Acanthocyte Information and Courses from MediaLab, Inc.

Two photographs of a peripheral blood smear are submitted for review . The smears are from a 9-month-old baby with a heart valve replacement. In the upper photograph is a nucleated RBC and platelets are decreased. Nucleated red cells and occasional giant platelets indicate an active marrow response. In the process of forcing blood cells through the heart valve, erythrocytes are damaged, schistocytes are formed, and platelets are destroyed leading to thrombocytopenia. In the lower field are schistocytes, acanthocytes, echinocytes (burr cells), spherocytes, and the absence of platelets. The presence of burr cells could represent an artifact of smear preparation, but with the history of valve replacement, the red cell changes are likely the result of red cell damage as the cells circulate through the new valve. This situation is described as Waring Blender Effect because of damage to blood cells passing through the new valve, looking as if they had suffered the onslaught of a blender. Target cells and mild hypochromia may reflect iron deficiency through the loss of iron from destruction of RBC's. Iron loss through red cell destruction may be reflected in some hypochromia.

Jaundice was recognized in a day-old infant. Notice particularly the size variation (anisocytosis) of the erythrocytes on the infant's peripheral smear. What does this observation mean? Does it provide immediate information that might serve as guidance in expediting diagnosis and treatment? Note that normal-sized red blood cells, microcytes, microspherocytes, macrocytes, and nucleated red blood cells are all present. Red cell variations are expected findings in healthy neonates, but the variations here are exaggerated. Hyposplenic functional features may appear, including acanthocytes, spherocytes, and possibly Howell-Jolly bodies, especially if hemolysis is particularly vigorous. A high (3-7%) reticulocyte count is not unusual during the first three or four days after birth, however, the marrow in this jaundiced infant is proliferating vigorously in response to hemolysis. A call for more red cells is urgent. Immature red cells (in the form of nucleated red cells) and red cells with stippling of RNA (basophilic stippling) are readily identified. Red cell maturation sequence has not been totally processed in the marrow nor is all residual red cell debris removed by the spleen. In the lower photograph are reticulocytes stained by supravital stain (new methylene blue). Basophilic stippling (specks of RNA) stains with both supravital stains and with routine Wright-Giemsa stain.

What clear courses of action might the clinician take if the technologist reports out from this smear 3+ acanthocytes, 1+ target cells and occasional helmet cells? Gleaning information from the review of peripheral blood smears is important for the technologist, physician, and surely for the patient. Extreme pressures of time constraints and shifting dynamics in communication, from face-to-face encounters to dependency on technology, make innovative solutions to physician-patient information dilemmas imperative. Reporting systems often are geared more toward retrievability, suiting the needs of administrators and record keepers rather than being clearly directed toward improving patient care outcomes. A prime solution to this communication dilemma is to provide technologists with written descriptions and images of specific abnormal findings from peripheral blood smears. With a high degree of probability, these may link directly with underlying information connected to diseases. Mutually understood terms must be established to convert subjective qualitative peripheral blood smear findings into mutually understandable information. For example, regarding the smear shown, it was learned that the patient had recently undergone splenectomy. Creating an integrated communication system for information sharing (providing essential patient information by telephone follow-up or use of a system for e-mail feedback) can help ensure a favorable clinical outcome.

Acanthocytes can also be seen in this slide. Alcoholic cirrhosis is the most common source of acanthocytes seen in blood smears in the laboratory (10-50%). Other sources are lipid disorders and a small number following splenectomy.

Echinocyte comes from the Greek word meaning “sea urchin,” which relates to its shell-like appearance. Echinocytes are reversible, meaning that this alteration can be the result of the cell’s environment, pH of the medium (including the glass slides on which blood smears are made), the metabolic state of the cell and the use of some chemical substances. An example of an echinocyte can be seen in the center of this slide. Notice the projections (10-30 can be seen) are rounded and evenly spaced around the cell. Acanthocytes have irregularly spaced thorn-like projections. An echinocyte is shown left of the B in this photomicrograph. A polychromatophilic cell is seen just above the echinocyte.