Morphology Information and Courses from MediaLab, Inc.

These are the MediaLab courses that cover Morphology and links to relevant pages within the course.

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CLIA Hematology / Hemostasis Review
Match each of the three boxes on the left with the appropriate magnification on the right:	View Page
Which of the following is not a routine component of semen analysis:	View Page

Current Topics in Clinical Microbiology
The Gram stain report to be issued based on the microscopic characteristics seen in the accompanying picture would most correctly be, "many wbc with"..	View Page
Based on the gram stain morphology observed before, the possible presumptive identifications might include "gram positive cocci consistent with...	View Page
The patient was admitted to the hospital. The sputum specimen was inoculated to sheep blood agar. Based on the colony morphology seen in the accompanying photograph, the most likely identification is:	View Page
The gram stain shown in the photograph was prepared from a positive anaerobic blood culture bottle after 36 hours incubation. Based on the morphology of the bacterial cells (some with spores--blue arrows), the most likely identification is:	View Page
Colony Morphology The growth observed on the anaerobic blood agar plate after 48 hours incubation (see upper photograph), revealed a spreading colony. The spreading nature of the colony is better observed in the close-in photograph (lower). No growth was observed on subcultures incubated aerobically indicating that this isolate is truly an anaerobe (although aerotolerance studies would be needed for confirmation). The spreading nature of the colony and the lack of hemolysis are highly suggestive of Clostridium septicum. However, biochemical confirmation is necessary.	View Page
Colony Morphology Photograph of the surface of blood agar after 24 hours incubation at 35C in 10% CO2, on which are growing tiny, translucent, gray colonies surrounded by a narrow zone of "soft" beta hemolysis.There was no growth on the MacConkey plate.	View Page

Fundamentals of Hemostasis
Which of the following is not true in terms of platelet characteristics?	View Page

Introduction to Bone Marrow
Preparation of Concentrated Smears In some laboratories the anticoagulated sample is used to prepare concentrated smears. Placing the fluid in a Wintrobe tube and centrifuging it separates the sample into four layers:fat and perivascular cellsplasmabuffy layer - myeloid and nucleated erythroid cellserythrocytesThe volume of each layer is measured using the scale on the Wintrobe tube and then the percentage of each layer is calculated. Next the plasma is removed and a smear is made from the buffy coat and top of the red cell layer. Either the manual push method or cytospin technique may be used to make the smears. They may be stained with a variety of cytochemical stains. Concentrated smears are used to examine cell morphology and demonstrate the presence of abnormal cells when the marrow is hypocellular. The smears cannot be used for differential counts or evaluation of cellularity.	View Page
Preparation of Direct Smears The sample in the first syringe is quickly delivered into a watchglass or onto a slide. After the technologist verifies the presence of white-gray marrow particles in the sample, push smears and/or coverslip smears from this unanticoagulated sample are made immediately. All films should be rapidly air dried. The appearance of fat as irregular holes in the films also give the assurance that marrow and not just blood has been obtained. This type of smear is referred to as a direct smear and is usually used to evaluate morphology. Although some evaluation of cellularity and M:E ratio is possible, particle smears or biopsy sections provide a more accurate representation of these factors.	View Page
Examination of Wright-Giemsa Stained Bone Marrow Examination of Wright-Giemsa stained bone marrow preparation involves examination under low power (10X objective) high power (40-50X objective )and oil immersion (100X objective). Low power examination: Assess quality of smear, assess number of megakaryocytes.Assess myeloid to erythroid ratio.Evaluate morphology and do differential count.	View Page
Normal M:E Ratio A normal M:E ratio is depicted in this slide. Notice that the area shown is a portion of the slide near a particle or spicule of marrow where the cells are numerous. The morphology can still be clearly differentiated. The small dark cells scattered throughout the slide are erythroid cells, while the larger, lighter staining cells are myeloid cells. The normal M:E ratio varies from 1.2 to 5 myeloid cells for each erythroid cell.	View Page
Megakaryocyte Morphology It is also important to examine the morphology of platelets. One megakaryocyte shows a single nucleus surrounded by cytoplasm which will eventually break off to form platelets. The other one at the arrow shows a lobated nucleus which has divided several times; the large amount of cytoplasm surrounding this nucleus means that this cell will be able to produce more platelets. In general, as the megakaryocyte gets older, it forms more nuclear lobes, more cytoplasm and therefore is able to produce more platelets.	View Page
Representative Counting Field The actual cell count is performed using the oil (100x) objective. This oil immersion field shows a representative counting field. Four granulocytes, a prorubricyte, and two rubricytes are completely visible here. 100 to 500 nucleated cells are generally counted,depending on the cellularity of the smear, and only cells completely visible in the field should be included in the count.	View Page
Oil Immersion Field Another oil immersion field showing good cellular morphology.	View Page
Evaluating Cellularity The biopsy section or particle smears are the preparations that are preferred for the evaluation of marrow cellularity and architecture. The low power objective is used to examine the slide and compare the cellular area to the amount of fat (fat cells appear as white circles interspersed among the cellular elements). On the biopsy section the specific type of cells present are difficult to determine but the cellularity can be clearly seen. The particle smear may be used to evaluate cellularity as well as morphology. The diagnostic significance of the evaluation of cellularity, is simply to see if there are too few, too many, or sufficient cell precursors present in the bone marrow.	View Page

