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Rbc Information and Courses from MediaLab, Inc.

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Laboratories Individuals

Alpha Thalassemia
Wright's stained peripheral blood smear made from EDTA specimen.What RBC morphologies are present?View Page
CBC Results

WBC 6.1 X 10 9/L (Reference range 4.0 - 10.5 X 109/LRBC 4.84 X 1012/L (Reference range 3.50 - 5.50 X 1012/LHb 8.4 g/dL (Reference range 12.0 - 16.0 g/dL)Hct 28.8 % (Reference range 36.0 - 48.0%)MCV 59 fL (Reference range 80.0 - 100.0 fL)MCH 17.4 pg (Reference range 26.0 - 34.0 pg)MCHC 29.3 g/dL (Reference range 32.0 - 36.0 g/dL)RDW 19.5 % (Reference range 11.0 - 15.0 %)Plat 591 X 109/L (Reference range 150 - 400 X 109/L)Even though the RBC count is normal, it is increased for the amount of hemoglobin present. The concentration of hemoglobin in the RBCs is slightly decreased (hypochromic) and the cells are small (microcytic). The variation in RBC size is also slightly increased as are the platelets.

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Alpha Thalassemia Major

Anemia is fatal.RBC count is increased.Hb is severely decreased.MCV is decreased. MCHC is decreased.RDW is increased.Red Blood Cell morphology shows slight hypochromic microcytosis with codocytes, schizocytes, nucleated RBCs.Reticulocytes are increased.Hb electrophoresis demonstrates abnormal pattern on cord blood: Hb A - absentHb Bart's - 80-90%Hb Portland - 0-20%Bone marrow demonstrates marked erythroid hyperplasia.

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Cerebrospinal Fluid
Normal Cell Counts

Up to 5 WBCs per microliter are present in normal adult CSF. Children have slightly higher counts, while in newborns a count of up to 30 leukocytes per microliter is within normal limits. CSF containing up to 200 WBCs or 400 RBCs per microliter may appear clear or only slightly hazy, so all specimens must be examined microscopically.

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WBC Correction for Traumatic Tap

A calculation is used to correct CSF WBC counts which are falsely increased due to a traumatic tap: WBCs added = WBC(blood) x RBC(CSF) / RBC(blood)The blood WBC count is multiplied by the ratio of the cerebrospinal fluid RBC count to blood RBC count.The result is the number of artificially introduced WBCs. The true CSF white cell count is then calculated by subtracting the artificially introduced WBCs from the actual CSF WBC count. If the patient's peripheral WBC and RBC counts are within normal limits, some laboratories use the following formula: Subtract one white cell from the CSF WBC count for each 750 RBC counted in the spinal fluid.

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Table of Normal CSF Properties

The following table lists the properties of normal CSF in adults and children: ConditionAppearancePredominant Cellnormal adultclear, colorlesslymph 60%monocytes 30%neurophil 2%0-5 WBC / ul0 RBC / ulnormal neonate clear, colorlesslymph 20%monocytes 70%neurophil 4%0-30 WBC / ulvariable RBCAdapted from Saunders Manual of Clinical Laboratory Science. Craig A. Lehrmann, Ed. WB Saunders, 1998.

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CLIA Blood Banking Review
Based on the following reactions indicate the correct blood group for each set of reactions:View Page
Which one of the following is not a benefit of using packed RBCs:View Page
Which of the following types of whole blood would be the least satisfactory to transfuse to a type AB patient:View Page
Which of the following types of packed RBCs could be transfused to a group O patient:View Page
The use of the direct antiglobulin test is indicated in all the following except:View Page
Which of the following is the proper storage temperature for frozen red cells:View Page
Which of the following is the proper storage temperature for fresh frozen plasma:View Page
Hemapheresis is used to harvest all of the following:View Page

CLIA Chemistry / Urinalysis Review
The cells present in this illustration are:View Page
Which of the following analytes would not be significantly increased in a plasma sample as a result of hemolysis:View Page
The measurement of total glycosylated hemoglobin A1c is an effective means of assessing the average blood glucose levels:View Page
Which of the following cells when found upon microscopic examination of the urine would be most indicative of kidney disease:View Page
In a patient with acute glomerulonephritis you would expect to find all but the following in the urine except:View Page

CLIA General Laboratory Review
Which of the following cells when found upon microscopic examination of the urine would be most indicative of kidney disease:View Page
Hematocrit is:View Page

