| Pia Arachnoid Mesothelial Cells (continued) Seven mesothelial cells are seen in this slide. Notice that all of the nuclei have a distinct shape with no evidence of irregular division. Chromatin pattern is typical of cells that originate in the tissues. Cytoplasm is irregular and some pseudopods are evident, especially in the lower portion of the field.
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| More Blast Cells Four blast cells are seen in this field. Notice the smooth chromatin pattern, nucleoli, high NC ratio and irregularly shaped nuclei. These blasts were observed in a spinal fluid sample from a patient with acute lymphocytic leukemia. | View Page |
| What type is the indicated cell? | View Page |
| More Neutrophils and Lymphocytes Two segmented neutrophils and a lymphocyte (indicated by an arrow) are in the center of this picture. Notice the mature chromatin structure in the nucleus of the lymphocyte. Three mature red cells are present around the lymphocyte. Two macrophages are also present in this picture.
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| Monocytes The arrow in this slide is pointing to a monocyte. The nucleus has an open chromatin pattern which gives it a spongy appearance. There is another monocyte in the lower right corner of the field. The other two cells could be classified as macrophages (histiocytes) because the nucleus is oval or kidney bean-shaped and the cytoplasm is very irregular. After circulating in the blood for one to three days, monocytes enter the tissues. The tissue form of the monocyte is called a macrophage or histiocyte.
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| Blast Cells Blast cells may be seen in the spinal fluid when cell proliferation in acute leukemia or lymphoma spreads to the central nervous system. The arrows indicate the two blasts in this field. Notice the smooth chromatin pattern in the nucleus and prominent nucleoli in both cells. Notice that an Auer rod is present in the cytoplasm in the blast to the right. The Auer rod indicates that these blasts are myeloblasts rather than lymphoblasts. A segmented neutrophil and several red cells can also be seen. | View Page |
| Spinal Fluid Sample The arrow in this slide indicates the location of another example of a blast that was seen in a spinal fluid sample. Notice the two prominent nucleoli in the nucleus of this blast. The other three cells in the field are mature lymphs. Notice that the chromatin pattern in the mature lymphs is more clumped than the chromatin in the blast cells. | View Page |
| Malignant Cells Malignant cells that have broken away from tumors located in other areas of the body may be seen in spinal fluid. All of the cells in this field are tumor cells. The cells in this slide are characterized by an open, loose chromatin pattern, nucleoli and vacuoles. Notice that the vacuoles are present in both the nucleus and the cytoplasm. Vacuoles in the nucleus are an unusual finding even in tumor cells. Tumor cells are often found in clumps and may have more than one nucleus due to their erratic mitotic patterns. Malignant cells sometimes have an irregular nuclear shape. Bizarre granules may be found in malignant cells but are absent in mesothelial cells.
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| Another Malignant Cell Another example of a malignant cell. This cell has a smooth chromatin pattern similar to the chromatin pattern commonly seen in blast cells. This cell has a high nuclear to cytoplasm (NC) ratio which is typical for malignant cells. No nucleoli are visible in this cell although malignant cells often have large nucleoli. | View Page |
| These cells tend to occur in tight clusters. They may have prominent nucleoli, immature chromatin, and scant cytoplasm. | View Page |
| Promegakaryocyte The next stage after the megakaryoblast is the promegakaryocyte. It is intermediate in maturity between a megakaryoblasts and mature megakaryocytes. It may have multiple nuclei, coarse chromatin, and more cytoplasm than a megakaryoblast. | View Page |
| Megakaryoblast This slide shows an example of the youngest cell in the megakaryocyte series, the megakaryoblast. Megakaryoblasts have a fine chromatin structure with multiple nucleoli, and scant basophilic cytoplasm. Cytoplasmic tags are frequently seen. It may vary 20-50 microns in diameter. | View Page |
| Megakaryocyte The next stage is the fully developed megakaryocyte. It typically shows nuclear divisions and abundant very granular cytoplasm. Megakaryocytes are the largest cell found in normal bone marrow and can range in size from 30-100 microns. The nuclear chromatin pattern is coarse. Nucleoli are absent. | View Page |
| Plasma Cells An occasional plasma cell is a normal finding in the bone marrow. The nuclear chromatin pattern is coarse, the cytoplasm is varying shades of blue with a "hoff" or light staining area adjacent to the nucleus. | View Page |
| Another Example of Tumor Cells Another example of tumor cells under higher magnification, showing large cells with loose immature chromatin structure and ill-defined cytoplasm. | View Page |
| Macrophage The large cell in the center of this slide is a macrophage, which is normally present in low numbers in the marrow. Macrophages have a loose chromatin pattern and on some smears the nucleoli appear blue/green. The cytoplasm is irregular in shape and contains granules. | View Page |
| When Lymphocytes Transform Lymphocytes "transform" in response to antigenic stimuli.Their nuclei becomes larger with more open chromatin and a greater degree of nuclear folding.The cytoplasm becomes abundant, the number of azurophilic granules may be increased and vacuoles may be present.The cytoplasmic membrane may be easily indented by surrounding red blood cells, resulting in a scalloped appearance of the cell's outer edge.These lymphocytes may also be referred to as reactive, activated or stimulated.
