Peripheral blood smear: Difference between revisions

(15 intermediate revisions by the same user not shown)

Line 3:

|author2=

}}

Look at and comment separately on white blood cells, red blood cells and platelets. You generally don't need to aim for a perfect report, because for most purposes, a peripheral smear is a relatively simple screening test, and clinicians may opt to perform for example flow cytometry and/or a bone marrow biopsy if they want a better evaluation.

Look at and comment separately on white blood cells, red blood cells and platelets.

==Oil immersion microscopy==

This is preferred for light microscopy of peripheral blood smears in order to achieve a very high magnification. First use low or medium power to center on suspicious cells, or where red or white blood cells are best appreciated. Put a drop of immersion oil on the location and switch to the immersion objective. ~~Be systematic in your~~ switching between objectives so as to avoid getting oil on any of your dry objectives (which is a bit tedious to clean off).

This is preferred for light microscopy of peripheral blood smears in order to achieve a very high magnification. First use low or medium power to center on suspicious cells, or where red or white blood cells are best appreciated. Put a drop of immersion oil on the location and switch to the immersion objective. Then, whenever there's oil on a slide, always think twice before switching between objectives so as to avoid getting oil on any of your dry objectives (which is a bit tedious to clean off).

==Red blood cells==

Line 82:

Line 81:

|}

;Burr cells versus spur cells

File:Micrograph of an echinocyte on a peripheral blood smear.jpg|'''Burr cell''' (echinocyte)

File:Human blood film with acanthocytes 02.jpg|'''Spur cell''' (acanthocyte)

Line 89:

Line 88:

;Intraerythrocytic findings

File:Micrograph of a red blood cells with an overlying platelet on a peripheral blood smear.jpg|When seeing what appears to a platelet overlying a red blood cells (as pictured), confirm that there is a halo.

File:Human blood film with babesia.jpg|Otherwise, make sure it is not '''babesia''' (pictured) or malaria (images below).

</gallery>

File:Blood stages of P. falciparum over 48h.jpg|'''Malaria''', showing appearance at different intraerythrocytic blood stages.

File:Thick blood film with Plasmodium falciparum rings and schizonts.png|If '''malaria''' is suspected, also make a thick blood film.

Line 112:

Line 111:

===White blood cells===

Look for:

[[File:Monoblast, promonocyte and monocyte.jpg|thumb|400px|Comparison of monoblast, promonocyte and monocyte. {{further|Suspected blasts on peripheral blood smear}}]]

A common practice is to evaluate at least 100 white blood cells. Look for:

File:Myeloblast with Auer rod.jpg|thumb|'''Blast cells''', generally having large nucleus, immature chromatin, a prominent nucleolus, scant cytoplasm and few or no cytoplasmic granules. This example has an Auer rod (to the left of the nucleus).

File:Myeloblast with Auer rod.jpg|thumb|'''Blast cells''', generally having large nucleus, immature chromatin, a prominent nucleolus, scant cytoplasm and few or no cytoplasmic granules. This example has an Auer rod (to the left of the nucleus). {{further|Suspected blasts on peripheral blood smear}}

File:Hypersegmented neutrophil.jpg|'''Hypersegmented neutrophils'''. This is abnormal when more than half of neutrophils have at least 4 segments, or more than 5% of neutrophils have more than 5 segments.<ref name="Glassy 1998 p. ">{{cite book | last=Glassy | first=Eric | title=Color atlas of hematology : an illustrated field guide based on proficiency testing | publisher=College of American Patholgists | publication-place=Northfield, Ill | year=1998 | isbn=978-0-930304-66-9 | oclc=40976106 | page=}}</ref>

File:Prolymphocyte in peripheral blood smear.png|In patients with known chronic lymphocytic leukemia, estimate the percentage of '''prolymphocytes''', which are medium-sized lymphocytes with prominent nucleoli.<ref>{{cite web|url=https://imagebank.hematology.org/image/19922/prolymphocytes-in-pll?type=upload|title=prolymphocytes in PLL|website=American Society of Hematology|date=2013-07-16}}</ref> A percentage of less than 5% can be reported as such.

