Vacuoles Information and Courses from MediaLab, Inc.
These are the MediaLab courses that cover Vacuoles and links to relevant pages within the course.
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|Alveolar Rhabdomyosarcoma (ARMS) in Plerual Fluid|
Metastatic alveolar rhabdomyosacroma tumor cells are not as large as adenocarcinoma , but will also present in clumps.Notice the extremely fine chromatin texture and the very large and prominent nucleoli. Several of these tumor cells are bi-nucleate and a few have very prominent glycogen storage vacuoles in the cytoplasm.
Plasma cells and plasmacytoid lymphocytes can be found in any viral-reactive effusion. This image is a pleural fluid from a patient with viral pneumonia. Notice the plasma cells (see arrows) which contain a large amount of cytoplasm compared to the smaller lymphocytes. The color is more basophilic and there is a noticeable clearing adjacent to the nucleus. Notice the dense and clumped chromatin pattern. Some of these cells have a hint of cytoplasmic vacuolation which can be prominent storage vacuoles.
|Monocytes vs Lymphocytes|
While the cytoplasm of the two monocytes in this image (red arrows) is not as grainy as some; the larger size, complex nuclear shape, fine chromatin pattern and cytoplasmic vacuoles help to identify them as monocytes.Lymphocytes (blue arrows) keep the shape of their nuclei much more simple, maybe displaying a bit of an indent, which is different compared to monocytes clefting.
The macrophages in this image have multiple large phagocytic vacuoles. This sample is a reactive pleural effusion in a patient with widely metastatic rhabdomyosarcoma. These particular macrophages have been removing some of the red blood cells (RBCs) that have been released into the pleural space due to the spread of this patient's tumor. While there are no intact RBCs in these cells, the size of the vacuoles is good indication of what they have most likely been phagocytizing.
|L3 Burkitt Lymphoma|
This photo is a peritoneal fluid from a patient with stage IV Burkitt's lymphoma. While this smear is more cellular than is ideal for optimum evaluation of morphology, it is still possible to recognize the characteristic morphology of the lymphoma cells present.The Burkitt cells are as large or larger than the few neutrophils present and somewhat resemble other types of lymphoblasts. However, they have course dense chromatin with very basophilic and markedly vacuolated cytoplasm (see arrows).This cytospin demonstrates the typical cytoplasic vacuolation of Burkitt's lymphoma in which the vacuoles break through the background of dense chromatin and intensely basophilic cytoplasm.
This cytospin was prepared from a pleural fluid obtained from a patient with multiply recurrent non-Hodgkin lymphoma. The patient had repeated pleurocentesis to remove excess and to improve his quality of life while on palliative therapy.The three large mononuclear cells in the center are the lymphoma cells (blue arrows). Notice their large total and nuclear size compared to the background lymphocytes and the scant amount of basophilic cytoplasm present with the few fine cytoplasmic vacuoles. Notice also the wide range of normal and reactive cells in the background. In patients with recurrent malignant effusions, it is not uncommon to see such mixed cell populations.It is important to look for low numbers of lymphoma cells in known lymphoma patients, as they may be present in low numbers during and after therapy, rather than in the large numbers that are usually present upon initial diagnosis.
|Anaplastic Large Cell Lymphoma (ALCL)|
This cytospin is from a patient who presented in respiratory distress and was found to have a large mediastinal mass and large bilateral pleural effusions.The lymphoid cells in this image are large and immature in appearance. These lymphocytes were initially believed to be consistent with lymphoma cells but, after immunophenotyping, were found to be reactive T-cells instead of lymphoma cells.The three larger cells in the image look similar. The two larger cells on the left are just macrophages. The one larger cell on the right is actually the malignant cell (see arrow). The malignant cell has a larger nucleus with softer more open chromatoin and a slightly more promanent nucleoli. The cytoplasm is also more basophilic, and the vacuoles are atypical. They are not the typical round vacuoles seen in macrophages/histocytes; these vacuoles are more elongated.The diagnosis of ALCL was confirmed when the cytogenetics proved positive for the specific translocation, t(2;5), that defines this lymphoma.
