Lymphocyte Information and Courses from MediaLab, Inc.

Lymphocytes, for the most part, have a more regular cytoplasmic border without the cytoplasmic blebbing and pseudopods that are present in monocytes.Observe the differences in character of the cytoplasm between the two cell types. Both cells have blue cytoplasm, however the monocyte (red arrow) has a grainy, gritty texture that is absent in the lymphocytes. In addition, there are fine red cytoplasmic granules present in the monocyte that are not apparent in the lymphocytes.Notice the relatively regular nuclear shape of the lymphocytes (blue arrow) versus the more complex nuclear shape of the larger monocyte. There is also a difference in the texture of the chromatin between the two cell types. The lymphocyte chromatin is more dense and clumped.

Similar to peripheral blood, lymphocytes in fluids come in all sizes. A larger lymphocyte is not necessarily an abnormal or atypical lymphocyte, however. In the image shown here there is one atypical lymphocyte (blue arrow) adjacent to the monocyte at the top of the smear. The atypical lymphocyte is almost as big as the monocyte, however the nucleus is more regular. The amount of cytoplasm is similar between the two cells, but the atypical lymphocyte has a deeper blue shading at the edge of the cytoplasm. Though there are nucleoli present in this atypical lymphocyte, it does not necessarily mean that this is a malignant cell. Cyto-spinning can expose nucleoli in cells that would not normally appear to have nucleoli in the peripheral blood. The balanced amount of cytoplasm in comparison to the nucleus and the overall size of the cell are consistent with the range of variation found with atypical lymphocytes.In this smear, there is also a plasmatoid lymph in the lower left of the cluster (green arrow) and a basophil in the lower right (orange arrow).

One of the normal roles of the marrow macrophage is to remove cellular debris. In a normal bone marrow, this includes the engulfment of extruded RBC nuclei and old, non-nucleated RBCs at the end of their lifespan. In some patients, macrophages lose their ability to distinguish self from non-self (i.e., invader/ pathogen) and good cells from old/senescent cells. This can happen because of an inborn error in the macrophages or by an infection-mediated transformation. When this change occurs, any cell in the vicinity of a defective macrophage become a target for engulfment. This term is called hemophagocytosis.The top image on the right shows two macrophages that have ingested several different cell types (see red arrows). There is the normally ingested non-nucleated RBC, but also the abnormally ingested segmented neutrophil and at least one early nucleated RBC precursor. Viable bone marrow precursors are not the usual diet of macrophages.The lower image on the right shows an even more impressive macrophage with at least a dozen or more ingested RBCs as well as three segmented neutrophils and a lymphocyte.

Hematogone is a term applied to a subset of early B-lymphocytes, found in normal bone marrow, whose morphology greatly resembles that of leukemic lymphoblasts. These cells are larger than the average mature lymphocyte, have scant cytoplasm, and a fine, soft chromatin texture; however, they are not quite as immature in appearance as a true leukemic lymphoblast. Hematogones are more common in younger children but can be found in bone marrow samples of patients at any age. They tend to be found in increased numbers within the bone marrows of patients recovering from bone marrow suppression. Common causes of increased concentrations of hematogones include: viral illness, chemotherapy recovery, and immune mediated cytopenias, such as idiopathic thrombocytpenic purpura (ITP). Hematogones are also common in patients with neuroblastoma.With experience, knowledge of the patients underlying clinical condition, and the ability to review a patient's bone marrow, it is possible to distinguish hematogones from blasts. When necessary, a hematogone flow cytometry panel can be obtained to distinguish these benign cells from lymphoblasts.Notice the size of these blast-like hematogones (see red arrows). They are larger than the few background lymphocytes present in these images. Notice the fine chromatin and scant cytoplasm. They are usually found mixed in with the full range of bone marrow cellular lineages, but can cluster with other lymphocytes within the spicules.

