan and colleagues, Hong Kong, and the

British Journal of Haematology

[72].

Fig. 3.33

Transmission electron micrograph showing a hemi-ghost cell containing Heinz bodies. Courtesy of Dr T.K. Chan and colleagues, Hong Kong, and the

British Journal of Haematology

[72].

Fig. 3.34

Blood film of a patient with hereditary elliptocytosis showing elliptocytes and ovalocytes.

Fig. 3.35

Blood film of a patient with primary myelofibrosis showing teardrop poikilocytes (dacrocytes).

Fig. 3.36

Echinocytes in the peripheral blood film of a patient with chronic renal failure.

Fig. 3.37

Scanning electron micrograph of an echinocyte. Courtesy of Professor Aaron Polliack, from Hoffbrand and Pettit [8].

Fig. 3.38

Spheroechinocyte in a peripheral blood film made from blood taken shortly after a blood transfusion. The spheroechinocyte is a transfused cell.

Fig. 3.39

Acanthocytes in the peripheral blood film of a patient with anorexia nervosa.

Fig. 3.40

Scanning electron micrograph of an acanthocyte. Courtesy of Professor Aaron Polliack, from Hoffbrand and Pettit [8].

Fig. 3.41

Blood film showing acanthocytes in choreo-acanthocytosis. By courtesy of Dr Peter Bain, London.

Fig. 3.42

Scanning electron micrograph showing acanthocytes in a patient with the McLeod phenotype. By courtesy of Dr Guy Lucas, Manchester.

Fig. 3.43

Medium power view of a blood film showing acanthocytes resulting from homozygosity for the A858D mutation in the

SLC4A1

gene. Courtesy of Dr Lesley Bruce, Bristol.

Fig. 3.44

Unusually numerous acanthocytes in the peripheral blood film of a haematologically normal subject who has had a splenectomy. The film also shows a target cell.

Fig. 3.45

Numerous acanthocytes in the blood film of a patient with abetalipoproteinaemia.

Fig. 3.46

Numerous acanthocytes in the blood film of a baby with infantile pyknocytosis.

Fig. 3.47

Keratocytes in the peripheral blood film of a patient with microangiopathic haemolytic anaemia.

Fig. 3.48

Scanning electron micrograph of a keratocyte, formed by removal of a Heinz body. Courtesy of Dr M. Amare and colleagues and the

British Journal of Haematology

[107].

Fig. 3.49

Fragments including microspherocytes in the peripheral blood film of a patient with the haemolytic–uraemic syndrome. The film also shows polychromasia and a nucleated red blood cell (NRBC).

Fig. 3.50

The blood film of a patient with sickle cell anaemia showing linear red cell fragments and increased numbers of irregularly contracted cells; the latter feature resulted from a severe pulmonary sickling crisis at the time the film was made.

Fig. 3.51

Blood film of a haematologically normal patient who has had a splenectomy, showing target cells and a Howell–Jolly body.

Fig. 3.52

Scanning electron micrographs of target cells. From Bessis [64].

Fig. 3.53

Blood film in hereditary stomatocytosis showing stomatocytes.

Fig. 3.54

Scanning electron micrograph of stomatocytes. From Bessis [64].

Fig. 3.55

Blood film of a patient with sickle cell anaemia showing sickle cells and boat-shaped cells.

Fig. 3.56

Scanning electron micrograph of a sickle cell. From Bessis [64].

Fig. 3.57

Blood film from a patient with compound heterozygosity for haemoglobin S and haemoglobin C showing a characteristic SC poikilocyte.

Fig. 3.58

Blood film of a patient with compound heterozygosity for haemoglobin S and haemoglobin S-Oman showing the ‘Napoleon hat’ red cells that are characteristic of haemoglobin S-Oman. Courtesy of Dr R.A. Al Jahdamy and colleagues, Oman.

Fig. 3.59

Blood film of a patient with hereditary spherocytosis as a result of a band 3 mutation, showing pincer or mushroom cells.

Fig. 3.60

Prominent basophilic stippling in the peripheral blood film of a patient who has inherited both β thalassaemia trait and hereditary elliptocytosis. The film also shows microcytosis and numerous elliptocytes and ovalocytes. One of the heavily stippled cells is a teardrop poikilocyte. Courtesy of Dr F. Toolis, Dumfries.

Fig. 3.61

Blood film from a patient with sickle cell anaemia showing an erythrocyte containing multiple Pappenheimer bodies. Their peripheral position and tendency to cluster are apparent.

Fig. 3.62

Cabot rings in the blood film of a patient who had received the microtubule inhibitor paclitaxel, medium power. By courtesy of Dr Greg Hapgood, Melbourne.

Fig. 3.63

Blood film of a patient with congenital erythropoietic porphyria showing radially arranged crystals in red cells. Courtesy of Dr Anna Merino and colleagues, Barcelona, and the

British Journal of Haematology

[131].

Fig. 3.64

Blood film of a patient with multiple myeloma showing increased rouleaux formation consequent on the presence of a paraprotein; the film also shows increased background staining and a circulating myeloma cell.

Fig. 3.65

Red cell rosetting.

Fig. 3.66

Blood film of a healthy subject showing a normal polymorphonuclear neutrophil and normal small lymphocyte. The disposition of the nuclear lobes around the circumference of a circle is apparent.

