Comparison Table for Peripheral Blood Smear Findings in Various Diseases
Disease | RBC Findings | WBC Findings | Platelet Findings |
ABO Incompatibility | Spherocytes (3+), Polychromasia (2+), Nucleated RBCs (1+) | Neutrophilia (2+), Left Shift | Normal Count and Morphology |
Iron Deficiency Anemia | Microcytes (2+), Hypochromia (2+), Target Cells (1+) | Generally normal | Often elevated (reactive thrombocytosis) |
Thalassemia | Microcytes (3+), Hypochromia (3+), Basophilic Stippling (2+), Target Cells (3+) | Generally normal | Generally normal |
Sickle Cell Disease | Sickle Cells (3+), Target Cells (2+), Polychromasia (2+) | Leukocytosis during vaso-occlusive crises | Generally normal |
Hereditary Spherocytosis | Spherocytes (3+), Polychromasia (2+) | Generally normal | Generally normal |
Immune Thrombocytopenic Purpura (ITP) | Generally normal | Generally normal | Thrombocytopenia, Large platelets |
Thrombotic Thrombocytopenic Purpura (TTP) | Schistocytes (2+) | Generally normal | Thrombocytopenia |
Hemolytic Uremic Syndrome (HUS) | Schistocytes (2+) | Generally normal | Thrombocytopenia |
Disseminated Intravascular Coagulation (DIC) | Schistocytes (3+) | Variable, often leukocytosis | Thrombocytopenia |
Explanation of Findings
RBC Findings
Spherocytes: Small, dense RBCs without central pallor; seen in hereditary spherocytosis and ABO incompatibility.
Polychromasia: Bluish-tinted cells indicating increased reticulocytes; seen in conditions with increased RBC production.
Nucleated RBCs: Immature red blood cells; seen in severe hemolytic anemias and bone marrow stress.
Microcytes: Small RBCs; seen in iron deficiency anemia and thalassemia.
Hypochromia: Pale RBCs due to low hemoglobin; seen in iron deficiency anemia and thalassemia.
Target Cells: Bullseye appearance; seen in liver disease, thalassemia, and hemoglobinopathies.
Basophilic Stippling: Fine granules in RBCs; seen in lead poisoning, thalassemia, and sideroblastic anemia.
Sickle Cells: Crescent-shaped RBCs; seen in sickle cell disease.
Schistocytes: Fragmented RBCs indicating mechanical damage; seen in DIC, TTP, and other hemolytic processes.
WBC Findings
Neutrophilia: Increased neutrophils; seen in infections and inflammatory conditions.
Left Shift: Presence of band cells indicating an active marrow response; seen in bacterial infections.
Leukocytosis: Increased white blood cell count; seen in infections and inflammatory conditions.
Generally Normal: No significant abnormalities.
Platelet Findings
Thrombocytopenia: Low platelet count; seen in ITP, TTP, HUS, and DIC.
Reactive Thrombocytosis: Elevated platelet count; seen in iron deficiency anemia.
Large Platelets: Indicates increased production; seen in ITP.
Generally Normal: No significant abnormalities.
This table summarizes the typical findings for each condition, providing a quick reference for interpreting peripheral blood smears in various pediatric hematologic disorders.
Grading System for Qualitative Analysis
Percentage of cells affected in high-power field:
1+: 25%
2+: 25-50%
3+: 50-75%
4+: 75-100%
This grading system is used to quantify the extent of various abnormalities seen in RBCs, WBCs, and platelets.
Red Blood Cells (RBCs)
Using the provided image, here's a detailed examination of RBC morphology:
Size Variation (Anisocytosis)
Normal: Standard size RBCs without significant variation.
Microcyte: Smaller than normal RBCs.
Macrocyte: Larger than normal RBCs.
Hemoglobin Distribution
Hypochromia: RBCs with reduced hemoglobin content.
Polychromasia: RBCs with a bluish tint, indicating immature red cells (reticulocytes).
