Erythrocyte, Mature

SYNONYMS
Red blood cell, anucleate
VITAL STATISTICS
size ............................. 7 m
n:c ratio ..................... not applicable
cell shape .................. round to slightly oval on smear,
biconcave disk
nuclear shape ........... not applicable
chromatin .................. not applicable
nucleoli ...................... not applicable
cytoplasm.................. pink-red, orange-red with area of
central pallor
KEY DIFFERENTIATING FEATURES
homogenous, agranular cytoplasm
POTENTIAL LOOK-ALIKES
fat droplet (on cell chamber count)
yeast forms (on cell chamber count)
ASSOCIATED DISEASE STATES AND CONDITIONS
traumatic tap
hemorrhage
malignant bloody effusions
postoperative effusions

Mature erythrocytes in body fluids are morphologically

similar to those present in the peripheral blood. They
have a round to oval, disc-shaped contour, with a central area of pallor that occupies less than one-third of
the total diameter. A nucleus is lacking, having been
extruded prior to release into the circulation, and the
cytoplasm is pink, a result of the abundant hemoglobin present. These cells circulate for approximately 120
days, before being removed from the circulation by
the reticuloendothelial system in the spleen and liver.
The hemoglobin in the cytoplasm is then processed
by the phagocytic system, with much of the iron conserved and released back into the circulation. They are
not found in normal body fluid samples. They may be
introduced as a contaminant when there is difficulty
in obtaining a specimen, represent traumatic hemorrhage, or occur secondary to other disease states such
as pancreatitis, pulmonary infarction, ruptured ectopic
pregnancy, or malignancy.

Normal Mature Red Blood Cell

central pallor is 1/3 the cell diameter

98

Erythroid Series

CM-09, 2001 (CSF, Wright-Giemsa, X400)

Identication
Erythrocyte, mature

Referee %
100.0

Participant %
88.9

This CSF specimen was obtained from a patient who

had sustained a subarachnoid hemorrhage and had an
externally draining ventriculostomy tube. The arrowed
cell in this CSF specimen is a mature erythrocyte. This
CSF sample contains numerous erythrocytes and large
numbers of extracellular bacilli. External collection devices such as these are placed temporarily to relieve
intracranial pressure and are always potential sources
for bacterial colonization.

CM-07, 2004 (Peritoneal, Wright-Giemsa, X400)

Identication
Erythrocyte, mature

Referee %
100.0

Participant %
100.0

This peritoneal fluid was obtained from a 25-year-old

HIV-positive woman complaining of fatigue, weakness and increasing abdominal girth. The arrowed cell
is a normal mature erythrocyte. It is small, ovoid, has
agranular pink-red cytoplasm, and is devoid of a nucleus. An area of faint central pallor can be appreciated.

CM-09, 1992 (CSF, Wright-Giemsa, X400)

Identication
Erythrocyte, mature

Referee %
100.0

Participant %
98.8

This CSF sample is from a premature neonate with

signs and symptoms of meningitis. The arrowed cell in
this CSF specimen is a mature erythrocyte. The large
cell noted above the erythrocyte is a ventricular lining cell. Ventricular lining cells may occur singly, as in
this photomicrograph, or in clusters. They are typically large with abundant, pink-blue, grainy cytoplasm.
They can be seen in neonatal specimens, particularly
those born prematurely, and should not be confused
with malignant cells.

Erythroid Series

99

Erythrocyte, Nucleated
SYNONYMS
nucleated red blood cell (NRBC)
VITAL STATISTICS
size ............................. varies with the stage of maturation (7 to 25 m)
n:c ratio ..................... varies with the stage of maturation; decreases with maturation
cell shape .................. round to oval
nuclear shape ........... round to oval
chromatin .................. varies with the stage of maturation; more condensed with maturation
nucleoli ...................... vary with the stage of maturation;
present in early stages; disappears in later stages
cytoplasm.................. varies with the stage of maturation; early stages are blue with
more orange or pink-red coloration predominating as the cell
matures
KEY DIFFERENTIATING FEATURES
normal nucleated red blood cell morphology matching
bone marrow morphology
agranular cytoplasm
POTENTIAL LOOK-ALIKES
necrobiotic segmented neutrophils
lymphocytes
ASSOCIATED DISEASE STATES AND CONDITIONS
peripheral blood contamination due to traumatic tap or
hemorrhage
bone marrow contamination

