3.

Polychromasia/Reticulocytes
The Wright stained slide, at left, demonstrates polychromatophilic red
cells in the peripheral blood. (The term "polychromasia" refers to the
bluish tinge of these cells.) These red cells have been recently released
from the bone marrow and still contain significant amounts of RN,
which is the reason for the bluish tinge (remember, RN stains blue with
the Wright!s stain). The right panel is a reticulocyte stain. "n this
procedure, RN is precipitated inside the erythrocytes. #ecause
precipitated RN gives the reticulated appearance shown, the cell is
called a reticulocyte. $or all practical purposes, reticulocytes and
polychromatophilic red cells represent red cells of similar age. These
cells remain as reticulocytes in circulation for about %& hours. #ecause
these cells have been recently released from the marrow, it stands to
reason that the number of reticulocytes would reflect the ability of the
marrow to respond to the challenges of anemia. "n other words, if a
person is anemic and has an elevated reticulocyte count, the li'ely
e(planation for his anemia is hemolysis. That is to say, the red cells are
being destroyed outside the bone marrow. What does an anemia with a
low reticulocyte count signify? Answer: nemia with a low
reticulocyte response signifies a production problem within the marrow
). Hereditary Elliptocytosis
*ereditary elliptocytosis ++ li'e hereditary spherocytosis ++ is an e(ample
of a hemolytic state associated with an intrinsic red cell membrane
defect. The red cells in this blood smear (,--() have an elliptical shape,
which results from an abnormality in the red cell membrane protein
s'eleton. What are clinicopathologic aspects of this disorder. Answer:
/ost patients with this defect have normal or only a slightly shortened
red cell survival time and no significant anemia.
0. 1old gglutinin + *emolytic nemia
The presence of a cold agglutinin antibody is another e(ample of an e(trinsic red cell
insult resulting in an immune+mediated hemolysis. The blood smear in these cases often
shows characteristic clumping of the red cells (as shown here). "n contrast to warm
antibodies described in the previous slide, cold agglutinin antibodies are always
autoantibodies. The antibody involved is most often "g/. What is the cause of hemolysis
in this process? Answer: The in vivo agglutination property of these antibodies is not the
cause of the hemolysis2 rather, their ability to fi( complement on the red cell surface at
low temperatures results in intravascular hemolysis when red cells move to warmer areas.
"n addition, at 34
o
1, "g/ antibody is released from the cell surface, leaving a coating of
13b. This is an opsonin and such opsoni5ed red cells are phagocytosed by monocyte+
macrophages. Thus, there is e(travascular hemolysis.
. Hemolytic Anemia ! "alarial Parasites
6et another e(ample of an e(trinsic insult which can result in a
hemolytic anemia is the infestation of red cells by parasites. This blood
smear, ta'en from a patient with 7lasmodium falciparum malaria, shows
two ring+form parasites in the red cell in the center of the field. This red
cell will be destroyed as the parasites mature and are eventually released
from the cell. What is the most common cause of infection+induced
hemolytic anemia. Answer
#. $eu%ocytosis ! Peripheral &lood
low magnification view (&() of the peripheral blood smear permits you to estimate the
total white blood cell count (TW#1), which in this case was reported to be ,) (,-839ml.
:Note; a rule of thumb for assessing the TW#1; ,) to %- W#19&( field correlates with a
TW#1 of appro(imately ,) + %-(,-839ml<. t a slightly higher magnification (,-(),
review of the smear now reveals that most of the leu'ocytes are granulocytes, specifically
neutrophils. superficial e(amination of these neutrophils reveals that some are fully
segmented while others are "band" forms. higher magnification (,--() reveals a
segmented neutrophil demonstrating the typical thin chromatin strand connecting the
lobes (segmented neutrophil +3a). "n addition, the smear shows a typical "band" form
with a horseshoe nucleus and no thin chromatin strands ("band" neutrophil +3b).
lthough the distinction between these two cells is clear in this picture, such is not
always the case. ,. What findings in the 1#1 report prompted an infectious disease
wor'+up. nswer
%. 1ompare and contrast neutrophilic leu'ocytosis, leu'emoid reaction, chronic
myelogenous leu'emia, and acute myeloblastic leu'emia. nswer
What findings in the '&' report prompted an infectious disease wor%!up?
Neutrophilic leu'ocytosis and "bandemia" (i.e., a "left shift").
'ompare and contrast neutrophilic leu%ocytosis( leu%emoid reaction(
chronic myelogenous leu%emia( and acute myelo)lastic leu%emia.
Neutrophilic leu'ocytosis refers to an increase in the number of neutrophils in the
peripheral blood. This may be caused by pyogenic infections or by non+microbial stimuli,
such as tissue destruction. The neutrophil increase results primarily from release of
mostly mature neutrophils from the marrow storage pool, and hence neutrophil precursors
are rare in the peripheral blood. =eu'emoid reaction refers to an e(treme form of reactive
neutrophilic leu'ocytosis in which the peripheral blood contains not only mature
neutrophils but also immature leu'ocytes, resembling leu'emia. *owever, in leu'emoid
reactions, there are fewer immature myeloid cells (myeloblasts are rare), leu'ocyte
al'aline phosphatase is normal or increased, and cytogenetic abnormalities are absent.
cute and chronic myelogenous leu'emias are clonal neoplastic disorders that are
discussed later.