|Acute Lymphoblastic Leukemia (ALL): L1 Morphology|
This is a cytospin from the CSF of a patient with L1 acute lymphoblastic leukemia (ALL) obtained at the time of diagnosis. Notice the monotonous look to the cells present. They are of moderate size with soft fine chromatin and have a scant amount of basophilic cytoplasm. There is some irregularity and slight cleavage to the nuclear shape. Some of these blasts have cytoplasmic vacuoles. Though these blasts have a hint of a nucleolus, it not necessary for them to be present in order for these cells to be considered blasts. The relative size, chromatin texture and scant amount of cytoplasm define these cells as L1 lymphoblasts. Notice the three small densely staining normal lymphocytes indicated by the arrows, that allow for a contrast of the relative sizes and chromatin textures of the blasts with those of the normal small lymphocytes.
The mesothelium is the name given to the membrane that lines most body cavities and surrounds the internal organs. Cells that shed from these membranes are commonly found in pleural, peritoneal and pericardial fluids. Mesothelial cells are large cells that may be found as single cells or in clusters and clumps. They tend to have a large round centrally placed nucleus with a generous amount of basophilic cytoplasm which can appear frayed at the edges. They will have one ore two small, well-defined, deeply staining nucleoli. While they may have small pinpoint vacuoles, they will not have the larger "foamy" vacuoles seen in macrophages or histocytes.There are two mesothelial cells in the image below (see arrows). While they are different in size, they are definitely larger than the background lymphocytes and plasmacytoid lymphocytes. Notice the irregular frayed edge to the cytoplasmic membrane.
The macrophage is the final stage of development in the monocyte lineage. It is a phagocyte whose roles include the removal of dead and dying tissue and the destruction and ingestion of invading organisms. Macrophages (histiocytes) act as immune modulators as they will present antigens from ingested pathogens to helper T-cells.Their primary role in the bone marrow is the removal of cellular debris, including old red blood cells (RBCs). As a result, they become a source of iron for maturing RBC precursors. A histiocyte is a less phagocytic form of a macrophage with fewer lysosomal granules. Histiocytes may form clusters, or even fuse together into mulitnucleated giant cells. These giant cells are particularly evident on bone marrow biopsy from a patient with a marrow granuloma.The top image on the right shows the early transformation of a monocyte into a macrophage (see red arrow). Notice the increase in the amount of cytoplasm present as the cell begins to ingest debris in the bone marrow. This is demonstrated by the increasing vacuolization present in the cytoplasm. The larger the debris ingested, the larger the vacuoles will be.The lower image on the right shows a macrophage with large vacuoles (red arrow) adjacent to an RBC cluster (blue arrow). This is a common placement, since the macrophage is the iron source for these developing RBCs in the bone marrow.
Plasma cells are terminally differentiated B-lymphocytes that have developed a characteristic morphology while actively producing and releasing immunoglobulins. While plasma cells have their origins in the bone marrow as B-cells, they usually leave the bone marrow to develop and mature in the lymph nodes or spleen. Plasma cells begin to produce immunoglobulins after being stimulated by T-cells and exposed to processed antigens.Under normal circumstances, plasma cells are not a large percentage of the lymphoid cells found in a marrow. They are usually placed in a separate category in the differential, unlike viral/atypical lymphs. There can be a relative increase in plasma cells in reactive marrows, and both plasma cells and their early precursors will be markedly increased in plasma cell disorders.While mature plasma cells somewhat resemble lymphocytes, there are a few important differences. The size of the cell is usually larger with more abundant cytoplasm. The nucleus is eccentrically placed and the overall shape of the cell generally resembles a wedge or comet with the nucleus leading the cytoplasm. The chromatin is just as thick and clumpy as a lymphocyte's but is aligned in a more "spokey" or "clockwork" pattern. The cytoplasm is usually more basophilic than the cytoplasm of a normal lymphocyte and will have a well-defined perinuclear halo or noticeable clearing in the golgi area. Vacuoles may or may not be present.Notice the size of the single plasma cell in the top image (see red arrow). It is larger than the neutrophil precursors surrounding it and is almost rectangular in shape. Observe that the nucleus leads the cytoplasm, causing the wedge or comet shape. Notice the prominent perinuclear halo. Find the two plasma cells in the upper left corner of the second image. There is much more cytoplasm in these plasma cells compared to the occasional lymphocyte present in the field. Notice the eccentric nuclear placement as well as the characteristic clearing in the golgi area.