CLIA Hematology / Hemostasis Review
Choose the term that describes the most prominent finding in this peripheral smear:View Page
The RBCs found in this illustration are the result of:View Page
The abnormal RBCs seen in this illustration are indicative of:View Page
The abnormal RBCs seen in this smear, such as those shown by the arrow are typically seen in:View Page
The abnormal RBCs shape seen in this illustration is:View Page
The RBCs indicated by the arrows in this illustration are indicative of:View Page
The RBCs seen in this illustration are indicative of:View Page
The intracellular precipitates seen in the RBCs in this illustration is termed:View Page
Which of the following observations would best explain why a peripheral blood smear is exhibiting polychromasia:View Page
Hypochromia can best be described as:View Page
The reticulocyte count is used to assess which of the following:View Page
Which of the following is not associated with RBC macrocytosis?View Page
Which of the following would best describe what you might observe after a traumatic CSF tap:View Page

Erythrocyte Inclusions - Wright Stained Smears
Which of the following statements best describes Pappenheimer bodies?View Page

Introduction to the ABO Blood Group System
Match the blood type on the left with the appropriate description on the right.View Page
Why does agglutination (clumping) sometimes occur when red cells from one individual are mixed with serum from another?View Page
Match the blood types in the drop down boxes with the characteristics on the right.View Page
In order to determine the ABO type, known antisera are mixed with patient RBCs and known red cells are mixed with patient serum.View Page
The H gene

Three separate loci (ABO, Hh, and Se) contain the genes that control the location and occurrence of the A and B antigens. Hh and Se genes are closely linked on chromosome 19. The precursor substance is acted upon by the H gene and is converted to H substance. The product of the H gene is an enzyme fucosyltransferase, responsible for attaching fucose to the terminal galactose of the precursor substance on the RBC membrane and thus forming H substance. There are only two recognized alleles at this locus: the active form, H, and an amorph, h. The H gene is a high-incidence gene. People who inherit hh are extremely rare. Since the h gene is amorphic, it does not act on the precursor substance.

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Normal Peripheral Blood Cells
The cell diameter of a normal RBC is slightly smaller than the nucleus of a small lymph.View Page
Erythrocyte Shape

In stained blood films, only the flattened surfaces of the RBC's are seen. Therefore, they appear circular with an area of central pallor corresponding to the indented area. The central pallor occupies about 1/3 of the diameter of the cell.

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Function and Kinetics

Erythrocytes are produced in the bone marrow and released into the peripheral blood where they may remain for approximately 120 days before senescence.Their main function is the transport of the respiratory gases (oxygen and carbon dioxide) between the lungs and body tissues.Each erythrocyte can be thought of as an "envelope" containing hemoglobin.Each hemoglobin molecule contains iron which has a high affinity for oxygen.As a result, when an erythrocyte passes through one of the capillaries of the lungs, it picks up oxygen.The oxygen is transported through the blood to the tissues where it is released.Carbon dioxide from the tissues then diffuses into the RBC where it undergoes chemical changes.About 70% of the altered carbon dioxide diffuses into the plasma, 25% binds to the hemoglobin molecule, and 5% goes into simple solution within the red cell.In each of these three ways carbon dioxide is transported from the body tissues back to the lungs, where it is released.

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All of the following methods can be used to transport carbon dioxide to the lungs EXCEPT:View Page
Erythrocytes or Red Blood Cells (RBC's)

The first group is composed of erythrocytes or red blood cells (RBC's). The main function of the erythrocytes is the transport of oxygen from the lungs to the body tissues. Most of the cells in this Wright's stained peripheral blood smear are red cells. On is shown at the arrowhead.

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Glossary of Terms A through M.