Atherosclerosis is one of the leading causes of heart disease and its presence is an important risk factor for events leading to acute myocardial infarction (AMI). In the past, atherosclerosis was described as a cholesterol and lipid storage event. Now we know it is a chronic inflammatory disorder of the arterial vessels with lipid components. Atherosclerosis begins with damage to the cells that line the blood vessels. Some possible causes of this cell injury are bacterial infection, hyperlipidemia, hypertension, glycosylated products of diabetes, cytokines from adipose tissue, or exposure to toxins such as pollution and second-hand smoke. Monocytes and lymphocytes adhere to the injured site; macrophages enter and ingest proteins and, along with modified lipoproteins, create foam cells. An inflammatory milieu results as cytokines and other inflammatory molecules become involved; foam cells and white blood cells begin secreting cytokines and metalloproteinases. Myeloperoxidase is also released by degranulated white blood cells and macrophages. As inflammation and accumulation of these products continues, fatty dots and streaks are formed on the vessel lining and the formation of plaque begins. As the atherosclerotic process continues, involved cells proliferate forming a complex extracellular matrix and a fibrous cap. If development continues, possibly over decades, the plaque formations are distributed throughout various vessels, become calcified or collagenized and make the vessel walls rigid. The risk to patients with significant atherosclerosis is that eventually a narrowing of the artery (stenosis) can cause a reduction in oxygen delivery to tissues and plaque rupture can lead to an acute coronary event.

A 63-year-old man was seen in the emergency room with the complaints of sudden onset of fever, chills, and abdominal pain, accompanied by mild diarrhea. The blood pressure was 140/84, the pulse rate 82/minute, and the body temperature 39.8C. A blood sample was drawn for a complete blood count, and a blood culture. A second blood culture was drawn from the opposite arm, with 10 mL of blood being placed into each an aerobic and an anaerobic bottle, following customary practice. The complete blood count revealed a hemoglobin of 15.8 mg/dL, a hematocrit of 45%, and a white blood count of 4.2/L. The neutrophils were 39%, lymphocytes 45%, monocytes 10%, eosinophils 4% and basophils 2%. The platelet count was 255/L. The patient was admitted to the hospital for further work-up and empiric antibiotic therapy. Within 24 hours after admission, the body temperature had decreased to 38.2C, although the mild diarrhea persisted. A stool toxin test for Clostridium difficile was negative and neither enteric pathogens nor Campylobacter species were recovered in stool culture after 24 hours incubation. Fecal neutrophils were not seen on direct examination. The anaerobic blood culture became positive 36 hours after inoculation.

The cytospin technique uses a high speed centrifuge to concentrate the cells on a slide in a uniform monolayer 6 mm in diameter. The monolayer distribution enhances the morphological appearance of the cells present.Allow the slides to dry in air for several minutes and then stain them with Wright-Giemsa stain. Cytospin slides may be placed in an automatic stainer or stained manually.Perform a 100 or 200 cell differential and record the number of neutrophils, eosinophils, basophils, lymphocytes, monocytes, macrophages, and blasts cells.Pathologists must review any slide which has tumor cells, unidentified cells, or immature stages of cells, such as blasts.Since criteria for review may vary from one laboratory to another, be sure to check the requirements in your laboratory before reporting the differential.

In normal spinal fluid from an adult, 60% of cells are lymphocytes and up to 30% are monocytes. Up to 2% neutrophils is also considered within normal limits when a cytospin smear is used for the differential. In children, normal CSF cells are 70% monocytes, up to 20% lymphocytes and up to 4% neutrophils. When any of these normal cell abundances are increased, the term pleocytosis is used. Neutrophil pleocytosis is an increase in neutrophils and usually indicates the presence of a bacterial infection.

Four small mature lymphocytes are seen in this picture. Sixty percent of the cells found in normal adult spinal fluid are lymphs.

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.

Many lymphocytes are present in this field. Two larger, reactive lymphocytes with intact cytoplasm and slightly indented nuclei are indicated by the blue arrows. Two other large cells with irregular, trailing cytoplasm are macrophages (histiocytes). These are indicated by the red arrows. Increased lymphocytes may be seen in viral meningoencephalitis, partially treated bacterial meningitis, multiple sclerosis, Guillian-Barre's syndrome, or polyneuritis.

A false positive result may occur in the presence of strong oxidizing agents in the collection container. In random urine specimens from women, a positive result for leukocyte esterase may be due to a source external to the urinary tract. Other urine sediment findings such as bacteria, squamous or renal epithelial cells, lymphocytes or red blood cells do not contain esterases, and would not produce a positive leukocyte esterase test.