Malignant cells that have broken away from tumors located in other areas of the body may be seen in spinal fluid. All of the cells in this field are tumor cells. The cells in this slide are characterized by an open, loose chromatin pattern, nucleoli and vacuoles. Notice that the vacuoles are present in both the nucleus and the cytoplasm. Vacuoles in the nucleus are an unusual finding even in tumor cells. Tumor cells are often found in clumps and may have more than one nucleus due to their erratic mitotic patterns. Malignant cells sometimes have an irregular nuclear shape. Bizarre granules may be found in malignant cells but are absent in mesothelial cells.
|T lymphocytes are larger and have more vacuoles than B lymphocytes.||View Page|
|When Lymphocytes Transform|
Lymphocytes "transform" in response to antigenic stimuli. As discussed earlier, 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. Again, these lymphocytes may also be referred to as reactive or atypical lymphocytes.
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.
|Differentiating Monocytes from Large Lymphocytes: Table.|
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-grayCloudy, opaque, "ground-glass" appearanceFine granulesFrequent vacuolesCytoplasm may have pseudopods
|All of the following descriptions are characteristic of monocytes EXCEPT:||View Page|
|When Lymphocytes Transform|
Lymphocytes "transform" in response to antigenic stimuli.Their nuclei becomes larger with more open chromatin and a greater degree of nuclear folding.The cytoplasm becomes abundant, the number of azurophilic granules may be increased and vacuoles may be present.The cytoplasmic membrane may be easily indented by surrounding red blood cells, resulting in a scalloped appearance of the cell's outer edge.These lymphocytes may also be referred to as reactive, activated or stimulated.
|T lymphocytes are larger and have more vacuoles than B lymphocytes.||View Page|
Frequently, cytoplasmic vacuoles are present. These vacuoles appear as unstained areas or "holes" in the cytoplasm.
|Monocytes often posses blunt pseudopods, have soft spongy nucleus, frequently has vacuoles in the cytoplasm.||View Page|
|All of the following descriptions are characteristic of monocytes EXCEPT:||View Page|
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 (>2 in the acrosomal region and/or vacuoles in the post-acrosomal region are abnormal). 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.WHO 5th edition contains multiple examples of normal sperm and borderline/abnormal variations that cause a sperm to be classified as abnormal. It is an excellent resource.
|The hematology analyzer reported an elevated white blood cell count and flagged for manual review due to the suspected presence of immature cells. What is the arrowed cell's identity, and what name is given to its inclusion?||View Page|
|What morphological change is present in the neutrophil that is present in this image?||View Page|
|What is the identity of the white blood cell inclusions present in this image?||View Page|
|What is the name of the structure that is indicated by the arrow in the image?||View Page|
|What cytoplasmic inclusion is indicated by the arrow in this image?||View Page|
|The inclusions that are seen in the white cell indicated by the arrow in this image are characteristic of which of the following conditions?||View Page|
Vacuoles are areas of the cytoplasm which do not stain with Wright's stain and appear as holes in the cytoplasm. Their composition may vary; some will contain remnants of bacterial digestion, autodigestion in an aging cell, while others may contain fat. It is not possible to differentiate the various types of vacuoles on Wright stained smears using light microscopy. Vacuoles may be seen occasionally in an aging granulocyte (degenerative vacuolation), but are seen more frequently and are significant in cases of bacterial infection and septicemia.