Antibody - A modified type of serum globulin synthesized by lymphoid tissue in response to antigenic stimulus. By virtue of specific combining sites each antibody reacts with only one antigen. Anucleate - Having no nucleus. Azurophilic granules - The well-defined large reddish granules (lysosomes) which may be present in large lymphocytes. They are called "azurophilic granules" because they stain blue with the azure stains which were originally used. Basophilic granules - Specific granules present in the cytoplasm of basophils. These granules are large and stain purple-black due to their strong affinity for basic stain. B-cell - Bone marrow derived lymphocytes which produce humoral antibodies. Biconcave - Having two concave surfaces. Cellular Immunity - The capacity of a small proportion of lymphoid population to exhibit response to a specific antigen. Chromomere - The centrally located granular portion of the platelet. Clone - A population of cells descended from a single cell. Delayed Hypersensitivity - (part of cellular immunity) that develops slowly over a period of 24-72 hours after an antigenic stimulus. It consists of an accumulation of cells around small vessels and/or nerves. Example: Tuberculin skin test reaction. Digestive Enzyme - A substance that catalyzes or accelerates the process of digestion. Eosinophilic Granules - Specific granules present in the cytoplasm of eosinophils. These granules are large, refractile spheres which stain reddish-orange due to their strong affinity for acid stain. Erythrocyte (red blood cell, RBC) - One of the elements found in peripheral blood. Normally the mature form is a non-nucleated, circular, biconcave disk adapted to transport respiratory gases. Fixed Macrophage - A phagocyte that is non-motile. Free Macrophage - An ameboid phagocyte present at the site of inflammation. Graft Rejection - A transplanted tissue that is rejected by the body's antibodies. Graft vs. Host Reaction - A complication that occurs when an implanted piece of tissue, which contains antibodies, rejects the host's tissue. Granulocyte - A leukocyte which contains granules in its cytoplasm, i.e., neutrophilic, eosinophilic, or basophilic granules. Half-life - is the length of time it takes for half of the cells circulating at a given time to leave the blood for the tissues. Hemocyte - Any blood cell or formed element of the blood. Hemostasis - A mechanism of the vascular system to arrest an escape of blood. It involves an interaction between blood vessels, platelets, and coagulation. Heparin - A mucopolysaccharide acid which, when present in sufficient amounts, functions as an anticoagulant by inhibiting thrombin. Histamine - A powerful dilator of capillaries and a stimulator of gastric secretions. Humoral Immunity - Acquired immunity produced after response to an antigenic stimulus in which B cells produce circulating antibodies. Hyalomere - the clear, blue non-granular zone surrounding the chromomere of a platelet. Immune Response - The interaction of a cell and an antigen that results in a proliferation of the cell and a capacity to produce antibodies. Isotonic Fluid - A fluid whose elements have an equal osmotic pressure. Leukocyte (white blood cell, WBC) - One of the formed elements of the blood; involved primarily with the body's defense. Lysosome - A microscopic body within cell cytoplasm; contains various enzymes, mainly hydrolytic, which are released upon injury to the cell. Megakaryocyte - A giant cell of the bone marrow from which platelets are derived. Mononuclear - A cell having a single nucleus.

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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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Phlebotomy
Discussion

Hemolysis can easily be caused by improper phlebotomy techniques. Hemolysis occurs when RBCs are broken up and hemoglobin is released into the plasma, causing it to become pink rather than its natural straw color. Hemolysis can occur by using too small a needle, pulling a syringe plunger too rapidly, expelling blood vigorously into a tube, or shaking a tube of blood too hard. Hemolysis can cause falsely increased potassium, magnesium, iron, and ammonia levels, and other aberrant lab results.In this case, Marcie did not properly wipe the site with gauze after cleaning it with alcohol, and alcohol contacting the blood could have caused RBCs to break up or hemolyze. Marcie also squeezed the baby’s foot too hard, causing hemolysis.Relevant topics:Site selection and preparation, Heelstick: Puncture, Hemolysis, Causes of hemolysis

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Reading Gram Stained Direct Smears
Size and Appearance of Cellular Elements

Epithelial cells are larger than white blood cells and red blood cells, and contain a single nucleus. White blood cells (pus cells) usually show a segmented nucleus. Red blood cells are 1/2 to 2/3 as large as white blood cells, contain no nucleus, and are gram negative.Hyphae are gram positive tubular filamentous fungal elements which may show branching or intertwining. Yeast cells are round to oval, often budding, gram positive fungal elements, about the same size as RBCs. They are generally much larger than bacteria.

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Red Cell Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
Note the view of a peripheral blood smear in the photograph. Pictured are scattered acanthocytes, echinocytes, target cells, spherocytes, and schistocytes. The condition in which each of these atypical RBC's may be found in varying numbers in the same peripheral blood smear is:View Page
The peripheral blood picture shown in the photograph is most consistent with an artifact of smear preparation.View Page
Pappenheimer bodies

Pappenheimer bodies are iron-containing granules that aggregate with mitochondria and are deposited in RBC or normoblast cytoplasm. Small and irregular, they are found only in pathological states as thalassemia and sideroblastic anemias(upper image). Wright-Giemsa stain defines the cytoplasmic content (protein), but Prussian blue staining is necessary to define the iron content, the essence of the Pappenheimer body (lower image). Pappenheimer bodies lie typically in small clusters (upper image) and tend to locate at the periphery of the red cell cytoplasm. A cluster is typically smaller than a single Howell-Jolly body.