Fig. 3.67

Blood film of a healthy female showing a normal neutrophil with a drumstick.

Fig. 3.68

A neutrophil band form. The nucleus is non-segmented and also has chromatin that is less condensed than that of the majority of segmented neutrophils.

Fig. 3.69

A hypersegmented neutrophil showing seven nuclear lobes. The film also shows anisocytosis with both microcytes and macrocytes.

Fig. 3.70

Blood film of a patient with MDS showing two neutrophils. Both are macropolycytes and one shows a defect of nuclear segmentation resembling myelokathexis. The size of the cells and the amount of nuclear material suggest that they are tetraploid cells.

Fig. 3.71

Blood film of a healthy female showing a band neutrophil with a sessile nodule.

Fig. 3.72

Blood film of a patient with chronic myelomonocytic leukaemia showing neutrophils with abnormal nuclear projections.

Fig. 3.73

Blood film of a patient with the inherited Pelger–Huët anomaly showing three neutrophils with: (a) bilobed nucleus; (b) peanut-shaped nucleus; and (c) non-lobed nucleus.

Fig. 3.74

Blood film of a patient with specific granule deficiency showing an agranular neutrophil with reduced nuclear lobulation. By courtesy of Dr Mike Leach.

Fig. 3.75

Blood film of a patient with the acquired Pelger–Huët anomaly as part of a therapy-related myelodysplastic syndrome showing: (a) neutrophil with non-lobed nucleus; and (b) anisocytosis, poikilocytosis and neutrophil with bilobed nucleus.

Fig. 3.76

Blood film from a patient with reversible myelodysplasia caused by mycophenolate mofetil. Both neutrophils have a non-segmented rounded nucleus with very coarse chromatin clumping; one also has a high nucleocytoplasmic ratio.

Fig. 3.77

Blood film of a patient with chronic myelogenous leukaemia (CML) showing neutrophils and neutrophil precursors. There is one neutrophil with a ring-shaped nucleus.

Fig. 3.78

Blood film from a patient with severe burns showing a neutrophil with a botryoid nucleus containing a small Döhle body.

Fig. 3.79

Composite image of peripheral blood film from a patient with cocaine-induced hyperthermia showing botryoid nuclei. With thanks to Dr Patrick Ward, Duluth, Minnesota.

Fig. 3.80

Blood film of a patient on combination chemotherapy for lymphoma showing a neutrophil with a detached nuclear fragment (Howell–Jolly body-like inclusion).

Fig. 3.81

Blood film of a patient with acute myeloid leukaemia (AML) showing three blasts and a hypogranular neutrophil.

Fig. 3.82

Three neutrophils in the peripheral blood film of a patient with bacterial infection showing toxic granulation and vacuolation.

Fig. 3.83

Blood film of a patient with the idiopathic hypereosinophilic syndrome showing a normal neutrophil, a neutrophil with abnormally heavy granulation and a hypogranular band eosinophil.

Fig. 3.84

Blood film of a patient with the Maroteaux–Lamy syndrome showing the Alder–Reilly anomaly of neutrophils. The neutrophil has granules that resemble ‘toxic’ granules. The other granulocyte is probably an eosinophil with granules having very abnormal staining characteristics. Courtesy of Mr Alan Dean, Nottingham.

Fig. 3.85

Blood film of a patient with the Chédiak–Higashi syndrome showing a neutrophil with giant and abnormally staining granules. Courtesy of Dr J. McCallum, Kirkaldy.

Fig. 3.86

Bone marrow film of a patient with giant actin inclusions (Brandalise syndrome) showing blue inclusions in a neutrophil and a promyelocyte. Similar inclusions were present in peripheral blood neutrophils and also in eosinophils, basophils, monocytes and lymphocytes. Courtesy of Dr R.C. Ribeiro, Memphis.

Fig. 3.87

Blood film of a patient with MDS showing pseudo-Chédiak–Higashi granules in a neutrophil.

Fig. 3.88

Peripheral blood film of a patient with AML showing blasts, one of which contains an Auer rod.

Fig. 3.89

Blood film of a patient with AML showing a blast cell and a mature neutrophil that contains an Auer rod. By courtesy of Professor Daniel Catovsky, London.

Fig. 3.90

Blood film of a patient with a heavy alcohol intake showing prominent vacuolation of neutrophils. Courtesy of Dr Wendy Erber, Perth, Australia.

Fig. 3.91

Blood film of a patient with septicaemia showing a Döhle body in a neutrophil.

Fig. 3.92

Blood film of a patient with severe burns showing a prominent Döhle body. The red cells also show abnormalities attributable to burns.

Fig. 3.93

Blood film of a patient with the May–Hegglin anomaly showing a May–Hegglin inclusion, which resembles a Döhle body. Large platelets are also apparent. Courtesy of Dr Norman Parker, London.

Fig. 3.94

Blood film of a patient with

Plasmodium falciparum

malaria showing malaria pigment in a neutrophil and ring forms of the parasite within red cells.

Fig. 3.95

Blood film of a patient with malaria showing microgametes of

Plasmodium vivax

that have been phagocytosed by neutrophils.