Acquired Immunodeficiency syndrome (AIDS) is caused by the Human Immunodeficiency virus (HIV). When HIV enters a person's bloodstream, it attacks and kills the T-helper lymphocytes, which are essential to the body in fighting off infections. As these cells are lost, so is the body's ability to fight infection. Possibly months after the initial infecting episode, an infected person develops a mononucleosis-like illness lasting a week or two. A person may then be free of symptoms for years. But as the T-helper cells die, the person becomes vulnerable to many serious infections. The expected mortality is 100%, and there is no vaccine available to develop specific immunity.

The normal M:E ratio in adults varies from 1.2:1 to 5:1 myeloid cells to nucleated erythroid cells. An increased M:E ratio (6:1) may be seen in infection, chronic myelogenous leukemia or erythroid hypoplasia. A decreased M:E ratio (<1.2-1) may mean a decrease in granulocytes or an increase in erythroid cells. M:E ratios are somewhat higher in newborns and infancy than in later childhood and in adults. It is important to note that lymphocytes, monocytes and plasma cells are not included in the M:E ratio.

A thin area of a slide taken from a patient who has chronic lymphocytic leukemia, which is characterized by an increased number of small lymphocytes in the bone marrow. At this power, numerous small dark cells similar in appearance to immature red cells are seen, but can be quickly confirmed as lymphocytes when viewed under oil. The actual M:E ratio is normal, since lymphocytes are not included in the final ratio. The arrows show several cell most likely representing small lymphocytes. Some small lymphocytes are normal in the bone marrow.

Gating is a method that is used in flow cytometry to isolate cells, thereby selecting a cell population of interest. An electronic "gate" is placed around the cells that have the same light scatter or fluorescence properties. The white oval in the cytogram below is drawn around the lymphocyte population in the tested sample. This selection of a specific cell population is very important because the extrinsic/fluorescent CD marker data (shown in the histogram on the right) directly reflects the population "gated" in the cytogram.

The cell representations are listed below. B cellsCD19= 7%CD20= 7%CD10= 0%HLA-DR= 10%CD19/CD5 dual + = 0%Kappa=4%Lambda=3%Interpretation of the above data (refer to the decision tree to assist with interpretation of the case): There is a good mix of kappa and lambda; neither one is predominant. The B cells do not express CD5 (a B cell that expresses CD5 is abnormal because CD5 is normally a T cell marker) CD10 is not present on the B cells. Conclusion: B cells are NORMALT cellsCD2= 91%CD5= 90%CD7= 91%CD3= 88% The pan T cell markers all are within a few percentage points of one another, which translates to the sample having all markers that should be there and no values are skewed toward one marker. CD4 plus CD8 equals the total CD3 (55 + 33 = 88), therefore, there is good representation of both T helper and cytotoxic T cells (a neoplastic process could have predominantly one or the other or dual positive CD4 and CD8). Conclude: T cells are NORMALFinal conclusion: this is a normal peripheral blood lymphocyte population and there is no indication of a neoplastic process. The B cells that are present, though a small percentage of the total lymphocytes, have no abnormal markers. Most of the lymphocytes in this sample are T cells, yet they are normal as well. The CD markers that should be there are present and there is a good representation of both helper and cytotoxic cells.

Lymphocytes are a specific type of white blood cell. Lymphocytes can either be T cells or B cells. In the mature T cell population, the T cells can either be helper T cells or suppressor/cytotoxic T cells.Understanding the principles behind the identification of these T cell populations is important. To begin, CD3 marks all mature T cells. Then: CD4 marks T-helper cells CD8 marks cytotoxic T cells Therefore, in any given lymphocyte population, the CD4+ cells plus the CD8+ cells should equal the CD3+ cells. This is because the CD4 cells and the CD8 cells will also mark with CD3 since they are both mature T cells.Provided the total white blood cell (WBC) count and the percentage of lymphocytes from a complete cell count/differential, one can calculate various values. These values include: absolute CD3 counts, CD4 counts, CD8 counts, and CD4:CD8 ratios.The following results represent a patient sample which is used to calculate the values above:WBC count= 2.5 cells/uL (2500 cells/L), % Lymphs= 30%Using the following calculation: Absolute (Abs) lymphs= WBC count x 1000 x percent lymphs (expressed as a decimal) we can determine the absolute lymphocyte count per liter.2.5 x1000 x 0.30 = 750 lymphs/L