File:Smudge cell in a peripheral blood smear.jpg|When '''smudge cells''' constitute more than 10% of white blood cells, or in patients with CLL, a separate smear with a drop of serum albumin to every four or five drops of blood should be made to stabilize cell membranes.<ref>{{cite web|url=http://www.captodayonline.com/Archives/0610/0610_qa.html|title=Q & A|website=CAP Today|author=Fredrick L. Kiechle}} June 2010</ref> A semi-quantification of different cell lines should then be made on the albumin slide, whereas white and red blood cell morphology should still be made on the original slide, since it is altered by albumin.

</gallery>

When '''smudge cells''' constitute more than 10% of white blood cells, or in patients with CLL, a separate smear with a drop of serum albumin to every four or five drops of blood should be made to stabilize cell membranes.<ref>{{cite ~~web~~|~~url~~=~~http~~://~~www~~.~~captodayonline~~.~~com~~/~~Archives~~/~~0610~~/~~0610_qa~~.~~html~~|~~website~~=~~CAP Today~~|~~author~~=~~Fredrick L~~. ~~Kiechle~~}} ~~June 2010<~~/~~ref>~~

{| class="wikitable" style="text-align:center; vertical-align:middle;"

|+ Atypical/Reactive lymphocytes:<ref name="Nozaka2023">{{cite journal

|last1=Nozaka |first1=Hiroyuki

|last2=Kushibiki |first2=Mihoko

|last3=Kamata |first3=Kosuke

|last4=Yamagata |first4=Kazufumi

|title=Classifying Microscopic Images of Reactive Lymphocytosis Using Two-Step Tandem AI Models

|journal=Applied Sciences

|year=2023

|volume=13

|issue=9

|page=5296

|doi=10.3390/app13095296

|doi-access=free

}} "This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/)."</ref>

! rowspan="2" | Morphological feature

! colspan="3" | Atypical lymphocyte<br />— Downey's categorization —

|-

! Type I<br />(monocyte-like)

! Type II<br />(plasma cell-like) - Most common

! Type III<br />(lymphoblast-like)

|-

! Typical morphology

| [[File:Type 1 atypical lymphocyte.png|180px|center|Type I (monocyte-like) atypical lymphocyte]]

| [[File:Type 2 atypical lymphocyte.png|180px|center|Type II (plasma cell-like) atypical lymphocyte]]

| [[File:Type 3 atypical lymphocyte.png|180px|center|Type III (lymphoblast-like) atypical lymphocyte]]

|-

! Size

| ≥16 µm

|-

! Nuclear features

| style="text-align:left;" |

* Kidney-shaped or segmented

| style="text-align:left;" |

* Fine nucleus

* Nucleolus (±)

| style="text-align:left;" |

* Agglutinated chromatin

* Nucleolus (±)

|-

! Cytoplasm

| style="text-align:left;" |

* Strongly basophilic

* Vacuoles (±)

| style="text-align:left;" |

* Strongly basophilic

| style="text-align:left;" |

* Strongly basophilic

|-

! Intracytoplasmic granules

| —

| Azurophilic granules (±)

| —

|}

==Report==

Example report:

{|class=wikitable

| Normochromic normocytic red blood cells. Red blood cells show <normal morphology / anisopoikilocytosis with occasional ___>. {{Comment-begin}}If thrombocytopenia, also add "Schistocytes are not significantly increased" if applicable.{{Comment-end}}

{{Finding-begin}}Leukocytosis with neutrophilia / lymphocytosis.{{Finding-end}} White blood cells show no left shift or blasts.

Platelets show no evidence of clumping, and show normal granularity.