Fig. 3.96

Blood film of a patient with cryoglobulinaemia showing cryoglobulin that has been ingested by neutrophils and appears as: (a) small round inclusions; and (b) large masses filling the cytoplasm and displacing the nucleus. Some extracellular cryoglobulin is also present. Courtesy of Mr Alan Dean.

Fig. 3.97

Blood film showing a lupus erythematosus (LE) cell that has formed spontaneously.

Fig. 3.98

Blood film showing a neutrophil containing melanin in a patient with widely disseminated malignant melanoma. By courtesy of Dr John Luckit, London, and the late Dr David Swirsky.

Fig. 3.99

The blood film of a young baby showing a neutrophil containing refractile bilirubin crystals. By courtesy of Dr Sudharma Vidyatilake, Colombo.

Fig. 3.100

Blood film of a patient with MDS showing a macropolycyte, which is twice the size of the adjacent normal neutrophil. The nucleus is also twice normal size and shows increased nuclear segmentation; it is likely that this is a tetraploid cell. In addition the film shows anisochromasia.

Fig. 3.101

Blood film of a patient with chronic lymphocytic leukaemia (CLL) and reversible chlorambucil-induced myelodysplasia showing a binucleated tetraploid neutrophil. Courtesy of the late Dr P.C. Srivastava.

Fig. 3.102

Blood film of a patient with the acquired immune deficiency syndrome (AIDS) showing a hypogranular (probably tetraploid) giant metamyelocyte.

Fig. 3.103

Blood film of a patient with megaloblastic anaemia showing an apoptotic neutrophil. The chromatin has condensed and the nucleus has fragmented into rounded pyknotic masses. The film also shows anisocytosis, macrocytosis and a teardrop poikilocyte.

Fig. 3.104

Blood film of a patient with AML showing five apoptotic leukaemic cells.

Fig. 3.105

Blood film of a patient with overwhelming sepsis showing neutrophil aggregation, left shift, toxic granulation and neutrophil vacuolation.

Fig. 3.106

Blood film of a patient with rheumatoid arthritis showing neutrophil aggregation caused by a cold antibody. In this patient,

in vitro

neutrophil aggregation was observed for more than a decade and often led to inaccurate automated white cell counts (WBCs).

Fig. 3.107

An eosinophil in the peripheral blood film of a healthy subject.

Fig. 3.108

Blood film of a female with idiopathic hypereosinophilic syndrome (HES) showing two eosinophils, one of which has a drumstick.

Fig. 3.109

Blood film of a patient with idiopathic HES showing eosinophil hypersegmentation. Both eosinophils have nuclei with four lobes.

Fig. 3.110

Blood film of a patient with the inherited Pelger–Huët anomaly showing a bilobed neutrophil and a nonlobed eosinophil.

Fig. 3.111

Blood film of a patient with cyclical oedema with eosinophilia showing an eosinophil with a ring-shaped nucleus.

Fig. 3.112

Blood film of a patient with MDS showing a non-lobulated and hypogranular eosinophil.

Fig. 3.113

Blood film of a patient with the Chédiak–Higashi syndrome showing an abnormally granulated eosinophil. Courtesy of Dr J. McCallum.

Fig. 3.114

An eosinophil in a peripheral blood film in GM1 ganglosidosis (β galactosidase deficiency) showing vacuolation and abnormal granules; the lymphocyte is also vacuolated. Courtesy of Dr Jií Pavl   , London.

Fig. 3.115

Blood film of a patient with CML showing a normal neutrophil and an eosinophil with some basophilic granules.

Fig. 3.116

A basophil and a small lymphocyte in the peripheral blood film of a healthy subject.

Fig. 3.117

Blood film of a patient with the inherited Pelger–Huët anomaly showing a hypolobated basophil.

Fig. 3.118

Blood film of a patient with the Chédiak–Higashi syndrome showing an abnormal basophil. Courtesy of Dr J. McCallum.

Fig. 3.119

Blood film of a patient with MDS showing a hypogranular basophil.

Fig. 3.120

A small lymphocyte in the peripheral blood film of a healthy subject.

Fig. 3.121

A large lymphocyte in the peripheral blood film of a healthy subject.

Fig. 3.122

A large granular lymphocyte in the peripheral blood film of a healthy subject.

Fig. 3.123

Blood film of a patient with the Chédiak–Higashi syndrome showing a lymphocyte with a large cytoplasmic inclusion. Courtesy of Dr J. McCallum.

Fig. 3.124

Blood film of a patient with the Sanfilippo syndrome showing: (a) abnormal lymphocyte inclusions, which are surrounded by a halo; and (b) metachromatic staining of the lymphocyte inclusions when stained with toluidine blue. Courtesy of Mr Alan Dean.

Fig. 3.125

Lymphocyte in a peripheral blood film in GM1 ganglosidosis (β galactosidase deficiency) showing vacuolation with abnormal granular material within the vacuoles. Courtesy of Dr Jií Pavl   .

Fig. 3.126

Blood film of a child with I-cell disease. One of the two lymphocytes shows heavy cytoplasmic vacuolation.

Fig. 3.127

Blood film of a post-operative patient showing a plasma cell and a neutrophil with toxic granulation and a drumstick.

Fig. 3.128

The same peripheral blood film as shown in Fig. 3.127 showing a plasmacytoid lymphocyte.