Nucleated red blood cells are uncommonly found in

body fluids. When present, they are usually secondary to blood contamination in cases where circulating
nucleated red blood cells are present in the peripheral
blood. Less commonly they represent accidental aspiration of the bone marrow from either a rib or vertebral
body during the fluid collection procedure. Nucleated
red blood cells due to peripheral blood contamination
tend to be at a later stage of development (orthochromatophilic) as that is the stage of nucleated red blood
cell most commonly found in the blood. If nucleated
red cells present in a body fluid are due to bone marrow contamination, earlier stages (polychromatophilic,
basophilic and rarely proerythroblast) may be noted.
Immature granulocytes and rarely megakaryocytes
may also be present in fluids with bone marrow contamination (see A Closer Look page 47). Bone marrow
contamination is most commonly seen in newborns or
infants and in adults with osteoporosis. This is secondary to the difficulty with which the needle is introduced
into the fluid cavity being sampled. They are also seen
in association with lumbar canal stenosis or kyphosis
where accessing the CSF is technically challenging due
to the narrow space through which the needle must
pass. In either situation, the bone marrow elements
enter the needle and then contaminate the fluid collected. Absence of immature granulocytes and/or nucleated red blood cells on the peripheral blood smear
provides support for the conclusion that the nucleated
erythroid and immature granulocytic elements noted
in the patients corresponding body fluid represent
bone marrow contamination.
It is important to appreciate the homogeneous
agranular cytoplasm of nucleated red blood cells so
as not to confuse them with necrobiotic neutrophils,
which can display a similar pyknotic nucleus. While
sometimes faint, the cytoplasm of the necrobiotic neutrophils will be granular.

Nucleated Red Blood Cells

(various maturation stages)
100

Erythroid Series

CM-11, 1990 (CSF, Wright-Giemsa, X250)

Identication
Erythrocyte, nucleated

Referee %
100.0

Participant %
99.7

The CSF sample is bloody and shows several nucleated

red blood cells (arrowed) and a promyelocyte. The
NRBCs demonstrate agranular orangeophilic cytoplasm and dense pyknotic nuclei. Above the group
of arrowed nucleated red blood cells are several other
NRBCs at a slightly more immature stage of maturation reflected by their more polychromatophilic pinkgray cytoplasm and more open nuclear chromatin. No
nucleated RBCs were found in the peripheral blood;
the sample represents marrow contamination. The
agranular homogeneous cytoplasm helps to distinguish the cells from necrobiotic neutrophils, which
may also have pyknotic nuclei.

CM-27, 1999 (CSF, Wright-Giemsa, X330)

Identication
Erythrocyte, nucleated

Referee %
100.0

Participant %
99.3

This CSF sample was taken from a 2-month-old infant

with fever and irritability. The fluid had a WBC=176/
L; RBC=1302/L. The arrowed cells are nucleated red
blood cells with polychromatophilic pink-gray cytoplasm and nuclei that have coarse clumped chromatin. Immature granulocytic cells are also present. The
presence of immature granulocytic cells and nucleated
red blood cells suggests the possibility of bone marrow
contamination.

CM-18, 2005 (CSF, Wright-Giemsa, X400)

Identication
Erythrocyte, nucleated
Ventricular lining cell

Referee %
95.2
4.8

Participant %
84.4
9.4

This CSF was obtained from a 75-year-old woman with

a left-sided CVA (cerebrovascular accident). The arrowed cells are nucleated erythroid precursors, which
are characterized by round nuclei with dark purple,
variably condensed chromatin. Most erythroid precursors have moderate amounts of cytoplasm which varies from blue to gray-pink to pink as the cell matures
and hemoglobinization occurs. These cells represent
bone marrow contamination during the lumbar puncture. There are also numerous red blood cells and two
neutrophils in the background.

Erythroid Series

101