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The RBC inclusions shown in the photograph represent which of the following?View Page
The peripheral blood smear represented by this field was submitted for hematologic review. The RBC inclusions most likely are:View Page
Intracellular RBC Inclusions-G6PD (continued)

G6PD deficiency occurs in the same geographic distribution as malaria. It has been theorized that enzyme deficient cells are more resistant to malarial parasites than normal cells.When hemolysis is triggered, the appearance of the red blood cells is modulated by activity of the spleen.Spherocytes, schistocytes, and nucleated red blood cells may appear in the peripheral blood.Denatured hemoglobin removed by an active spleen may leave bite cells, identified by the arrows in this photomicrograph, suggesting the presence of G6PD deficiency.

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Leukoerythroblastosis

Illustrated in this field is a normoblast and a myelocyte, representing leukoerythroblastosis, a term associated with the release of immature cells from a disrupted marrow. Metastatic disease in the bone marrow, particularly in patients with primary breast or prostate cancer, is usually the culprit. Leukoerythroblastosis in the absence of anemia or thrombocytopenia is a signal to search for cancer metastic to the marrow. Nucleated RBCs were not identified on the blood smear seen here but were detected by an automated analyzer.The mortality rate of elderly patients with increased NRBCs, especially following accidents or general surgery, is greater.

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DIC: graft vs. host disease

The peripheral smear illustrated in the photograph was obtained from a patient with a recent renal transplant. The patient developed a rash, accompanied by nausea and diarrhea. Graft vs. host disease was clinically suspected. The peripheral smear findings are consistent with that diagnosis. The presence of spherocytes suggests a hemolytic process which is supported by the presence of nucleated RBCs. A few scattered schistocytes and the decrease of platelets suggests DIC. The presence of target cells presents the possibility of associated liver disease. Additional tests, particularly coagulation studies, should confirm the diagnosis of microangiopathic hemolytic anemia.

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Cardiac hemolysis (Waring Blender Effect)

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.

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The presence of erythrocytes with altered morphology (as photographed here) has a close association with each of the following conditions except:View Page
The underlying condition where the defective erythrocytes marked by arrows are of diagnostic importance is:View Page
Atypical smear: Case follow-up

The patient whose blood smear is shown in the photograph was a 32-year-old female from Virginia who came to the high country of Colorado to ski. The day after arrival, she experienced shortness of breath, fatigue, and upper abdominal pain. She was seen in a medical center in the mountains where a working diagnosis of altitude sickness was made. A CBC revealed RBCs 5.1 x 1012/L, hemoglobin 12.8g/dL, MCV 60fL, hematocrit 40.9%, and normal total WBC, differential, and platelet count. The RDW was normal. Further questioning revealed a previous diagnosis of heterozygous beta-chain thalassemia. No other abnormal hemoglobins were found on hemoglobin electrophoresis, but HbA-2 was elevated to 5%, supporting the diagnosis of beta thalassemia. The patient's poikylocytosis and anisocytosis may be a clue to an underlying erythrocyte abnormality. Persons with iron deficiency anemia may experience various degrees of hypoxia upon arriving at high altitudes. Those with sickle cell disease and thalassemia minor (as in this case) may experience bone pain or other symptoms of "crisis" and/or alteration in the appearance of their erythrocytes upon sudden high altitude exposure. The classic teaching is that in differentiating iron deficiency anemia from thalassemia, increased RDW would favor iron deficiency; normal RDW favors thalassemia.

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The photograph is representative of the peripheral blood smear of a five-month-old immigrant from Asia. Her mother was concerned that the child was not eating well. Her spleen was palpable.The hemogram revealed the following:Hb 9.6g/dL (normal 12.0 - 16.0 g/dL)RBC 5.48 X 1012/L (normal 4.2 - 5.9 X 1012/LHCT 30.4% (normal 37 - 48%)MCV 55.4 fl (normal 86 - 98 fl)MCH 17.5 pg (normal 27 - 32 pg)MCHC 31.6 g/dL (normal 31 - 37 g/dL)RDW 34.9% (normal 11 - 15%)Reticulocyte count 10.9% (normal 0.5 - 1.5%)Select the most likely diagnosis based on the clinical information and peripheral blood findings.View Page
Hb E disease (continued)