A 60-year-old man presented to the emergency department with complaints of fatigue and weakness which began during the previous week. He also stated that he had been experiencing shortness of breath without chest pain, cough, or dizziness. Upon physical examination, he had normal vital signs. However, his spleen was mildly enlarged. Laboratory tests were ordered. The white blood count (WBC) and absolute lymphocyte counts were both elevated:WBC= 28.5 x 109/L (normal 4 - 10) Lymphocyte count= 20.0 x 109/L (normal 1.2 - 4.0)A manual differential confirmed the elevated lymphocyte count. Smudge cells were also noted, as shown in the image.To evaluate the patient's lymphocytosis, a blood sample was submitted for flow cytometry analysis.

The B cell analysis produced the following results (abnormal findings are highlighted in yellow):CD19 = 81%CD20 = 82%HLA-DR = 83%Kappa = 80%Lambda = 1%CD19+/CD5+ = 81%CD10 = negativeCD45 = 99%Two apparent abnormalities are present; the B cells are clonal because they express primarily Kappa light chains and the B cells are positive for CD5, which is not normally present on B cells.If Kappa or Lambda is predominant and CD5 is co-expressed with CD19 (CD19/CD5 dual positive lymphocyte population), B-cell chronic lymphocytic leukemia (B-CLL) is a possible diagnosis. In order to confirm this finding, it is important to determine whether or not CD23 is present. The flow cytometry pattern can look identical for B-CLL and Mantle Cell Lymphoma (MCL), except CD23 is generally positive in B-CLL and negative in MCL, as shown in the decision tree on the right. This particular case does have CD23 = 82% Therefore, the final interpretation of Case Two is B-CLL.

Specialists in cytogenetics detect chromosome abnormalities and genetic disorders. Cytogenetics counseling may only be performed by an individual licenses in the cytogenetics specialty at the director level. Specialists in molecular genetics analyze DNA and RNA to find disease-related genotypes, mutations, and phenotypes in order to detect or predict disease and identify carriers. Specialists in histocompatibility test to determine tissue compatibility, prevent infections, and investigate and post-transplant problems. Techniques include blood typing, HLA typing, HLA antibody screening, disease markers, flow cytometry, crossmatching, HLA antibody identification, lymphocyte immunophenotyping, immunosuppressive drug assays, allogenic, isogeneic and autologous bone marrow processing and storage, mixed lymphocyte culture, stem cell culture, cell mediated assays, and assays for the presence of cytokines. Specialists in andrology and embryology examine gametes and embryos, including production, morphology, number, and motility, to address issues of fertility and infertility.

N:C Ratio - Nuclear: cytoplasmic Ratio - The ratio of nuclear volume to cytoplasmic volume within any one cell.Neoplasm - Any new and abnormal growth, such as a tumor.Neutrophilic Granules - Specific granules present in the cytoplasm of neutrophils. These granules resemble pencil stippling and stain a lilac color due to their affinity for both basic and acid dyes.Phagocyte - Any cell that ingests microorganisms or other cells and foreign particles.Phagocytosis - The ingestion and destruction of microorganisms or other foreign particles.Plasma - The fluid portion of blood in which the various blood cells are suspended.PF3 (platelet Factor 3) - A lipoprotein component of the platelet membrane; functions as a surface catalyst during blood coagulation.Pseudopod - A temporary protrusion of the cytoplasm of a cell.Refractile - Capable of refracting or changing the direction of light.Senescence - The process or condition of growing old.Serotonin - A constituent of blood platelets and other cells and organs; induces constriction of the blood vessels.Specific Granules - Granules found in cells of the more mature stages of the granulocytic series. They have distinct staining reactions which differ with each type of granulocyte.T-cell - Thymus derived lymphocyte which mediates cellular immunity.Thrombocyte (Platelet) - A circular or oval disk found in the blood; concerned with hemostasis.Thymus - A ductless gland-like body situated in the anterior mediastinal cavity; reaches its maximum development during the early years of childhood.Vacuole - Any small space or cavity formed in the cytotoplasm of a cell.