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| The Chromatin Pattern of the Basophil Nucleus The chromatin pattern of the basophil nucleus is not quite as coarse as that of the neutrophil or eosinophil nuclei. Although the nucleus is usually segmented, the lobes are often difficult to discern because they tend to crowd together and are obscured by the cytoplasmic granules.
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| The Nucleus of a Eosinophil The eosinophil nucleus has a coarse, clumped chromatin pattern. There are normally only two lobes present, and often they are bigger than those of the seg. | View Page |
| Differentiating Bands from Segs When viewing a confusing cell, it is helpful to focus through several planes, taking special note of overall chromatin structure, appearance or presence of any filaments, and general cytoplasmic characteristics.For example, here we see a neutrophilic cell that is folded, making exact identification difficult.However, due to the thickness of the nucleus and the absence of a filament, we would classify it as a band. | View Page |
| Nucleus of the Band Neutrophil The nucleus of a band neutrophil is sausage or band-shaped (U-shaped).Sometimes it appears folded or twisted, thus making identification more difficult.The nucleus stains a deep purplish-blue color, and the nuclear chromatin appears condensed, coarse, and clumped. | View Page |
| Nucleus of the Segmented Neutrophil The nucleus is a deep reddish-purple color, and the chromatin has a coarse, clumped texture.The seg nucleus normally has from 2-5 lobes, with an average of 3.The lobes are connected to each other by a fine filament or strand of nuclear membrane.A filament has been defined as a thread-like strip which is so narrow that there is no visible nuclear material between the two sides. | View Page |
| Chromatin Pattern of Large Lymphocytes The chromatin pattern is not as dense as that of the small lymphocyte, but even so the nucleus appears hard and flat. | View Page |
| Nucleus of Lymphocyte The nucleus is slightly larger than a normal RBC. It is usually round or oval in shape, but may be slightly indented. The chromatin is very dense and clumped.
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| Monocytes Nucleus compared to other Leukocytes Monocytes have generally lighter staining nuclei than do other leukocytes. The nucleus stains a pale bluish-violet, and the chromatin is fine and skein-like. | View Page |
| Arrange the following Plasmodium morphologic forms in order from immature to mature: | View Page |
| This suspicious form, recovered from a stool sample, measures 30 µm in diameter. | View Page |
| This suspicious form measures 13 µm and was recovered from a stool sample. | View Page |
| This suspicious form, found in a stool sample, measures 15 µm. | View Page |
| Recovered in a stool sample, this suspicious form measures 7 µm. | View Page |
| This parasite was found on a blood smear. | View Page |
| This suspicious form, found in stool, measures 25 µm. | View Page |
| These suspicious forms were seen on a blood smear. | View Page |
| This suspicious form, found in stool, measure 10 µm. | View Page |
| This suspicious form, which was recovered in stool specimen and measures 32 µm, is responsible for which of the following diseases? | View Page |
| The suspicious form pictured here is responsible for which of the following conditions? | View Page |
| Match each parasite pictured with its respective classification: | View Page |
| Match the parasite pictured with its corresponding name & morphologic form(s): | View Page |
| Which of the following parasites resembles Entamoeba histolytica but lack ingested red blood cells in the trophozoite form? | View Page |
| The small mass of chromatin located in the amebic parasites is termed: | View Page |
| The nuclei of which of the following parasites lack peripheral chromatin? | View Page |
| Match each parasite listed here with its corresponding typical nuclear appearance: | View Page |
| Match each pair of parasites listed here with the key morphologic characteristics that help to distinguish between them: | View Page |
| Match each parasite listed here with the key characteristic that aids in its identification: | View Page |
| Match each picture with its respective morphologic form: | View Page |
| Label the morphologic structures on this parasite form: | View Page |
| Label the morphologic structures on this parasite form: | View Page |