The family (cited in the previous case history) was from a region of Thailand where the physician knew HbE carriers are prevalent. Homozygous hemoglobin E is common in Southeast Asia and presents with very mild anemia and seldom requires transfusion. Over 30 million people in the world are HbE carriers, making this abnormal hemoglobin almost as common as HbS. Hemoglobin E is uncommon in North America and in Europe, but with changing immigration patterns, hemoglobinopathy E cannot be ignored. Peripheral blood smear findings of target cells, microspherocytes, red cell hypochromia, a few red blood cell fragments, and nucleated red blood cells require evidence from hemoglobin electrophoresis to establish a diagnosis. Clinically, a very important and severe syndrome is hemoglobin E/beta thalassemia in which there is hemolysis requiring repeated transfusions. The patient has a severe anemia, low MCV (50's), and high RBC. This is characteristic of Hgb E/beta thalassemia.

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Rouleaux

Rouleaux formation correlates with an increased concentration of serum monoclonal proteins. Rouleaux may be seen as an artifact in the thicker portions of blood smears. The addition of a drop of saline to the blood smear will serve to disperse any artifactual rouleaux formation. The presence of rouleaux formation or RBC agglutination may result in a falsely decreased electronic red blood count and falsely increased MCV, as these clusters may be read as one cell.

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The arrangement of erythrocytes on this peripheral blood smear may be seen in each of the following conditions except:View Page
The arrangement of the erythrocytes in this peripheral smear should be reported out as rouleaux formation.View Page
Dimorphic RBC population

Illustrated in the photomicrograph of a peripheral smear are two populations of erythrocytes. Approximately 50% of the erythrocytes are normal size and contain a full complement of hemoglobin. The patient had received blood transfusions. The transfused red blood cells are the normocytic, normochromic red cells. Admixed are microcytic erythrocytes and larger erythrocytes, some faintly mottled or smudged, suggestive of reticulocytes. This picture represents a hemolytic process with a reticulocyte response. A similar dimorphic red cell population appears following erythropoietin therapy. It is important to recognize when a population of cells in the peripheral smear is not in context with anticipated laboratory findings and the clinical situation.

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Stomatocytes

Stomatocytes are erythrocytes with a slit-like central pallor. Otherwise, they resemble typical RBC's in size and shape. Unless 10% or more of the RBC's are stomatocytes, their presence is probably artifactual. Stomatocytes form at a low blood acidic pH as seen in exposure to cationic detergents, and in patients receiving phenolthiazine. Hereditary stomatocytosis has some resemblance to hereditary spherocytosis, as stomatocytes may develop into spherocytes with further metamorphosis. In hereditary stomatocytosis, mild anemia and findings of on-going hemolysis should be evident if the condition presents as a clinical problem at all.

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Criteria for peripheral blood smear review

Initial analysis of the peripheral blood picture is made in most clinical laboratories with an automated instrument. Samples are selected for further analysis when quantitative or qualitative abnormalities beyond a defined standard are found. The following are examples of quantitative RBC abnormalities that may prompt a blood smear review. Each laboratory, however, should develop its own guidelines: Hgb: < 8 or >18 g/dL (<10 or > 21g/dL in a newborn)Hct: <20% or > 60% in adults (<40% or >65% in a newborn)MCHC: <29 g/dLMCV: <69 femtoliters (fl) or >110flFlags generated by the hematology analyzer that indicate possible red cell abnormalities or spurious resultsAny of these findings should be followed up with a peripheral blood smear review.

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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.

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Red Cell Morphology
The MCHC value is 39 gm/dl of RBC. Which of the following is the most likely explanation?View Page
Hypochromia

Examples of hypochromic cells are seen in this slide. Notice the thin rim of hemoglobin and the large area of central pallor present in most of these cells. Hypochromic cells are cells which are unusually thin, or in which the hemoglobin concentration is decreased. Decreased hemoglobin concentration can be caused by decreased amounts of iron available for hemoglobin production. The MCHC for this patient was significantly decreased (26 gm/dl of RBCs) indicating a severe degree of hypochromia. When hypochromia is less severe, not all cells will be affected; thus some cells may appear almost normal whereas others show hypochromia.

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Another Example of Hyperchromia

Another example of "hyperchromic" cells seen at the edge of a smear. If MCHC is above 36 gms/dl of RBC, recheck hemoglobin and hematocrit; technical error is most likely the cause.