Shape Variation (Poikilocytosis)
Target Cell: RBCs with a bullseye appearance, often seen in liver disease, thalassemia, and hemoglobinopathies.
Why: These cells indicate abnormal hemoglobin content or structural integrity.
Additional Conditions: Iron deficiency anemia, post-splenectomy states.
Acanthocyte: Spur cells with irregular projections, seen in liver disease, abetalipoproteinemia, and lipid disorders.
Why: Due to altered lipid composition in the RBC membrane.
Additional Conditions: McLeod syndrome.
Spherocyte: Small, dense, and round RBCs without central pallor, typical of hemolytic anemias like hereditary spherocytosis and ABO incompatibility.
Why: Due to membrane protein defects or immune-mediated damage.
Additional Conditions: Autoimmune hemolytic anemia.
Helmet Cell: Fragmented RBCs, often seen in microangiopathic hemolytic anemias (MAHAs) such as DIC, TTP, and HUS.
Why: Mechanical damage as RBCs pass through microvascular abnormalities.
Additional Conditions: Severe burns.
Ovalocyte (aka Elliptocyte): Oval-shaped RBCs, seen in hereditary elliptocytosis and various anemias.
Why: Due to membrane protein defects.
Additional Conditions: Iron deficiency anemia, myelodysplastic syndromes.
Schistocyte: Fragmented RBCs indicating mechanical damage, seen in DIC, TTP, and other hemolytic processes.
Why: Shearing forces in the vasculature.
Additional Conditions: Mechanical heart valves.
Stomatocyte: RBCs with a mouth-shaped area of central pallor, seen in hereditary stomatocytosis and liver disease.
Why: Altered ion content within RBCs affecting membrane shape.
Additional Conditions: Alcoholic liver disease.
Tear Drop: RBCs shaped like teardrops, seen in myelofibrosis and other marrow infiltration disorders.
Why: Mechanical distortion during RBC development.
Additional Conditions: Thalassemias.
Sickle Cell: Crescent-shaped RBCs, seen in sickle cell disease.
Why: Abnormal hemoglobin (HbS) polymerization under low oxygen conditions.
Additional Conditions: None.
Burr Cell: RBCs with short, evenly spaced projections, seen in uremia, liver disease, and pyruvate kinase deficiency.
Why: Altered cell membrane due to metabolic or environmental factors.
Additional Conditions: Gastric cancer.
Inclusions
Pappenheimer Bodies: Iron-containing granules in RBCs, seen in sideroblastic anemia and post-splenectomy.
Why: Abnormal iron metabolism within RBCs.
Additional Conditions: Myelodysplastic syndromes.
Cabot's Ring: Ring-shaped structures in RBCs, seen in severe anemia and lead poisoning.
Why: Remnants of mitotic spindle.
Additional Conditions: Pernicious anemia.
Basophilic Stippling: Coarse granules in RBCs, seen in lead poisoning, thalassemia, and sideroblastic anemia.
Why: Aggregated ribosomal RNA.
Additional Conditions: Alcohol abuse.
Howell-Jolly Bodies: Nuclear remnants in RBCs, seen in asplenia or after splenectomy.
Why: Failure to remove nuclear remnants.
Additional Conditions: Severe anemia.
Red Cell Distribution
Agglutination: Clumping of RBCs, often due to cold agglutinins or autoimmune hemolytic anemia.
Why: IgM antibody-mediated RBC clumping.
Additional Conditions: Mycoplasma pneumonia, infectious mononucleosis.
Rouleaux: Stacking of RBCs like coins, seen in high protein states like multiple myeloma and chronic inflammatory states.
Why: Increased plasma proteins (IgG) decreasing zeta potential.
Additional Conditions: Waldenström's macroglobulinemia, Multiple myeloma
White Blood Cells (WBCs)
Count and Distribution: Estimate the relative proportions of different WBC types.
Neutrophils: Usually the most abundant, look for segmentation (bands and segmented).