Fig. 3.129

A Mott cell in a peripheral blood film.

Fig. 3.130

A plasmacytoid lymphocyte containing crystals in the peripheral blood film of a patient with bacterial sepsis.

Fig. 3.131

A buffy coat film from the same patient whose peripheral blood film is shown in Fig. 3.130 showing one plasmacytoid lymphocyte containing globular inclusions and another containing a giant crystal.

Fig. 3.132

An immunoblast in the peripheral blood film of a patient with infectious mononucleosis.

Fig. 3.133

Atypical lymphocytes in the peripheral blood film of a patient with cytomegalovirus infection.

Fig. 3.134

A peripheral blood lymphocyte in mitosis.

Fig. 3.135

A binucleated lymphocyte in the peripheral blood film of a female cigarette smoker with persistent polyclonal B-cell lymphocytosis.

Fig. 3.136

An apoptotic lymphocyte in the peripheral blood of a patient with infectious mononucleosis. There are also red cell agglutinates.

Fig. 3.137

Blood film in chronic lymphocytic leukaemia showing globular cytoplasmic inclusions. There is also a smear cell. Courtesy of Dr Jan Haskta and Professor Georgia Metzgeroth, Mannheim.

Fig. 3.138

Blood film in non-Hodgkin lymphoma showing Auer rod-like cytoplasmic inclusions. Courtesy of Lyndall Dial, Brisbane.

Fig. 3.139

Lymphocyte aggregation of uncertain significance (low power). There was no evidence of a clonal disorder. With thanks to Dr Jecko Thachil and Dr Anthony Carter, Liverpool.

Fig. 3.140

A normal monocyte in the peripheral blood film of a healthy subject.

Fig. 3.141

Blood film of a patient with the Maroteaux–Lamy syndrome showing a monocyte with an abnormal cytoplasmic inclusion. Courtesy of Mr Alan Dean.

Fig. 3.142

A monocyte containing a large brick-red inclusion in Chédiak–Higashi syndrome. There is also an eosinophil with giant granules, some of which are more darkly staining than normal. With thanks to Dr Abbas Abdulsalam, Baghdad.

Fig. 3.143

An abnormally vacuolated monocyte and a very heavily vacuolated lymphocyte in the peripheral blood of a patient with galactosidaemia. By courtesy of Dr Guy Lucas.

Fig. 3.144

Blood film of a patient with chronic renal failure taken during haemodialysis showing erythrocytes that have been phagocytosed by monocytes. The patient had a positive direct antiglobulin test but no overt haemolysis.

Fig. 3.145

Blood film of a patient with cryoglobulinaemia showing cryoglobulin within a monocyte. Courtesy of Mr Alan Dean.

Fig. 3.146

Blood film of a patient with malaria showing malaria pigment within a monocyte. The film also shows a

Plasmodium falciparum

gametocyte.

Fig. 3.147

Blood film of a patient with acute monocytic leukaemia showing a monoblast (left) and a promonocyte (right). The promonocyte has a lobulated nucleus but its chromatin pattern is as delicate as that of the monoblast. Both cells have abundant blue-grey vacuolated cytoplasm.

Fig. 3.148

A phagocytic macrophage in a peripheral blood film. Courtesy of Dr Z. Currimbhoy, Mumbai.

Fig. 3.149

A promyelocyte in the peripheral blood film of a patient with megaloblastic anaemia. The nucleolus and the Golgi zone are readily detectable. The film also shows anisocytosis and teardrop poikilocytes.

Fig. 3.150

A neutrophil myelocyte in the peripheral blood film of a healthy pregnant woman.

Fig. 3.151

An eosinophil and an eosinophil myelocyte in the peripheral blood film of a patient with CML.

Fig. 3.152

A basophil myelocyte in the peripheral blood film of a patient with CML.

Fig. 3.153

A metamyelocyte and two neutrophils in the peripheral blood film of a patient with CML.

Fig. 3.154

A mast cell in the peripheral blood film of a patient having a health check for non-specific symptoms.

Fig. 3.155

Intact lymphocytes and several disintegrated cells (smear cells or smudge cells) in the peripheral blood film of a patient with CLL.

Fig. 3.156

A giant platelet, almost as large as the adjacent basophil, in the peripheral blood of a patient with primary myelofibrosis. The film also shows a platelet of normal size. The red cells show poikilocytosis.

Fig. 3.157

The peripheral blood film of a patient with Wiskott–Aldrich syndrome showing thrombocytopenia and small platelets.

Fig. 3.158

The peripheral blood film of a patient with CML showing a mixture of normally granulated and agranular platelets. There is also platelet anisocytosis.

Fig. 3.159

Blood film showing platelet satellitism.

Fig. 3.160

Blood film showing phagocytosis of platelets.

Fig. 3.161

A bare megakaryocyte nucleus in the peripheral blood film of a healthy subject; the size and lobulation of the nucleus indicate its origin from a polyploid megakaryocyte.

Fig. 3.162

A micromegakaryocyte in the peripheral blood film of a patient with primary myelofibrosis.

Fig. 3.163

Micromegakaryocyte in the peripheral blood film of a neonate with transient abnormal myelopoiesis of Down syndrome. There is also a blast cell and an NRBC.