| A 12 year old female went to her doctor for her yearly back-to-school check-up. She was in good health and was asymptomatic at the time of the examination. Due to the increased incidence of parasites in the area, the doctor ordered a stool for parasite examination as part of the routine physical testing. Multiple suspicious forms, measuring approximately 9 µm each were seen. Which of the following is most likely the identification of these forms? | View Page |
| A 27 year old female graduate student recently returned from South America, where she completed a nature study of the rain forest. She spent months "living off the land." The woman went to her physician seeking treatment for a sinus infection, which she thought was responsible for several recent bouts of diarrhea. Upon questioning the patient, the doctor decided to collect stool for culture and parasitic examination. The stool culture was reported as "no enteric pathogens isolated." This suspicious form was seen on both wet preparations and on permanent stain. It measures 17 µm. The identify of this form is most likely: | View Page |
| I measure 15 µm and am found in stool. | View Page |
| I measure 12 µm and am found in stool. | View Page |
| I am 12 µm in size and reside in stool. I may be easily missed since I tend to "blend-in" with fecal debris. | View Page |
| I reside in red blood cells where I assume these characteristic appearances: | View Page |
| I am found in blood. | View Page |
| I am found in cerebral spinal fliud (CSF) and measure approximately 15 µm. | View Page |
| The locomotive structures of Entamoeba histolytica are known as: | View Page |
| Match each amebic cyst with its respective name: | View Page |
| This suspicious form measures 18 µm and was seen in stool. Name that parasite! | View Page |
| Which of the following statements is true regarding HYPOSEGMENTED neutrophils? | View Page |
| Single-Lobed Pelger-Huet Cells This mature neutrophil has a single nuclear lobe. The nuclear chromatin is dense. Cells such as this and the previously shown bilobed "pince-nez" form may be seen with inherited Pelger-Huet or acquired pseudo Pelger-Huet. | View Page |
| Pelger-Huet Cells Another nucleus of a neutrophil with a band-shaped nucleus. The chromatin pattern in this cell is more normal in appearance than the chromatin seen in the previous slide, but is still coarse. | View Page |
| Hyposegmentation of Neutrophils Hyposegmented cells are neutrophils with fewer than three nuclear lobes. The nucleus may be round, peanut-shaped, band-shaped or bilobed. Since nuclear lobe development is abnormal, the chromatin structure often appears more mature than normal. It is sometimes very smooth, almost pyknotic. | View Page |
| Pelger-Huet Cells The arrowed cells are typical of the bilobed cells seen in Pelger-Huet anomaly. Notice the dense nuclear chromatin, showing little parachromatin. | View Page |
| Normal Band Forms vs. Pelger-Huet Bands Recognition and diagnosis of the inherited form is important because many of these Pelger-Huet neutrophils may be classified as bands, therefore; increased numbers of bands might be erroneously reported in these patients. Since increased bands frequently indicate infection, reporting Pelger-Huet cells as normal band forms could result in inappropriate treatment for infection. Pelger-Huet cells have denser nuclear chromatin than neutrophilic band forms. | View Page |
| The nuclear appendage at the tip of the arrow is a normal finding in females but not in males. | View Page |
| The upper image of a peripheral blood smear reveals RBC Rouleaux formation. Several blood cells that are similar in appearance to the one indicated by the arrow in the bottom image are also seen on the smear. Which of the following conditions is associated with both of these findings? | View Page |
| Assume that several other lymphocytes similar to the one in the center of the photograph are found on review of the peripheral smear. A work up for leukemia should be recommended. | View Page |
| Megakaryocyte in Bone Marrow The large cell illustrated in this photograph of a Wright/Giemsa-stained bone marrow smear is a megakaryocyte. This megakaryocyte appears mature. The nucleus has at least 8 lobes and the nuclear chromatin is coarse and distinct. Clusters of young platelets are being released from distinct platelet territories at the periphery of the cytoplasm (blue arrows). When mature, each megakaryocyte produces approximately 4000 platelets/day. Production can expand by 8-fold during times of increased demand and under the stimulus of thrombopoietin. | View Page |
| The cytoplasmic inclusion illustrated at the tip of the blue arrow is characteristic of: | View Page |