Lymphocytes: Smaller with a large nucleus.
Monocytes: Larger cells with a folded or indented nucleus.
Eosinophils: Bilobed nucleus with red-orange granules.
Basophils: Bilobed or S-shaped nucleus with dark blue granules.
Morphology: Check for any abnormal features.
Toxic Granulation: Coarse granules in neutrophils, indicating severe infection or inflammation.
Atypical Lymphocytes: Larger with abundant cytoplasm, seen in viral infections like infectious mononucleosis.
Blast Cells: Large immature cells, indicating leukemia.
Band Cells: Immature neutrophils, indicative of a left shift often seen in bacterial infections.
Platelets
Count: Estimate the number of platelets. Generally, 1 dot in high power field (HPF) x 15,000 is roughly equivalent to the platelet count (e.g., 10 dots in HPF approximately equals 150,000 platelets).
Thrombocytopenia: Low platelet count.
Thrombocytosis: High platelet count.
Morphology: Examine the size and appearance.
Normal: Small, disc-shaped.
Giant Platelets: Seen in some myeloproliferative disorders.
Clumping: Platelet clumps can falsely lower automated counts.
Example Interpretations in Pediatric Ward
ABO Incompatibility
RBC Findings:
Spherocytes 3+: Small, dense RBCs without central pallor.
Polychromasia 2+: Bluish-tinted cells, indicating increased reticulocytes.
Nucleated RBCs (NRBCs) 1+: Presence of immature red blood cells.
WBC Findings:
Neutrophilia 2+: Increased neutrophils, possibly with toxic granulation.
Left Shift: Presence of band cells, indicating an active marrow response.
Platelet Findings:
Normal Count and Morphology: Platelets typically appear normal.
Iron Deficiency Anemia
RBC Findings:
Microcytes 2+: Small RBCs.
Hypochromia 2+: Pale RBCs due to low hemoglobin.
Target Cells 1+: Occasionally seen.
WBC Findings:
Generally normal unless there's concurrent infection.
Platelet Findings:
Often elevated (reactive thrombocytosis).
Thalassemia
RBC Findings:
Microcytes 3+: Small RBCs.
Hypochromia 3+: Pale RBCs.
Basophilic Stippling 2+: Fine granules in RBCs.
Target Cells 3+: Commonly seen.
WBC Findings:
Generally normal unless there's concurrent infection.
Platelet Findings:
Generally normal.
Sickle Cell Disease
RBC Findings:
Sickle Cells 3+: Crescent-shaped RBCs.
Target Cells 2+: Bullseye appearance.
Polychromasia 2+: Increased reticulocytes.
WBC Findings:
Leukocytosis during vaso-occlusive crises.
Platelet Findings:
Generally normal.
Hereditary Spherocytosis
RBC Findings:
Spherocytes 3+: Small, dense RBCs without central pallor.
Polychromasia 2+: Bluish-tinted cells.
WBC Findings:
Generally normal unless there's concurrent infection.
Platelet Findings:
Generally normal.
Immune Thrombocytopenic Purpura (ITP)
RBC Findings:
Generally normal.
WBC Findings:
Generally normal.
Platelet Findings:
Thrombocytopenia: Low platelet count.
Large platelets: Indicates increased production.
Thrombotic Thrombocytopenic Purpura (TTP)
RBC Findings:
Schistocytes 2+: Fragmented RBCs.
WBC Findings:
Generally normal.
Platelet Findings:
Thrombocytopenia: Low platelet count.
Hemolytic Uremic Syndrome (HUS)
RBC Findings:
Schistocytes 2+: Fragmented RBCs.
WBC Findings:
Generally normal.
Platelet Findings:
Thrombocytopenia: Low platelet count.
Disseminated Intravascular Coagulation (DIC)
RBC Findings:
Schistocytes 3+: Fragmented RBCs.
WBC Findings:
Variable, often leukocytosis.
Platelet Findings:
Thrombocytopenia: Low platelet count.
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