Laws and Rules of the Florida Board of Clinical Laboratory Personnel
Description of Specialties (1) Specialists in microbiology perform testing to diagnose and stop the spread of infectious organisms, including bacteria, viruses, and parasites. Specialists should be able to isolate and identify a wide variety of these organisms. Testing procedures include direction examination and antigen detection methods. Specialists in serology and immunology measure antibodies to infectious organisms. Specialists should be familiar with all serology techniques (except those specific to immunohematology). This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in hematology must be able to identify and evaluate cells in blood and bone marrow and identify disorders of these cell. Specialists should be familiar with routine and special tests to determine the number, morphology, and function of cells in body fluid.	View Page
Description of Specialties (4) 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.	View Page

Mycology: Yeasts and Dimorphic Pathogens
Match the names of each of the yeast species with its most likely colony morphology as seen in the images on the right.	View Page
Match the names of each of the yeast species listed with its corresponding appearance when grown in cornmeal agar, as seen in the images.	View Page
Arrange in sequence the steps that should be taken to make a definitive identification of Cryptococcus neoformans.	View Page
The colony shown in the upper image was recovered from peritoneal fluid of a patient receiving continuous peritoneal dialysis. The lower image is a photomicrograph prepared from a small portion of the colony illustrating the microscopic morphology. Each of the following species of yeast can be eliminated except:	View Page
A yeast identification system gave a biotype number for an unknown isolate that did not differentiate between Candida tropicalis and Candida parapsilosis. This isolate could be identified as C. parapsilosis in a cornmeal agar preparation if it produced:	View Page

Normal Peripheral Blood Cells
T lymphocytes are larger and have more vacuoles than B lymphocytes.	View Page
Overview All of these peripheral blood cells have different characteristics. In order to accurately identify each of them, a peripheral blood film must be made, preferably from capillary blood or blood anticoagulated with EDTA (Ethylenediaminotetracetic Acid). EDTA, in contrast to many other anticoagulants, preserves cellular morphology. The individual characteristics of each cell type are made visible by staining the blood films with the Wright stain, and observing them under the microscope.	View Page

Reading Gram Stained Direct Smears

Reading Gram Stained Smears From Cultures

Principle

The culture smear is used to determine the staining characteristic and shape of the unknown organism since this data helps the microbiologist to decide on additional culture and identification methods. By correlating the Gram stain reaction, colony morphology and growth requirements, the microbiologist may be able to tentatively identify the organism, which the physician may use to modify treatment, until definitive culture and antibiotic susceptibility results become available.