Monocytes are the largest of the normal peripheral blood cells, ranging from 14-20µm in diameter with an N:C ratio of approximately 3:1. Monocytes have abundant blue-gray cytoplasm containing many fine lilac granules. These give the cytoplasm a "ground glass" appearance. However, these granules may be difficult to see if the blood film is poorly stained. Frequently, cytoplasmic vacuoles are present. These vacuoles appear as unstained areas or "holes" in the cytoplasm; an example of which can be found in the lower image to the right.Because monocytes are extremely motile cells, blunt pseudopods may be seen. These should not be confused with the apparent cytoplasmic projections produced when large lymphocytes are indented by surrounding cells. Monocytes have generally lighter staining nuclei than do other leukocytes. The nucleus stains a pale bluish-violet, and the chromatin is fine. Overall, the nucleus has a soft, spongy, three-dimensional appearance, in contrast to the hard, flat nucleus of the large lymphocyte and the densely clumped nucleus of the band. The nucleus may be round, kidney-bean shaped, folded, indented, or horseshoe, and may show "brain-like" convolutions.

Cellular immunity includes delayed hypersentivity reactions, graft rejection, graft-versus-host reactions, defense against intracellular organisms, and probably defense against neoplasms.Cellular immunity is mediated by lymphocytes which we call T-cells.T-cells are so named because they are dependent on the thymus for their production and development.The majority of T-cells are long-lived with an average lifespan of 4.4 years, but it is known that some survive for as long as 20 years or more.T-cells are capable of leaving and re-entering the circulation many times during their long life.T and B cells cannot be differentiated when viewing blood films.They are identified through the use of immunologic cell markers.

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.

Lymphocytes are primarily involved in the body's immune response mechanism. This involves complex phenomena which end in the development of humoral and cellular immunity.

The cell diameter is slightly less than that of the nucleus of the small lymphocyte. The cytoplasm stains pink to brick-red, and no nucleus is present.

N:C Ratio - Nuclear: cytoplasmic Ratio - The ratio of nuclear volume to cytoplasmic volume within any one cell.Neoplasm - Any new and abnormal growth, such as a tumor.Neutrophilic Granules - Specific granules present in the cytoplasm of neutrophils. These granules resemble pencil stippling and stain a lilac color due to their affinity for both basic and acid dyes.Phagocyte - Any cell that ingests microorganisms or other cells and foreign particles.Phagocytosis - The ingestion and destruction of microorganisms or other foreign particles.Plasma - The fluid portion of blood in which the various blood cells are suspended.PF3 (platelet Factor 3) - A lipoprotein component of the platelet membrane; functions as a surface catalyst during blood coagulation.Pseudopod - A temporary protrusion of the cytoplasm of a cell.Refractile - Capable of refracting or changing the direction of light.Senescence - The process or condition of growing old.Serotonin - A constituent of blood platelets and other cells and organs; induces constriction of the blood vessels.Specific Granules - Granules found in cells of the more mature stages of the granulocytic series. They have distinct staining reactions which differ with each type of granulocyte.T-cell - Thymus derived lymphocyte which mediates cellular immunity.Thrombocyte (Platelet) - A circular or oval disk found in the blood; concerned with hemostasis.Thymus - A ductless gland-like body situated in the anterior mediastinal cavity; reaches its maximum development during the early years of childhood.Vacuole - Any small space or cavity formed in the cytotoplasm of a cell.

Large lymphocytes are relatively fragile cells, and as a result are frequently squeezed out of shape by surrounding cells, giving them a scalloped appearance.

The chromatin pattern of the large lymph, seen in the upper image, is not as dense as that of the small lymphocyte, seen in the lower image, but even so the nucleus appears hard and flat.

Lymphocytes are a heterogeneous group of cells that have different origins, lifespans and functions, and vary markedly in size. Some have a diameter of approximately 7µ, while others are as large as 18µ. The variations in size are mainly due to different amounts of cytoplasm. Therefore, the N:C ratio may range from 5:1 in some lymphocytes to 1:2 in others.

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.