{{Moderate-begin}}Causes of the above findings include ___.{{Moderate-end}}

|}

@@ Line 3: / Line 3: @@
 |author2=
 }}
+Look at and comment separately on white blood cells, red blood cells and platelets. You generally don't need to aim for a perfect report, because for most purposes, a peripheral smear is a relatively simple screening test, and clinicians may opt to perform for example flow cytometry and/or a bone marrow biopsy if they want a better evaluation.
-Look at and comment separately on white blood cells, red blood cells and platelets.
+{{Comprehensiveness|otherlegend=yes}}
-{{Comprehensiveness}}
 ==Oil immersion microscopy==
-This is preferred for light microscopy of peripheral blood smears in order to achieve a very high magnification. First use low or medium power to center on suspicious cells, or where red or white blood cells are best appreciated. Put a drop of immersion oil on the location and switch to the immersion objective. Be systematic in your switching between objectives so as to avoid getting oil on any of your dry objectives (which is a bit tedious to clean off).
+This is preferred for light microscopy of peripheral blood smears in order to achieve a very high magnification. First use low or medium power to center on suspicious cells, or where red or white blood cells are best appreciated. Put a drop of immersion oil on the location and switch to the immersion objective. Then, whenever there's oil on a slide, always think twice before switching between objectives so as to avoid getting oil on any of your dry objectives (which is a bit tedious to clean off).
 ==Red blood cells==
@@ Line 82: / Line 81: @@
 |}
 ;Burr cells versus spur cells
-<gallery mode=packed heights=150>
+<gallery mode="packed" heights="150">
 File:Micrograph of an echinocyte on a peripheral blood smear.jpg|'''Burr cell''' (echinocyte)
 File:Human blood film with acanthocytes 02.jpg|'''Spur cell''' (acanthocyte)
@@ Line 89: / Line 88: @@
 ;Intraerythrocytic findings
-<gallery mode=packed heights=150>
+<gallery mode="packed" heights="150">
 File:Micrograph of a red blood cells with an overlying platelet on a peripheral blood smear.jpg|When seeing what appears to a platelet overlying a red blood cells (as pictured), confirm that there is a halo.
 File:Human blood film with babesia.jpg|Otherwise, make sure it is not '''babesia''' (pictured) or malaria (images below).
 </gallery>
-<gallery mode=packed heights=220>
+<gallery mode="packed" heights="250">
 File:Blood stages of P. falciparum over 48h.jpg|'''Malaria''', showing appearance at different intraerythrocytic blood stages.
 File:Thick blood film with Plasmodium falciparum rings and schizonts.png|If '''malaria''' is suspected, also make a thick blood film.
@@ Line 112: / Line 111: @@
 ===White blood cells===
-Look for:
+[[File:Monoblast, promonocyte and monocyte.jpg|thumb|400px|Comparison of monoblast, promonocyte and monocyte. {{further|Suspected blasts on peripheral blood smear}}]]
-<gallery mode=packed>
+A common practice is to evaluate at least 100 white blood cells. Look for:
-File:Myeloblast with Auer rod.jpg|thumb|'''Blast cells''', generally having large nucleus, immature chromatin, a prominent nucleolus, scant cytoplasm and few or no cytoplasmic granules. This example has an Auer rod (to the left of the nucleus).
+<gallery mode="packed" heights="190">
+File:Myeloblast with Auer rod.jpg|thumb|'''Blast cells''', generally having large nucleus, immature chromatin, a prominent nucleolus, scant cytoplasm and few or no cytoplasmic granules. This example has an Auer rod (to the left of the nucleus). {{further|Suspected blasts on peripheral blood smear}}
 File:Hypersegmented neutrophil.jpg|'''Hypersegmented neutrophils'''. This is abnormal when more than half of neutrophils have at least 4 segments, or more than 5% of neutrophils have more than 5 segments.<ref name="Glassy 1998 p. ">{{cite book | last=Glassy | first=Eric | title=Color atlas of hematology : an illustrated field guide based on proficiency testing | publisher=College of American Patholgists | publication-place=Northfield, Ill | year=1998 | isbn=978-0-930304-66-9 | oclc=40976106 | page=}}</ref>