| The neutrophils seen in two fields in the upper and lower photographs are representative of a majority of the left shift neutrophils found in this peripheral blood smear. The diagnosis of Pelger-Huet anomaly can be made. | View Page |
| Case Follow-up Illustrated in the upper and lower photographs are two-lobed, eye glass ("pince nez") nuclei of neutrophils typical for patients with Pelger-Huet anomaly. In addition to the characteristic two lobes connected by a delicate bridge, the dense, homogeneous nuclear chromatin helps to define Pelger-Huet anomaly. Since the peripheral blood smear did not support the diagnosis of appendicitis in this patient, and since abdominal pain localized to the right lower quadrant never developed, the boy was hydrated with intravenous fluid and observed. After hydration, his constitutional symptoms improved and the abdominal pain subsided. In fact, the lad was back on the ski slopes the next afternoon. People entering high altitude where the humidity may be very low are susceptible to dehydration and may experience symptoms related to mountain sickness. Therefore, close observation and hydration may be the best practice in monitoring patients with stories and findings similar to this one. A further lesson here is that technologists must be alert to the possibility of Pelger-Huet anomaly if a high white blood cell count with a high percentage of band neutrophils with strikingly uniform morphology and without toxic granulation are found. Inappropriate therapy or an invasive procedure as was contemplated here may be avoided by a proper smear assessment and clinical corroboration. | View Page |
| The smudge cells pictured in the photograph may be found in each of the following situations except: | View Page |
| The peripheral smear photographed here was submitted for morphologic/clinical examination.The predominant cells comprised 70% of the total white blood cells and are consistent with lymphocytes in a 4 month old infant. | View Page |
| More about lymphocytes, their impostors and varied faces In this photograph of blood cells from yet another submitted slide, we find cells resembling lymphoblasts with increased nuclear/cytoplasmic ratios and dense, finely meshed nuclear chromatin. In addition, note the extrusion of delicate strands of cytoplasm from the outer cell membranes (blue arrow). These are cells connoting hairy cell leukemia (HCL). Under scanning electron microscopy, the cytoplasmic extensions appear to be either slender microvilli or delicate pseudopods. The most helpful confirmatory finding is the detection of acid phosphatase isoenzymne 5 in the cytoplasm of suspected hairy cells by staining. The enzyme concentrates primarily in golgi bodies and in the nuclear membrane and its staining is not inhibited by the addition of tartrate. Stated in another way, hairy cells on the peripheral smears are detected by their staining positively for tartrate-resistant acid phosphatase. Be suspicious of HCL if marrow resists aspiration-a consequence of reticulin fibrosis of the marrow in HCL. | View Page |
| Multiple myeloma Plasma cells are uncommonly observed in the peripheral blood smear.They are normal constituents of lymph nodes, spleen, connective tissue and bone marrow. The presence of plasma cells in the peripheral blood is indicative of a large number of conditions mostly related to infections , immune disorders, malignancies, toxic exposures, hypersensitivity reactions and their responses.Although mature plasma cells have a distinct appearance, they still may be confused morphologically with immature plasma cells and other cells with inclusions, reactive changes or nucleated red bloods cell with altered identities.In the upper and lower photographs are plasma cells with features mindful of myeloma cellsThe large myeloma cell in the upper photograph has an eccentric immature nucleus with a muddy chromatin pattern.Note also clumping and stacking of the erythrocytes, bordering on rouleaux formation ,implicating an increase in plasma gamma globulin.The plasma cell with the double nucleus in the lower photograph is particularly suggestive of myeloma.Further studies are in order including a bone marrow examination where at least 30% of bone marrow cells should be variations of mature and immature plasma cells.Serum electrophoresis will reveal a monoclonal globulin spike, and light chains in excess of 1.0 gm/24 hours may be seen in the urine.The presence of lytic bone lesions is a convincing clinical clue.With these findings in combination, a diagnosis of myeloma can be made with assurance. | View Page |