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The Urine Microscopic: Microscopic Analysis of Urine Sediment
The patient was a female and the examination was completed within two hours of collection. Which of the following findings correlate with the presence of a yeast infection of the bladder?View Page
What element is present in this slide?View Page
True or false? RBCs are present in this slide.View Page
True or false? WBCs are present in this slide.View Page
Match the following:View Page
Red Cell Casts

Red cell casts appear as clear cylinders containing red blood cells and may have an orange red tinge. Their presence indicates bleeding into the nephron. Red cells within the cast are rapidly hemolyzed and the cast becomes a hemoglobin cast, having an orange color and a homogeneous ground-glass texture. In order for a cast to be considered an RBC cast, the outline of the red cells must be clearly visible in at least one area of the cast.

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Red and White Cells

There are many red and white cells in this high power field. There are a group of five red cells that can be identified on the lower right-hand side of the field. It is important to use the fine focus adjustment on the microscope when trying to differentiate RBCs from WBCs.

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Swollen RBCs

In contrast, RBCs appear swollen in dilute or alkaline urine, having taken on water from their surroundings.

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Yeast

Yeast can appear as single cells or in the budding form. As single cells they can be confused with RBCs because they are about the same size. In the budding form, yeast is easily identified as demonstrated on this slide. Yeast can be found in patients with cystitis due to yeast, usually candida, or as a vaginal contaminant from patient's with vaginal candidiasis.

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Which of the following are characteristic of normal RBCs under high power (40x) brightfield microscopy?View Page
All of the following are characteristic of WBCs under high power (40x) brightfield microscopy except that they:View Page
Cells Types Observed in Urine Sediment

Cells which may be present in the urine include epithelial cells, white blood cells (WBC) and red blood cells (RBC). The epithelial cells in the urine may originate from any site in the genitourinary tract. It is normal to find a few epithelial cells in the sediment. White blood cells may enter the urinary tract anywhere from the glomerulus to the urethra. The WBCs are mostly neutrophils. Red blood cells may originate in any part of the urinary tract. Normally, RBCs do not appear in the urine, although the presence of a few RBCs is not considered abnormal.

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Red Blood Cells

Red blood cells (RBCs) may also be found in the urine sediment. The presence of RBCs in the sediment is associated with damage to the glomerular membrane or vascular injury within the genitourinary tract (the possibility of menstrual contamination must be considered).

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In concentrated urine RBCs may appear:View Page
Specimen #4 - Adult Male

The results of this specimen are abnormal but the abnormalities correlate with each other. The turbidity can be explained by the presence of bacteria and crystals. The presence of RBCs in the microscopic explains the blood found on the dipstick. The casts, bacteria and WBCs can account for the increased protein. The results may be reported.

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Match the following.Note: Answers may be used more than once.View Page
Counting Elements

Next the number of RBCs, WBCs, epithelial cells, parasites, and fat will be counted. Move to the center of the coverslip and examine 10 fields under high power (40x) brightfield. Use phase-contrast as needed. Determine the average number of each element found and record the findings as number per high power field (#/HPF). An abundance of any one element may be recorded as >100/HPF when 1/4 field is counted and the total field is estimated to be greater than 200/HPF.

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White Cell and Platelet Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
The cells included in the composite image were found in a peripheral blood smear with a total WBC of 24,500/mm3. The differential count was: myelocytes 1 metamyelocytes 4 band neutrophils 15 segmented neutrophils 40 monocytes 8 eosinophils 2 basophils 1 lymphocytes 29. This hematologic picture is most consistent with:View Page
The upper photograph of a peripheral blood smear reveals RBC rouleaux formation. Nucleated cells evident in both upper and lower photographs comprise approximately 5% of the total white blood cell count. The most probable underlying condition is:View Page
The peripheral blood smear tagged in the photograph was held for review because of too many platelets, about double the normal average of 8 - 15/oil immersion field or one per 10 - 20 RBC's. Conditions in which platelets are increased as noted in the photograph include: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 History 2

An 80 year old man was seen in the emergency room with sudden onset of right sided chest pain accentuated on inspiration. His cough was productive of yellow sputum, and he was short of breath.His temperature was 101.2F. A chest X-ray revealed right middle lobe pneumonia. His hemoglobin was 15.2 gm/dl, HCT 44%, and RBC 4.5 m/ml. The white blood count was 35,000/cuml, with 45% neutrophils, 20% bands, 5% lymphocytes, 3% eosinophils, 2% basophils, and 25% atypical monocytes as noted in the photograph.The atypical monocytes had abundant blue-grey cytoplasm with a few scattered vacuoles, which, in company with toxic neutrophils appeared to be a response to infection.The patient had a past history of tuberculosis which may account for the monocytosis.

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