+File:Prolymphocyte in peripheral blood smear.png|In patients with known chronic lymphocytic leukemia, estimate the percentage of '''prolymphocytes''', which are medium-sized lymphocytes with prominent nucleoli.<ref>{{cite web|url=https://imagebank.hematology.org/image/19922/prolymphocytes-in-pll?type=upload|title=prolymphocytes in PLL|website=American Society of Hematology|date=2013-07-16}}</ref> A percentage of less than 5% can be reported as such.
+File:Smudge cell in a peripheral blood smear.jpg|When '''smudge cells''' constitute more than 10% of white blood cells, or in patients with CLL, a separate smear with a drop of serum albumin to every four or five drops of blood should be made to stabilize cell membranes.<ref>{{cite web|url=http://www.captodayonline.com/Archives/0610/0610_qa.html|title=Q & A|website=CAP Today|author=Fredrick L. Kiechle}} June 2010</ref> A semi-quantification of different cell lines should then be made on the albumin slide, whereas white and red blood cell morphology should still be made on the original slide, since it is altered by albumin.
 </gallery>
-When '''smudge cells''' constitute more than 10% of white blood cells, or in patients with CLL, a separate smear with a drop of serum albumin to every four or five drops of blood should be made to stabilize cell membranes.<ref>{{cite web|url=http://www.captodayonline.com/Archives/0610/0610_qa.html|website=CAP Today|author=Fredrick L. Kiechle}} June 2010</ref>
+{| class="wikitable" style="text-align:center; vertical-align:middle;"
+|+ Atypical/Reactive lymphocytes:<ref name="Nozaka2023">{{cite journal
+ |last1=Nozaka |first1=Hiroyuki
+ |last2=Kushibiki |first2=Mihoko
+ |last3=Kamata |first3=Kosuke
+ |last4=Yamagata |first4=Kazufumi
+ |title=Classifying Microscopic Images of Reactive Lymphocytosis Using Two-Step Tandem AI Models
+ |journal=Applied Sciences
+ |year=2023
+ |volume=13
+ |issue=9
+ |page=5296
+ |doi=10.3390/app13095296
+ |doi-access=free
+}} "This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/)."</ref>
+! rowspan="2" | Morphological feature
+! colspan="3" | Atypical lymphocyte<br />— Downey's categorization —
+|-
+! Type I<br />(monocyte-like)
+! Type II<br />(plasma cell-like) - Most common
+! Type III<br />(lymphoblast-like)
+|-
+! Typical morphology
+| [[File:Type 1 atypical lymphocyte.png|180px|center|Type I (monocyte-like) atypical lymphocyte]]
+| [[File:Type 2 atypical lymphocyte.png|180px|center|Type II (plasma cell-like) atypical lymphocyte]]
+| [[File:Type 3 atypical lymphocyte.png|180px|center|Type III (lymphoblast-like) atypical lymphocyte]]
+|-
+! Size
+| ≥16 µm
+| ≥16 µm
+| ≥16 µm
+|-
+! Nuclear features
+| style="text-align:left;" |
+* Kidney-shaped or segmented
+| style="text-align:left;" |
+* Fine nucleus
+* Nucleolus (±)
+| style="text-align:left;" |
+* Agglutinated chromatin
+* Nucleolus (±)
+|-
+! Cytoplasm
+| style="text-align:left;" |
+* Strongly basophilic
+* Vacuoles (±)
+| style="text-align:left;" |
+* Strongly basophilic
+| style="text-align:left;" |
+* Strongly basophilic
+|-
+! Intracytoplasmic granules
+| —
+| Azurophilic granules (±)
+| —
+|}
+==Report==
+Example report:
+{|class=wikitable
+| Normochromic normocytic red blood cells. Red blood cells show <normal morphology / anisopoikilocytosis with occasional ___>. {{Comment-begin}}If thrombocytopenia, also add "Schistocytes are not significantly increased" if applicable.{{Comment-end}}
+{{Finding-begin}}Leukocytosis with neutrophilia / lymphocytosis.{{Finding-end}} White blood cells show no left shift or blasts.
+Platelets show no evidence of clumping, and show normal granularity.
+{{Moderate-begin}}Causes of the above findings include ___.{{Moderate-end}}
+|}
 {{Bottom}}

Peripheral blood smear: Difference between revisions

Navigation menu

Search