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Red Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
The presence of erythrocytes with altered morphology (as photographed here) has a close association with each of the following conditions except:	View Page
A blood smear represented by the photograph was submitted for hematologic review. Based on the erythrocyte morphology and the accompanying histogram, which of the following choices is the most likely situation or condition?	View Page
References Glassy, Eric F.,(Ed). Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing. 1998. College of American Pathologists Hematology and Cliical Microbiology Research Committee. College of American Pathologists, Northfield, IL 60093-2750.Hookey,L., Dexter, D., Lee,D. H. The Use and Interpretation Of Quantative Terminology In Reporting Red Blood Cell Morphology. Laboratory Hematology 7:85-88, 2001.Peterson P, Blomberg DJ, Rabinovitch A, Cornbleet PJ. Physician Review of the Peripheral Blood Smear: When and Why. For the Hematology and Clinical Microscopy Resource Committee of the College of American Pathologists. Laboratory Hematology 7:175-179, 2001	View Page
Reporting of laboratory data in regard to blood cell abnormalities Laboratory data must be presented to clinicians in a user friendly way to promote effective decision making. Databases must be designed to provide clear information that leads quickly to the best patient care outcome. We continue learning how to collect and retrieve laboratory data from our machines, but we are not always in tune to how entry and retrieval of data is geared to and, more directly, influences patient care outcomes. Examples of blood cell abnormalities on a peripheral blood smear that may immediately direct the physician to a specific diagnosis are: (1) presence of target cells as found in thalassemia or hemoglobinopathies and target cells in liver disease, particularly with obstructive jaundice; (2) burr cells as a signal of chronic renal disease and uremia; and (3)atypical neutrophil inclusions relating to genetic disorders. Critical appraisal of such observations could add valuable clues for a diagnosis. Laboratory professionals must establish a set of principles for orderly observation of blood cell morphology, have a clear vision of the applications of their work, and understand the potential clinical implications of their reports and interpretations. Emphasis on values and relevance focuses on patient care outcomes and their dependency on prompt availability of results and contextual interpretations.	View Page
Guidelines for standard reports In a study on the reporting of red blood cell morphology abnormalities conducted in Ontario, Canada (Hookey L, Dexter D, Lee DH, Laboratory Hematology 7:83-88, 2001), fewer than 50% of 33 participants used the same term to describe the quantitative frequency of peripheral blood abnormalities. Seven blood smears, each containing one of several abnormal erythrocytes-- schistocytes, teardrop cells, acanthocytes, and Howell-Jolly bodies--were evaluated by 32 participants. The participants were asked to document their evaluations from a list of quantitative terms. There was a heterogeneity in the use of terms "rare," "slight," "occasional," "few," "mild", "present," "moderate," "many," and "marked." Choices of terms were subjective without points of reference. Guidelines for establishing standardized qualitative estimations of abnormal erythrocytes in the peripheral smear are presented as follows: 1+ = 2 - 4/Oil Immersion Field (OIF) 2+ = 5 - 7/OIF 3+ = 8 - 10/OIF 4+ = >10/OIF. The terms "few," "moderate," "many," and "marked" may be substituted for the 1+ - 4+ grading system, but only when their specific points of reference are universally understood in tandem with the above guidelines. A comment should be triggered if any erythrocyte abnormalities are seen in numbers >3/OIF including, but not limited to, polychromasia, basophilic stippling, nucleated RBC's, and Howell-Jolly bodies. Rouleaux or RBC agglutination are important findings and must be documented.	View Page

Red Cell Morphology
Red Cell Morphology Red cell morphology can be defined as the appearance of the erythrocytes on a Wright's stained smear.Careful examination of the red cells for the purpose of identifying abnormalities is part of the differential procedure. This examination is important because it may provide valuable diagnostic information to the physician, as well as provide a quality control mechanism to verify red cell indices values as determined by automated or manual methods.Evaluating red cell morphology involves differentiating normal morphology from abnormal and artificial morphology. The abnormal morphology covered in this unit may be seen in a variety of disorders.	View Page
Assessing Red Cell Morphology Procedure The procedure for assessing red cell morphology includes examining the smear in the feathered (thinner) edge where the erythrocytes are randomly distributed and, for the most part, lie singly, with occasional doublets. This area is referred to as the "critical area." If the area is too thin, the red cells will appear flat and somewhat square (cobblestone effect) with no central pallor. If the area examined is too thick, the cells will be too close together to evaluate the morphology of individual cells. To begin the red cell morphology examination, use the low power (10X) objective to locate the "critical area." The oil immersion objective (100X) is used for the actual evaluation.	View Page
Artifactual Morphology These cells are in an area which is too thick, and should not be used for red cell morphology assessment. Some of the cells appear to be stacked like coins because of the large number of cells present in this section of the slide. The morphology seen in the too thin and too thick areas of the smear is referred to as artificial morphology.	View Page
Rouleaux and Autoagglutinaton Rouleaux and autoagglutination are considered forms of poikilocytosis, but differ from the forms discussed previously because groups of cells are involved rather than single forms. In addition, these types must be differentiated from similar-appearing artifacts caused by improperly made slides and/or examining morphology in an area which is too thick.	View Page
Summary It is important to differentiate in vitro changes which are secondary to preparing the slide, from in vivo morphology, which is the result of the pathophysiological condition of the patient. Examining erythrocytes in the critical viewing area is extremely important in making this distinction. The determination of the clinical significance of the morphology reported is the responsibility of the physician, who must correlate the blood smear findings with the clinical diagnosis, and other laboratory parameters.	View Page
The predominant forms of abnormal morphology seen in this slide are:	View Page
All of the following statements are true of hypochromic red cells EXCEPT:	View Page