Fig. 3.164

Peripheral blood film of a patient with megakaryoblastic transformation of CML showing three megakaryoblasts. One of these is large with no distinguishing features, another shows some maturation and has cytoplasm that resembles that of a platelet, while the third resembles a lymphoblast. The lineage was confirmed by ultrastructural cytochemistry.

Fig. 3.165

Blood film from a premature but healthy infant, showing macrocytosis (relative to the film of an adult), a Howell–Jolly body in a polychromatic cell, target cells and a schistocyte.

Fig. 3.166

Endothelial cells obtained by scraping the vena cava during post-mortem examination. Courtesy of Dr Marjorie Walker, Newcastle, Australia.

Fig. 3.167

Endothelial cells in a peripheral blood film made from a venous blood sample.

Fig. 3.168

Epithelial cells in a peripheral blood film prepared from a drop of blood obtained by finger prick: (a) nucleated epithelial cell; and (b) anucleate epithelial cell.

Fig. 3.169

A clump of fat cells, likely to represent subcutaneous fat, in a blood film prepared from EDTA-anticoagulated venous blood (× 40 objective).

Fig. 3.170

Malignant cells in the routine peripheral blood film of a patient subsequently found to have widespread metastatic adenocarcinoma.

Fig. 3.171

Malignant cells in the peripheral blood of a patient with a past history of carcinoma of the breast, subsequently found to have widespread metastatic disease.

Fig. 3.172

Melanoma cell containing melanin in a buffy coat film from a patient with metastatic malignant melanoma and a leucoerythroblastic anaemia; the bone marrow was among the infiltrated tissues. By courtesy of Dr John Luckit and the late Dr David Swirsky.

Fig. 3.173

Borrelia species in the peripheral blood of a febrile North African child.

Fig. 3.174

A neutrophil containing diplococci from a patient with fatal

Neisseria meningitidis

septicaemia.

Fig. 3.175

Blood film from a patient who had been bitten by a dog showing

Capnocytophaga canimorsus

: (a) May–Grünwald–Giemsa (MGG) stain; (b) Gram stain. By courtesy of the late Dr Alan Mills.

Fig. 3.176

Blood film showing multiple small rod-shaped bacilli associated with erythrocytes in a patient with bartonellosis. There is also a red cell containing a Howell–Jolly body. Courtesy of the late Dr David Swirsky and the late Professor Sir John Dacie.

Fig. 3.177

Blood film from a hyposplenic patient with Whipple disease showing a red cell fragment, a red cell containing a Howell–Jolly body and several red cells with which are associated numerous delicate rod-shaped bacilli. Wright’s stain. Courtesy of Dr B. J. Patterson, Toronto.

Fig. 3.178

Blood of a patient with human granulocytic anaplasmosis showing the morular form of the organism within a neutrophil. By courtesy of Dr Vandita Johari, Minneapolis.

Fig. 3.179

Blood film from a patient with plague showing the bipolar bacilli of

Yersinia pestis

. By courtesy of the American Society of Hematology Slide Bank.

Fig. 3.180

Klebsiella oxytoca

in a film of blood obtained from an indwelling venous line, showing failure of septation: (a) MGG stain. (b) Gram stain. Courtesy of Dr Carol Barton and Mr J. Kitaruth, Reading.

Fig. 3.181

Blood film of a patient with AML who developed

Escherichiae coli

infection. The patient was receiving prophylactic antifungal agents and it is postulated that this is the reason for the failure of the bacilli to separate from each other. By courtesy of Dr Catherine Bagot, Glasgow.

Fig. 3.182

Candida parapsilosis

in a peripheral blood film: (a) within neutrophils; and (b) free between red cells. Several organisms are budding. Courtesy of Dr Bipin Vadher and Dr Marilyn Treacy, London.

Fig. 3.183

A band neutrophil in a buffy coat film showing three

Histoplasma capsulatum

. By courtesy of Dr Sian Lewis, Oxford.

Fig. 3.184

Methenamine silver stain of

Histoplasma capsulatum

in the peripheral blood. Courtesy of Dr Hector Musa, Minneapolis.

Fig. 3.185

Penicillium marneffei

in the peripheral blood of a patient with AIDS. Courtesy of Dr K.F. Wong, Hong Kong.

Fig. 3.186

Features that are useful in distinguishing between the different species of malaria parasites.

Fig. 3.187

Stages in the life cycle of

Plasmodium vivax

shown in Giemsa-stained peripheral blood thick (a) and thin (b–h) films: (a) two ring forms within red cell ghosts; (b) a ring form and an ameboid trophozoite – both the parasitised cells are enlarged and decolorised and contain faint Schüffner’s dots; (c) a ring form and an early schizont containing two chromatin masses – both parasitised cells are decolorised and contain faint Schüffner’s dots; (d) a microgametocyte – the pigment is fine and scattered and the parasite does not completely fill the cell; (e) a microgametocyte – the pigment is fine and scattered and the parasite completely fills the cell and is larger than the nonparasitised red cells; (f) exflagellation of microgametes from a gametocyte – this stage of the parasite life cycle usually occurs in the stomach of the mosquito. (g) microgametes – this stage of the parasite life cycle usually occurs in the stomach of the mosquito; (h) microgametes clustered around three macrogametes – it appears that one microgamete has fertilised a macrogamete since its nucleus appears to have penetrated the macrogamete – this stage of the parasite life cycle usually occurs in the stomach of the mosquito; (i) ookinete – this stage of the malaria parasite life cycle usually occurs in the stomach of the mosquito and is very rarely seen in the peripheral blood of man. By courtesy of Dr Wendi Bailey, Liverpool.