The table below lists some characteristics that help to distinguish large lymphocytes from monocytes. CellImageNucleusCytoplasmLarge lymphocyteOval, round, indented, "stretched Deep purplish-blue Dense Sky-blue Clear, transparent No granules or azurophilic (reddish) granules Infrequent vacuoles Cytoplasm may be indented by surrounding cells MonocyteRound, oval, indented, convoluted Pale purplish- blue Fine, lacy, spongy Blue-gray Cloudy, opaque, "ground-glass" appearance Fine granules Frequent vacuoles Cytoplasm may have pseudopods

Because monocytes are extremely motile cells, blunt pseudopods may be seen. These should not be confused with the apparent cytoplasmic projections produced when large lymphocytes are indented by surrounding cells.

HIV infection is caused by the human immunodeficiency virus. The infection occurs when HIV enters a person's bloodstream, where it attacks and kills the helper T-cells. Helper T-cells are part of a group of white blood cells known as lymphocytes that are essential for fighting off infections.As the numbers of these cells decreases, so does the body's ability to fight infection.

HIV is caused by the Human Immunodeficiency virus.When HIV enters a person's bloodstream, it attacks and kills the T-helper cells. These cells are part of a group of white blood cells known as lymphocytes, which are essential to the body in fighting off infections.As these cells are lost, so is the body's ability to fight infection.

Contain either acid citrate dextrose (ACD), which maintains RBC viability and may be used for HLA phenotyping, DNA, paternity testing, or lymphocyte surface markers, or: Sodium polyanetholesulfonate (SPS) which is sometimes used to collect blood culture specimens.

Cell TypeImageCellular DescriptionAssociated Diseases and ConditionsNormocyteMCV 80-100 fL (approximately the same size as the nucleus of a small lymphocyte) MCHC 32-36 g/dL or 32%-36%N/A; cell is normalMicrocyteRed blood cells are smaller than normalMCV < 80 fLIron deficiency anemiaSideroblastic anemia Certain thalassemias Lead poisoning Certain hemoglobinopathiesMacrocyteRed blood cells are larger than normalMCV > 100 fLMegaloblastic Anemia (Vitamin B12/Folate deficiency)MyelodysplasiaLiver disease

Another view taken from the same patient's slide. Although no lymphocyte is seen in this field, many of the cells appear quite small with increased areas of central pallor. This patient had iron deficiency anemia.

Another example of microcytes seen in a slide from a patient with hemolytic anemia. Compare the two microcytes in the center of the field with the lymphocyte to the right. Notice the larger red cell just below the microcytes is about the same size as the lymphocyte. Several other microcytes can also be seen in this field.

Macrocytes have a diameter of 9-14 µm (1.5 to 2 times larger than normal red cells) and the MCV is >100 fL. Several macrocytes are indicated by the blue arrows in the top image on the right. By comparison, macrocytes are larger than the nucleus of a normal lymphocyte. Macrocytes are frequently oval; two examples are indicated by the red arrows in the top image on the right.Oval macrocytes are most commonly associated with vitamin B-12 and/or folic acid deficiency. Decreased DNA synthesis causes the nucleus in the developing red cells to mature at a slower than normal rate. Since hemoglobin production is not affected, the mature red cell that is larger than normal is filled with hemoglobin, resulting in cells with little central pallor. Note that polychromatophilic red cells may also be larger than normal RBCs. However, if stained with a supravital stain, it would be obvious that these cells are reticulocytes. From a Wright-stained smear, they would be reported as polychromatophilic RBCs and not macrocytes. Examples of polychromatophilic RBCs are indicated by the arrows in the bottom image on the right. The cells stain gray-blue with Wright stain.

Urine sediment may also contain white blood cells (WBCs). Most of the WBCs in urine are segmented neutrophils. Since it is possible that lymphocytes, monocytes, and/or eosinophils may be present, the cells in urine can be stained if it is necessary to differentiate them. The segmented neutrophil indicated by the blue arrow shows a distinct nucleus. When viewing urinary sediment under the microscope, the fine focus adjustment must be used to identify white blood cells. White blood cells swell in dilute alkaline urine and the cytoplasmic granules exhibit brownian movement resulting in "glitter cells." These cells lyse rapidly. "Glitter cells" are most easily seen when viewed under phase-contrast microscopy.

This image shows a peripheral smear from another patient with Alder anomaly. Notice that neutrophil seen in the image has granulation which is much heavier than what would be classified as normal. The amount of granulation may vary from cell to cell, with some cells being unaffected. A lymphocyte showing abnormal granules is also present on this slide.