The vacuoles seen in the cytoplasm of this cell are somewhat smaller and several are located near the lower edge of the cytoplasm.
|Toxic Granulation and Vacuolation|
Vacuoles are frequently seen in conditions such as infection or burns when toxic granulation is also present. The cell in this image exhibits toxic vacuolation as well as toxic granulation. Note: Toxic vacuolation and toxic granulation are classified as reactive and not pathologic since the body is responding normally in an effort to rid itself of infection caused by bacteria.
Vacuoles, toxic granulation and degranulation are classified as reactive since the body is responding normally in an effort to rid itself of infection caused by bacteria. Morphological changes related to aging are also classified as reactive.
|Which of the following inclusions may be seen in the cytoplasm of myeloblasts? ||View Page|
|Chediak-Higashi anomaly is characterized by which of the following? ||View Page|
|Alder anomaly inclusions may be found in which of the following white blood cell types?||View Page|
|Döhle Bodies, continued|
Döhle bodies are seen in a number of conditions, including:infections burns measles leukemia chemotherapyDöhle bodies are only present when the body is responding to unusually severe stress or stimulus. This severe stress may cause the cytoplasm of some cells to mature improperly. Their presence does not aid in the diagnosis of the disorders in which they are found, but they are frequently seen along with toxic granulation and/or vacuoles in cases of infection or burns.
Toxic granulation is manifested by the presence of large granules in the cytoplasm of segmented and band neutrophils in the peripheral blood. The color of these granules can range from dark purplish blue to an almost red appearance. Toxic granules are actually azurophilic granules, normally present in early myeloid forms, but are not normally seen at the band and segmented stages of neutrophil maturation. These granules contain peroxidases and hydrolases. Toxic granulation is seen in cases of severe infection, as a result of denatured proteins in rheumatoid arthritis or, less frequently, as a result of autophagocytosis. Infection is the most frequent cause of toxic granulation. This phenomenon may be seen in cells which also contain Döhle bodies and/or vacuoles. Cells containing toxic granules may have decreased numbers of specific granules. Note: Cells containing only a few specific granules, with or without toxic granules, are said to be degranulated. The nucleus in degranulated cells may often be round-bilobed, smooth and pyknotic. This type of nucleus is the result of aging and will disintegrate soon. Increased basophilia of azurophilic granules simulating toxic granules may occur in normal cells with prolonged staining time or decreased pH of the stain. The blue arrow in the image points to a neutrophil with toxic granulation. Döhle bodies are also present in the cell, indicated by the red arrows.
There are two large vacuoles (unstained areas in the cytoplasm) present in this cell.
|The inclusions that are frequently seen on the same peripheral blood smear with toxic granulation include: (Choose ALL that apply)||View Page|
|Match each of the following. Answers may be used more than once or not at all.||View Page|
|The white blood cell indicated by the arrow is representative of the atypical white blood cell associated with infectious mononucleosis.||View Page|
|Cells that appeared similar to those illustrated in this image were repeatedly encountered as the smear was reviewed. The peripheral white blood cell count was 51.0 X 109/L with an orderly maturation sequence. The comment "leukemoid reaction" may properly be appended to the report.||View Page|
|A peripheral blood smear with many myeloid cells was presented for morphology review (see image on the right). Toxic granulation and vacuoles in the neutrophil most likely represent which of the following conditions?||View Page|
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.
|A peripheral smear was submitted for review due to increased monocytes on the automated differential. The images on the right are representative fields from the Wright-Giemsa stained blood smear (1000X magnification). The increased monocytes and peripheral picture are consistent with each of the following conditions EXCEPT:||View Page|
|Case History Two|
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.