Fig. 3.188

Stages in the life cycle of

Plasmodium ovale

in Giemsa-stained thin films: (a) a late trophozoite in an enlarged, decolorised and oval red cell that has a fimbriated end – pigment is coarser and darker than in

Plasmodium vivax

, the parasite is more compact and Schüffner’s dots are more prominent; (b) a schizont containing eight merozoites – coarse pigment is clustered centrally.

Fig. 3.189

Stages in the life cycle of

Plasmodium falciparum

in Giemsa-stained thin films; the cells are not enlarged or decolorised: (a) ring forms and one late trophozoite; (b) ring forms with prominent Maurer’s clefts; (c) ring forms and early and late schizonts (schizonts are not commonly seen in the peripheral blood); (d) ring forms and an early gametocyte that has not yet assumed its banana shape; (e) a macrogametocyte – the parasite is sickle-shaped with a compact nucleus and pigment clustered centrally; (f) a microgametocyte that is broader and less curved than the macrogametocyte with a more diffuse nucleus and less concentrated pigment.

Fig. 3.190

Stages in the life cycle of

Plasmodium malariae

in Giemsa-stained thin films; red cells are not enlarged or decolorised: (a) early ring forms that are small but less delicate than those of

Plasmodium falciparum

– one parasite has a chromatin dot within the ring; (b) ameboid trophozoite with coarse dark-brown pigment; (c) band trophozoite; (d) schizont with about seven merozoites in a daisy-head arrangement with central coarse brown pigment; (e) schizont with merozoites grouped around the centrally placed pigment; (f) a gametocyte and a reactive lymphocyte.

Fig. 3.191

Stages in the life cycle of

Plasmodium knowlesi

in Giemsa-stained thin films: (a) early ring forms – the erythrocytes are neither enlarged nor decolorised and confusion with

P. falciparum

could occur; (b) band forms – confusion with

P. malariae

could occur; (c) developing trophozoites; (d) further examples of developing trophozoites; (e) heavy parasitaemia with double-infected erythrocytes. (f) heavy parasitaemia with double- and triple-infected erythrocytes; (g) a ring form and a ruptured schizont containing 10 merozoites and pigment; (h) a ring form and a ruptured schizont composed of 8 merozoites with pigment. By courtesy of Dr Janet Cox-Singh, St Andrews.

Fig. 3.192

Blood film from a splenectomised monkey parasitised by

Babesia microti

: (a) a single ring form and a pair of pyriform parasites; (b) a single ring form and four pyriform parasites in a tetrad or Maltese cross formation. By courtesy of Mr John Williams, London.

Fig. 3.193

Blood film from a hyposplenic patient with babesiosis caused by

Babesia divergens

, showing numerous parasites including a Maltese cross formation and paired pyriform parasites. By courtesy of Mr C. Murphy, Cork.

Fig. 3.194

Summary of the morphological features of haemoflagellates.

Fig. 3.195

Trypanosoma brucei gambiense

; the parasites are serpentine with a small kinetoplast (× 40 objective).

Fig. 3.196

Trypanosoma cruzi

; the parasite is curved but not usually serpentine and has a large kinetoplast (× 40 objective).

Fig. 3.197

Leishmania donovani

in: (a) a monocyte; and (b) a neutrophil in the peripheral blood of a patient with AIDS.

Fig. 3.198

Morphological features that are useful in distinguishing between the microfilariae of different species of filaria.

Fig. 3.199

Microfilariae of

Wuchereria bancrofti

in thick films: (a) microfilaria showing the negative impression of the sheath (× 40 objective); (b) tail of a microfilaria showing that the nuclei do not extend into the tail.

Fig. 3.200

Microfilariae of

Brugia malayi

in thick film showing the widely separated tail nuclei. By courtesy of Dr Saad Abdalla, London.

Fig. 3.201

Microfilariae of

Loa loa

: (a) a thick film showing the head and tail of microfilariae – nuclei extend to the tail (× 40 objective); (b) the tail of a microfilaria in a thin film showing the negative impression of the sheath – the nuclei extend to the tail.

Fig. 3.202

Microfilaria of

Mansonella perstans

in a thin film. By courtesy of Dr Saad Abdalla.

Chapter 4

Fig. 4.1

Instrument printout from: (a) Bayer H.2; and (b) Beckman–Coulter Gen S counters from a specimen accidentally contaminated with subcutaneous fat [1]. The signals generated by the fat are arrowed. The H.2 count was inaccurate whereas the Gen S count was accurate.

Fig. 4.2

Peripheral blood film of a patient with acute monoblastic leukaemia. Despite only a slight reduction of the ‘platelet’ count the patient had major bleeding. Inspection of the film showed that there were many fragments of cytoplasm derived from leukaemic cells that were of similar size to platelets and accounted for an erroneous Beckman–Coulter Gen S platelet count.