A lymphocyte from a patient with Chediak-Higashi syndrome. The azurophilic granules appear much larger than those seen in normal lymphocytes.

Alder anomaly is a rare autosomal recessive disorder in which the basic defect involves protein-carbohydrate complexes called mucopolysaccharides. The accumulation of partially degraded (broken down) protein-carbohydrate complexes within the lysosomes account for the larger than normal purple-staining inclusions seen in all types of mature white blood cells, and sometimes in earlier cells. The granules may occur in clusters, rather than diffusely, throughout the cytoplasm as in toxic granulation. These inclusions may be seen in the bone marrow more frequently than in peripheral blood. The physical characteristics associated with this disorder include gargoylism and dwarfism. The function of the cells involved is not affected. This morpholical change would be classified as pathological since the body is responding abnormally even though the function is not affected.

Automated cell counters will flag abnormal findings. The following guidelines represent typical review criteria, although specific requirements vary between laboratories. Follow the criteria established by your laboratory's procedure:Total white blood cell count <3.0 X 109/L or >12.0 X 109/LNeutrophils >80% Lymphocytes >45% or <10% Monocytes >15% Eosinophils >10% Basophils >5%A morphology review may also be indicated if the platelet count is <100 X 109/L or >650 X 109/L.

In most clinical hematology laboratories, an initial blood count is performed by an automated cell counting instrument. Additionally, most of these instruments also produce a five-part differential count, indicating the percentage of neutrophils, lymphocytes, monocytes, basophils, and eosinophils. Some instruments can also provide information about cellular immaturity and abnormal cellular morphologies.Occasionally, atypical cells, similar to those shown in the image to the right, would be flagged or counted as mixed cells, at which point a smear review would be required to make an identification. In cases where there are automated instrument differential flags, mixed cell count is high, or there are other indications that atypical cells may be present, a review of the smear is indicated.

Alder anomaly is characterized by large azurophilic granules that stain dark-purple and are seen throughout the leukocyte cytoplasm, even covering the nucleus. The inclusions (granules) are seen in the cytoplasm of almost all mature leukocytes i.e., granulocytes, lymphocytes, and monocytes. This distinguishes Alder anomaly inclusions from toxic granulation, which is only observed in neutrophils. Another feature that distinguishes Alder anomaly from toxic changes is the lack of cytoplasmic vacuoles of toxic origin in the neutrophils of Alder anomaly.The background condition in Alder anomaly is mucopolysaccharidosis, collectively, a group of inherited disorders where a deficiency of lysosomal enzymes are lacking that are needed to degrade mucopolysaccharides. The inclusions observed in the leukocytes represent partially degraded mucopolysaccharides within lysosomes. Accompanying conditions are hepatosplenomegaly, corneal opacities, and mental retardation.

An 80-year-old man was seen in the emergency room with sudden onset of right-side chest pain accentuated on inspiration. His cough was productive of yellow sputum, and he was short of breath. His temperature was 101.2°F. A chest X-ray revealed right middle lobe pneumonia. A complete blood count (CBC) was ordered. The results were as follows:CBC ParameterPatient ResultReference IntervalWBC33.0 x 109/L4.0 - 11.0 x 109/LRBC4.5 x 1012/L4.5 - 5.9 x 1012/LHemoglobin15.2 g/dL13.5 - 17.5 g/dLHematocrit44%41 - 53%Platelet200 x 109/L150 - 450 x 109/LSegmented neutrophil6540 - 80%Band neutrophil100 - 5%Lymphocyte 525 - 35%Eosinophil 30 - 5%Basophil 20 - 2%Monocyte252 - 10%A peripheral smear was reviewed based on the elevated WBC and increased monocyte count. A representative field from the Wright-Giemsa stained smear (1000X magnification) is shown on the right. The cells indicated by the blue arrows are atypical monocytes. They have abundant cytoplasm that is more blue than the typical gray-blue cytoplasm of normal monoctes. A few scattered vacuoles are also present. The atypical monocytes, in company with toxic neutrophils (indicated by the red arrow), appeared to be a response to infection. The patient had a past history of tuberculosis, which may account for the monocytosis.