Semen Analysis
Which of the following are TRUE for the morphology examination?	View Page
A specimen was collected three hours before it was brought to the laboratory for examination. What course of action should be taken?	View Page
Materials Needed The following is a list of materials needed for semen analysis. Laboratories will differ slightly in the equipment used. Use of this equipment will be described further in the later pages of this course. Materials needed include:graduated test tube or serological pipets with safety bulb to measure volumepH paper in neutral to basic range (e.g. 7.2-8.8)counting chamber and/or automated counting machineglass slides and coverslips for wet mount if motility and sperm count are to be assessed separatelyhand counterif dilution is donediluting fluid calibrated automatic pipetspositive pressure pipets and glass boreslight microscope with phase contrast objectives for sperm count and bright field objectives for morphology assessmentglass slides and fixative for morphology slidesset-up for performing Papanicolaou or other morphology stainingEvery laboratory should also have a copy of the "WHO Laboratory Manual for the Examination of Human Semen and Sperm-Cervical Mucus Interaction", published on behalf of the WHO by Cambridge University Press. The fourth edition was published in 1999.	View Page
In summary the procedure will involve the following: The following aspects of semen analysis will be described in further detail during this course: Check the identity of the patient Record information that has been obtained from the patient including: time of collection, collection method, problems during collection, medications the patient is taking Note time to liquefaction Measure the volume by pouring into a graduated test tube or by drawing the specimen into an appropriately sized graduated serological pipet Assess viscosity Note color Measure pH by putting a drop on a strip of pH paper Count the sperm in the specimen Assess motility Count round cells, if present Assess the proportion of round cells that are white cells Fix and prepare specimen for morphology assessment; assess morphology	View Page
Morphology of sperm Describing the morphology of the sperm in a semen specimen is an essential part of the microscopic examination. The presence of abnormal forms along with low counts and/or poor motility contributes to a poor prognosis in infertility cases. There are several different methods for determining morphology. The most common are the WHO III (WHO III manual, 1992)assessment and the Strict Morphology method found in the WHO IV manual (1999). A specimen is considered normal if 30% or more of the sperm are normal morphology according to WHO III criteria. If strict morphology criteria are used then the specimen is considered normal if it has 14% or more normal forms.	View Page
Abnormal forms There are a number of abnormalities of sperm morphology. Abnormal heads can include enlarged head, double head, round head, constricted head, amorphous head, pinhead, and acute tapering forms. There are also heads with abnormal numbers of vacuoles. Midpiece abnormalities include distended and thin midpiece regions. Abnormal tails include short tails, double, triple or multiple tails, coiled tails, broken tails, or absent tail. Cytoplasmic droplets are also seen in some specimens. These are large regions of cytoplasm just below the head assumed to represent failure of complete sperm maturation or a sign of either toxicity or oxidation. There have also been reports that cytoplasmic droplets may be artifacts from the fixation and staining for morphology analysis.	View Page
Morphology of normal sperm Normal sperm morphology requires that the head tail and midsections of the sperm be normal. The heads of normal mature sperm are slightly oval in shape and measure approximately 4.0 to 5.5µm in length and 2.5-3.5µm at the widest part. The acrosomal region should be 40-70% of the head area. Normal midsections are tapered. They do not bulge out or contain extra cytoplasm. Sperm have a long tail which is slightly thicker near the head than at the end. Sperm tails measure about 50µm. Normal sperm are seen on the right (a) front view, and (b) lateral view.	View Page
Staining and fixation for sperm morphology To examine sperm morphology a semen smear is prepared on a clean glass slide, much like making a blood smear. It is important that the sperm be spread evenly on this slide and that the concentration be such that individual sperm can be clearly viewed. Too many sperm per slide makes evaluation difficult. Too few, makes it hard to find enough sperm for an adequate count.The examination of morphology is made using one of several commonly used stains. These include: Papanicolaou stainDiff QuikShorr stainDetails of these staining methods are available in the WHO IV reference manual.Two slides are prepared and 100 sperm are counted per slide using a bright field 40X or 100X objective.	View Page
Morphology: What this presentation will teach you. This presentation will describe basic aspects of WHO III assessment. For information on details of some of the morphological assessments you will need to review information presented in the 1992 WHO III manual.Learning to do strict morphology assessments is more complicated than learning WHO III and generally requires that the technician take one of the many hands-on laboratory courses offered periodically around the country. Details of strict morphology assessment are presented in the 1999 WHO IV manual.	View Page
Summary: Reference values The following are reference values for a normal semen analysis. It should be noted that these are recommended reference ranges only and that they may require adjustment for your particular laboratory or region of the country:Liquefaction: ≤30 minutesVolume: ≥2.0 mlColor: white, yellowish, grayViscosity: non-viscouspH: ≥7.0Sperm count: ≥20 million / mlMotility: ≥50%Leukocytes: ≤1 million / mlWHO III Morphology: ≥30%Strict Morphology: ≥14% In addition some people find it useful to have a total motile count (TMC). This is calculated by multiplying the concentration x the percent motility x the volume. Normal TMC is 10 million or greater.	View Page
Microscopic Examination of Semen Microscopic examination of semen includes assessment of: sperm concentration percent motility percent viability cellular elements other than spermatozoa sperm morphology Sperm counting will be covered in this section. Assessment of other cellular components and of morphology will be covered in the next sections. For assessing count, motility, viability and other cellular components your laboratory will require a phase contrast microscope with 10x oculars and objectives up to 20x. For assessing morphology you will need bright field objectives up to 40x and 100x (oil immersion).	View Page
Which of the following is NOT part of the microscopic examination performed on semen?	View Page
Requirements for the microscopic examination of semen For assessing count, motility, viability and other cellular components your laboratory will require a microscope with 10x oculars and phase contrast objectives up to 20x. You will also need hand counters.For assessing morphology you will need bright field objectives of 40x and/or 100x (oil immersion).You will also need counting chambers, glass slides and coverslips and a method for staining sperm for morphology assessment.	View Page