Fig. 4.3

Peripheral blood film of a patient with persistent pancytopenia after intensive chemotherapy for acute myeloid leukaemia. After many weeks of platelet dependency the ‘platelet’ count suddenly rose. Inspection of the film showed that platelets continued to be very sparse; the particles that were counted as platelets were fungi, subsequently identified as

Candida glabrata

, originating from the patient’s indwelling central intravenous line [50].

Fig. 4.4

Bayer H.2 histograms and scatter plots showing an erroneous differential count caused by failure of lysis of neonatal red cells (green arrows). The peroxidase channel white blood cell count (WBC) of 75.8 × 109/1 has been rejected in favour of the basophil channel WBC of 5.48 × 109/1, but the differential count has been derived from the peroxidase channel where many of the non-lysed red cells have been counted as lymphocytes or large unstained cells (LUC). This has led to a factitious neutropenia. The erroneous differential count was flagged. The plots also illustrate the increased size of fetal red cells.

Fig. 4.5

Bayer H.2 white cell scatter plots from a patient with severe neutrophil peroxidase deficiency leading to an erroneous neutrophil count. Virtually all the neutrophils have been classified as large unstained (i.e. peroxidase-negative) cells (green arrow) and the neutrophil count was zero. The basophil lobularity channel, however, shows a normal number of granulocytes.

Fig. 4.6

Bayer H.2 white cell scatter plots from a patient with partial eosinophil peroxidase deficiency showing an eosinophil cluster (green arrow) that has not been recognised. About two-thirds of the eosinophils have been classified as neutrophils.

Fig. 4.7

Bayer H.2 white cell scatter plots from a healthy subject with monocyte peroxidase deficiency causing an erroneous monocyte count. Almost all the monocytes have been counted as LUC (green arrow). The automated monocyte count was 0.09 × 10

9

/1 while the manual count was 0.5 × 10

9

/1.

Fig. 4.8

Bayer H.1 white cell scatter plots showing neutrophils that have caused less forward light scatter than normal (green arrow) and have been misclassified as eosinophils.

Fig. 4.9

Bayer H.2 white cell scatter plots from a patient with follicular lymphoma showing pseudobasophilia as a consequence of lymphoma cells (green arrow) being misclassified as basophils.

Fig. 4.10

Scatter plots and histograms produced by the Siemens Advia 120 on a blood sample from a patient with diffuse large B-cell lymphoma showing pseudobasophilia as a result of circulating lymphoma cells. The basophil/lobularity channel (centre top) shows an abnormal compact cluster of signals that extends from the mononuclear area (blue) to the basophil area (yellow); the ‘basophil’ count was 0.95 × 10

9

/l (15.9%). In the peroxidase channel (top left) the lymphoma cells appear in the LUC area (turquoise); the count was 1.41 × 10

9

/l (23.5%). There were flags for atypical lymphocytes, blast cells and left shift. Other abnormalities shown by the red cell histograms and cytograms are an increase of hypochromic cells and of macrocytes, including hypochromic macrocytes. By courtesy of Professor Gina Zini, Rome.

Fig. 4.11

Siemens Advia series cytograms and histograms from a patient with T-lineage non-Hodgkin lymphoma. The full blood count (FBC) showed WBC 74.6 × 10

9

/l, neutrophils 7.23 × 10

9

/l, lymphocytes 58.4 × 10

9

/l, monocytes 1.35 × 10

9

/l, eosinophils 0.2 × 10

9

/l, basophils 2.7 × 10

9

/l, large unstained (i.e. peroxidase-negative) cells 4.7 × 10

9

/l. There were flags for blast cells (+) and atypical lymphocytes (+). The Perox scattergrams show that there is an abnormal population extending from the lymphocyte box into the LUC box. This is a clue to the fact that the basophilia is factitious. The abnormal population can be seen in the Baso scattergram to be extending from the lymphocyte box into the basophil box. By courtesy of Professor Gina Zini.

Chapter 5

Fig. 5.1

Haemoglobin concentrations in 265 healthy fetuses and reference range derived from the data, modified from Mari

et al

. [87].

Chapter 7

Fig. 7.1

A methyl violet preparation showing Heinz bodies in a patient exposed to the oxidant drug, dapsone. By courtesy of the late Dr David Swirsky and Mr David Roper, London.

Fig. 7.2

Haemoglobin H preparations showing: (a) haemoglobin H-containing cells (containing multiple small pale blue inclusions) and reticulocytes (with a purple reticular network) in a patient with haemoglobin H disease; and (b) haemoglobin H-containing cells, a reticulocyte and Heinz bodies (large peripherally placed blue inclusions) in the blood of a patient with haemoglobin H disease who had been splenectomised.

Fig. 7.3

Acid elution technique (Kleihauer test) for haemoglobin F-containing cells; the blood specimen was taken from a postpartum woman and shows that a fetomaternal haemorrhage had occurred. A single stained fetal cell is seen against a background of ghosts of maternal cells.

Fig. 7.4

Perls stain showing: (a) siderocytes (cells containing fine blue dots) in the blood of a patient with thalassaemia major; and (b) a ring sideroblast in the blood of a patient with sideroblastic anaemia.

Fig. 7.5

Neutrophil alkaline phosphatase (NAP) reaction (method of Ackerman [9]) showing cells with reactions graded 0 to 4: (a) neutrophil with a score of 0 plus a lymphocyte, which is also negative; (b) two band cells with a score of 1; (c) two neutrophils with a score of 2 and one with a score of 3; and (d) two neutrophils with a score of 4 and one with a score of 2.

