RBC Morphology


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Complete Blood Count (CBC)

A CBC is performed using an automated laboratory instrument which measures the numbers of RBC's, WBC's, and platelets per unit volume. In addition, the RBC indices are generated. Some instruments can also generate an automated WBC differential count.

View an automated instrument for performing a CBC in the laboratory

Red Cell Indices

A standard complete blood count is performed on an automated laboratory instrument that quantitates the amount of Hgb as well as the size, shape, and number of RBC's. A variety of calculations are performed to produce indices that provide information about RBC disorders. The standard indices are:

RBC Count

The number of RBC's per unit volume is measured directly and given in millions per microliter.

Mean Corpuscular Volume (MCV)

The MCV is measured directly; the unit is a femtoliter (fL). The MCV measures the size of RBC's and is the most important index for classification of anemias into "macrocytic" with higher than normal MCV and "microcytic" with low MCV.

Hemoglobin (Hgb)

The Hgb content is measured directly and given in grams per deciliter (g/dL). This value, along with Hct, provides the most useful measure of the oxygen carrying capacity of the blood.

Hematocrit (Hct) in % = (RBC count X MCV) ÷ 10

The Hct is a calculated value and provides a measure of the amount of oxygen carrying capacity of the blood.

Mean Corpuscular Hemoglobin (MCH) in pg = (Hgb X 10) ÷ RBC count

The MCH is calculated and gives the average mass of Hgb in an individual RBC; the unit is a picogram (pg).

Mean Corpuscular Hemoglobin Concentration (MCHC) in g/dL = (Hgb X 100) ÷ Hct

The MCHC is calculated and provides a measure of the concentration of Hgb in the cells in g/dL.

Red Cell Distribution Width (RDW) = standard deviation of MCV

The RDW is calculated to provide a measure of the anisocytosis, or variation in size of the RBC's.



An example of the data generated by an automated instrument for performing a CBC is shown below. The graph at the lower right demonstrates the red cell distribution width (RDW) by relative numbers of sizes of RBC's as measured in femtoliters (fl).


In addition to these indices obtained from an automated instrument, a reticulocyte count (RC) can be calculated. The "retic" count is generated manually, because a peripheral smear must be stained with a supravital dye so that the number of reticulocytes can be enumerated. Most retic counts are given as a "corrected reticulocyte count" which compensates for a falsely elevated retic count with anemia: RC (corrected) = RC x (patient Hct ÷ 45).


Nomenclature

The following terms are used in describing the morphology of RBC's, as seen on a standard peripheral blood smear:

AcanthocyteCell with irregular, long, asymmetrical projections; sporadically seen with severe liver disease or post-splenectomy; seen with rare disorder of abetalipoproteinemia
AnisocytosisVariation in size of RBC's
BabesiosisSimilar to ring forms of malaria
Basophilic stipplingSmall aggregates of RNA are seen as small blue dots in the RBC; fine stippling may be a feature of reticulocytes; coarse stippling can appear with toxic marrow damage, myelodysplasia, and thalassemias
ElliptocyteElongated, elliptical cell; non-specific when occasionally seen; rare disorder of hereditary elliptocytosis
Heinz bodyPrecipitated Hgb seen as a perimembranous blue dot only after supravital staining; seen with some hemoglobinopathies
Howell-Jolly bodySmall, round deeply basophilic nuclear remnant; seen when spleen is absent
HypochromiaCells with decreased MCH, typical of iron deficiency
MacrocytosisCells with increased MCV, typical of megaloblastic anemias
MalariaPlasmodium infection seen as "ring forms", stippling, and gametocytes, depending upon the species
MicrocytosisCells with decreased MCV, typical of iron deficiency anemia and thalassemias
Pappenheimer bodyMultiple, tiny iron containing granular blue dots; seen when spleen is absent and with iron overload
PoikilocytosisVariation in shape of RBC's
PolychromatophiliaThe bluish tint to young RBC's with high RNA content
ReticulocyteYoung RBC's with increased RNA content that can be precipitated by supravital staining for identification and enumeration
RouleauxLinear aggregation of RBC's that resembles a stack of coins; seen when surface charge is reduced with increased serum protein, particularly increased fibrinogen or globulin
SideroblastNon-nucleated RBC with stainable iron
SpherocyteSmall, round dense cell without central pallor; suggests extravascular (splenic) hemolysis in previously normal persons; with hereditary spherocytosis there is increased osmotic fragility
SchistocyteFragmented, irregularly shaped seen with intravascular hemolysis such as microangiopathic hemolytic anemias (DIC, TTP). A variant called a "helmet cell" appears cut in half
Sickle cellCurved, banana-shaped cell with pointed ends found in sickle cell disease from aggregation of Hgb S
StomatocyteCell with slit-like central pallor; occasional stomatocytes are non-specific or an artefact; many are seen with rare hereditary stomatocytosis
Target cellCell with central and peripheral staining with intervening pallor due to increased redundancy of RBC membrane; seen with liver disease, in some thalassemias, and with Hgb C
Tear drop cellCell pinched at one end, prominent in myelofibrosis and myelophthisic conditions


RBC Morphology Diagrams

Morphologic changes seen in RBC's on a peripheral blood smear include the findings pictured below. Moving the mouse over each image will reveal the name in the status bar at the bottom.



RBC Morphology in Peripheral Blood Smears

The following images illustrate findings with RBC's in peripheral blood smears:

  1. Normal RBC's.
  2. Hypochromic, microcytic RBC's.
  3. Hypochromic, microcytic RBC's.
  4. Macro-ovalocytes.
  5. Spherocytes and reticulocyte.
  6. Nucleated RBC with basophilic stippling.
  7. Schistocytes.
  8. Hemolysis with spherocytosis and reticulocytosis.
  9. Tear drop cells.
  10. Howell-Jolly bodies in RBC, nucleated RBC, spherocytes.
  11. Rouleaux formation.
  12. Sickle cells.
  13. Sickle cells.
  14. Beta-thalassemia with marked poikilocytosis and microcytosis.
  15. Hemoglobin SC disease.
  16. Malaria.


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