The Urine Microscopic: Microscopic Analysis of Urine Sediment
Transitional Epithelial Cells A third type of epithelial cell are transitional epithelial cells. They are often pear-shaped with a thin tail on one end. Transitional epithelial cells are not clinically significant unless they are seen in large numbers or have abnormal morphology which may indicate transitional cell carcinoma. Catherization may cause increased numbers of transitional epithelial cells.	View Page
Identification of Crystals Identification of crystals found in the urine sediment requires knowledge of the urinary pH. Large crystals are identifiable under low power. High power magnification is required for smaller crystals. Most crystals can be identified by morphology alone. Urine pH and reagent strip results can provide supporting information. If further examination is necessary birefringence and solubility characteristics should be performed.	View Page
Uric Acid Crystal Morphology The morphology of uric acid crystals varies more than any other type of crystal, from "whetstone" to hexagonal plate, from rosettes to rectangles or other irregular shapes. Their color also can vary from almost colorless to yellow or brown. Large numbers of uric acid crystals may be seen in individuals with leukemia or patients undergoing chemotherapy.	View Page

Variations in White Cell Morphology - Granulocytes
Variations in Morphology Many variations in morphology may be seen when examining Wright's stained peripheral blood smears. One method of classifying these variations in white cell morphology is based on the way the body responds to a stimulus, deficiency, or the presence of an inherited defect. This classification falls into three groups:Pathological: Cells may show abnormalities in appearance and/or function. The body is responding abnormally to a stimulus or inherited defect, resulting in physiological impairment in the patient. Nonpathological: Cells may show variation in morphology but their function is normal. Their presence does not cause physiological impairment. Reactive: Cells show variation in morphology but are functioning normally in response to a specific stimulus, such as a virus or bacteria. There is a disease process in progress to which the cells are responding. Although the morphology has varied from normal and their presence is significant, the body is responding normally to a stimulus.	View Page
Match the following:	View Page
Choose ALL of the answers that correctly complete the following statement: Barr bodies are important to recognize because they	View Page

White Cell and Platelet Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
The nuclear appendage at the tip of the arrow is a normal finding in females but not in males.	View Page
The neutrophils illustrated in this photograph are representative of those seen in the smear. The total WBC was 28,500 cells/cumm. The appropriate report to be issued following a morphology consultation would be:	View Page
A peripheral blood smear with many myeloid cells (photograph) was presented for morphology review. Toxic vacuoles in the neutrophil and monocyte most likely represent:	View Page
A peripheral blood smear is submitted for morphology review. The patient is a 10 year-old boy with symptoms suggesting appendicitis and an appendectomy is being considered. The total WBC is 18.5 X 1000/uL, RBC's = 5.45 X 1M/uL, hemoglobin = 16.0 g/dL, hematocrit 48.2%;wbc differential: Segs = 53%, bands = 42% (two of which are shown in the photograph), monocytes = 2%, and lymphocytes= 2%. These findings support the diagnosis of appendicitis.	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
A peripheral smear was submitted for morphology/clinical because of the number of monocytes as captured in the upper and lower photographs. This picture is consistent with each of the following conditions except:	View Page