Fig. 7.6

Changes in NAP score during the menstrual cycle.

Fig. 7.7

Changes in NAP score with age in men and women. Data from Stavridis

et al.

[17].

Fig. 7.8

Leukaemic blast cells stained by the Hanker technique [2] for myeloperoxidase showing a brownish-black deposit in the cytoplasm. This was a case of acute myeloid leukaemia (AML) of French–American–British (FAB) M2 category.

Fig. 7.9

Leukaemic blasts cells stained with Sudan black B (SBB). One large blast cell contains both granules and Auer rods. Several other blasts contain granules. The cells of this case, which was acute myeloid leukaemia of FAB M1 category, had very few granules and only rare Auer rods visible on a May–Grünwald–Giemsa (MGG)-stained film.

Fig. 7.10

Peripheral blood film from a patient with acute myeloid leukaemia stained with SBB, showing two blast cells that are positive. The presence of neutrophils that are largely or entirely SBB-negative demonstrates dysplastic neutrophil maturation.

Fig. 7.11

Leukaemic blast cells stained for chloroacetate esterase (CAE) activity, using Corinth V as the dye. This was a case of AML of FAB M2 category.

Fig. 7.12

Leukaemic blast cells stained for α-naphthyl acetate esterase (ANAE) activity using fast RR as the dye. This was a case of AML of FAB M5 category.

Fig. 7.13

Periodic acid–Schiff (PAS) reaction showing block positivity in the blast cells of a case of B-lineage acute lymphoblastic leukaemia (ALL) of FAB L1 category. By courtesy of Dr Ayed Eden, Southend-on-Sea.

Fig. 7.14

Acid phosphatase stain by the method of Janckila

et al.

[5] showing focal positivity in the blast cells of a patient with T-lineage ALL.

Fig. 7.15

Immunophenotyping by flow cytometry in a case of follicular lymphoma. The lower plot demonstrates clonality, cells being kappa-negative and lambda-positive, and shows that surface membrane immunoglobulin is strongly expressed. The upper plot demonstrates that the lymphoma cells are CD19 positive and CD5 negative, thus differing from both chronic lymphocytic leukaemia and mantle cell lymphoma. By courtesy of Mr Ricardo Morilla, London.

Fig. 7.16

Immunophenotyping using a monoclonal antibody to CD13 and the immunoperoxidase technique. The blast cells of this case gave negative reactions with myeloperoxidase (MPO), SBB and CAE, but were identified as myeloid (FAB M0 category) by the positivity with CD13 and negativity with monoclonal antibodies directed at lymphoid antigens. By courtesy of Professor Daniel Catovsky, London.

Fig. 7.17

Immunophenotyping using a monoclonal antibody to CD42 (antiplatelet glycoprotein Ib) and the alkaline phosphatase-anti-alkaline phosphatase (APAAP) technique. Positive reactions are given by two platelets, by a lymphocyte-sized micromegakaryocyte and by a larger hypolobated megakaryocyte.

Fig. 7.18

Ultrastructural examination in Sézary syndrome showing a Sézary cell with a highly irregular nuclear outline. By courtesy of Dr Estella Matutes, Barcelona.

Chapter 8

Fig. 8.1

The blood film of a patient with iron deficiency anaemia showing anisocytosis, poikilocytosis (including elliptocytes), hypochromia and microcytosis. The full blood count (FBC, Coulter S Plus IV) was: red blood cell count (RBC) 4.22 × 10

12

/1, haemoglobin concentration (Hb) 70 g/l, haematocrit (Hct) 0.29 l/l, mean cell volume (MCV) 67 f1, mean cell haemoglobin (MCH) 16.6 pg, mean cell haemoglobin concentration (MCHC) 245 g/l.

Fig. 8.2

The blood film of a patient with the anaemia of chronic disease consequent on a lymphoma, showing mild anisocytosis, poikilocytosis and hypochromia. The FBC (Coulter S Plus IV) was: RBC 3.10 × 10

12

/1, Hb 74 g/l, Hct 0.23 l/l, MCV 75.6 fl, MCH 23.8 pg, MCHC 315 g/l.

Fig. 8.3

A dimorphic blood film from a patient with congenital sideroblastic anaemia. There is a minor population of cells that are hypochromic and microcytic with a tendency to target cell formation; there is also poikilocytosis. The patient had previously responded to pyridoxine with a rise of Hb and was taking pyridoxine when this blood specimen was obtained.

Fig. 8.4

Blood film obtained from a non-anaemic carrier of congenital sideroblastic anaemia, the daughter of a patient with moderately severe microcytic anaemia. The film is dimorphic, showing a minor population of hypochromic microcytes.

Fig. 8.5

The blood film of a patient with lead poisoning showing anisocytosis, hypochromia and prominent basophilic stippling. The FBC (Coulter S Plus IV) was: RBC 2.99 × 10

12

/1, Hb 83 g/l, Hct 0.25 l/l, MCV 85 fl, MCH 27.8 pg, MCHC 327 g/l. The reticulocyte count was 281 × 10

9

/1.

Fig. 8.6