RBC, Erythrocytes

1. RED BLOOD CELLS

2. Three Phases of an Erythrocyte Life
 A) Erythropoiesis or Erythrocyte
Production
 B) Release from Bone Marrow to
Circulation
C) Destruction and Death

3. RBC
 Materials needed for Red Blood
Production
a) Metals e.g. Copper, Iron, Cobalt, Zinc
b) Vitamins e.g. Thiamine, Folate
Cyanocobalamin
c) Amino Acids e.g.
Glutamic, Lysine,
Leucine
d) Hormones e.g.
Erythropoietin,
Androgen

4. RBC
 Erythrokinetic Evaluation states that Red
Cell Production is equal to Red Cell
Destruction
 Erythrocyte Kinetics ( M = P x S)
M - Total Erythrocyte
Mass P–
Production ( Number of New RBC
produced per day)
S – RBC Life
Span

5. Erythrocyte Kinetics
 Ex: A 70 kg man with 2 liters of Erythrocyte
must produced 20 ml of new erythrocytes each
day to replace the 20 ml. normally lost RBC
due to cell senecent 2000 (M) = 20 ml /day (P)
100 days (S)
If Survival time is decreased by half, the BM
must double its production to maintain the man
of 2000 ml of RBC 2000 ml(M)= 40 ml/day (P)
50 days(S)

6. Tests to Measure Erythropoiesis
 A) M/E Ratio ( 3:1) or E:G Ratio (1:3)
 B) Fecal Urobilinogen
 C) PITR ( Plasma Iron Turnover Rate)

7. Two Types of Erythropoiesis
 A) Effective Erythropoiesis
1) Reticulocyte count
2) Red Cell
Utilization of Iron
3) Red Cell Survival Time
 B) Ineffective Erythropoiesis
Two groups demonstrating
I.E. 1)
Hypoproliferative anemias
2) Anemias secondary
to maturation

8. Factors Involved in the Release of
RBC
1) Hypoxia
2) Presence of Erythropoietin
3) Thyroid Hormone
4) Androgenic Hormone
5) Growth Hormone
6) Prostaglandins

9. Normal red cells
 Normal red cells or
erythrocytes show only slight
variation in size and shape.
The blood film should be
examined in the area where
the red cells are touching but
not often overlapping. In this
area many red cells have an
area of central pallor which
may be up to a third of the
diameter of the cell. This is
consequent on the shape of a
normal red cell, which
resembles a disc that is
thinner in the centre.

10. Variation of RBC ( Anisocytosis)
 Anisocytosis
 Anisocytosis refers to
increased variation in
the size of red cells. This
image also shows
anisochromasia, i.e. an
increased variation in
the staining of red cells.
Anisochromasia
indicates variation in the
haemoglobin
concentration between
different cells.

11. Macrocytosis
 Macrocytosis.
Macrocytosis refers to
an increase in the
average size of red
cells. A large red cell is
referred to a macrocyte.
This blood film is from a
patient with
macrocytosis caused by
liver disease. The MCV
was 105 fl (normal range
82-98).

12. Macro-ovalocyte
 An ovalocyte which is
appreciably larger than a
normal erythrocyte is
referred to as a macro-
ovalocyte [arrow].
Macro-ovalocytes are a
feature of megaloblastic
anaemia, congenital
dyserythropoietic
anaemias and South-
East Asian ovalocytosis

13. Microcytosis
 The term microcytosis means
that red cells are smaller than
normal. Small red cells are
referred to as microcytes.
This blood film is from a
blood sample with a mean
cell volume (MCV) of 72 fl
(normal range 82-98). There
is also hypochromia, i.e. the
cells have an increased area
of central pallor.

14. Microspherocytes
 Microspherocytes
resemble spherocytes in
that they lack central
pallor but differ in that
they are smaller than
normal discocytes. They
result from red cell
fragmentation. This
photograph also shows
large red cells, which
are likely to be young
cells, and a nucleated
red cell or erythroblast

15. Variation of RBC (Poikilocytosis)
 Poikilocytosis in a baby with
hereditary elliptocytosis and
transient neonatal
poikilocytosis. Poikilocytosis
means an increased
variability in red cell shape. A
poikilocyte is a red cell of
abnormal shape. An
individual may have a
predominance of a particular
type of poikilocyte or there
may be cells of a variety of
shapes.

16. Classification of poikilocytes
 Poikilocytes can be
classified as shown.

17. Acanthocyte
 An acanthocyte is an
erythrocyte that is
irregular in shape and is
covered with a small
number of spicules
(2-20) which vary in
length and thickness.
The spicules are
irregularly distributed
over the surface of the
red cell. The presence of
acanthocytes is referred
to as acanthocytosis.

18. Severe Liver Disease (Acanthocytosis
– Spur Cell Anemia)
 Acanthocyte are  Scanning electron
irregularly shape and micrograph of
is covered with a acanthocyte
small spicules (2 to
20)

19. Echinocyte
 An echinocyte is an erythrocyte
with a large number of short
blunt spicules (10-30), regularly
distributed over the surface of
the cell. The presence of
echinocytes is referred to as
echinocytosis. In this case the
abnormality was caused by
chronic renal failure but much
more often echinocytes
represent a storage artefact
indicating that EDTA-
anticoagulated blood has been
stored for too long before the
blood film was made.

20. Elliptocytes in iron deficiency
 Elliptocytes are quite
common in iron deficiency.
They are usually particularly
long and thin and for this
reason are sometimes
referred to as 'pencil cells'.
This film also shows
anaemia, mild anisocytosis,
hypochromia and
microcytosis.

21. Spherocyte
 Spherocytes in
hereditary
spherocytosis. The
spherocytes are the
cells that lack central
pallor. Cells which have
rounded up to become
spherocytes have a
reduced diameter in
comparison with normal
discocytes but the cell
size is normal.

22. Sickle cell and boat-shaped cell
 Sickle cell and boat-shaped
erythrocytes in sickle cell
anaemia. Sickle cells [dark
red arrow] are sickle- or
crescent-shaped red cells
with both ends being pointed.
Boat-shaped cells [dark blue
arrows] are pointed at one or
both ends but are not curved.
Sickle cells are
pathognomonic for sickle cell
disease whereas boat-
shaped cells are suggestive
but not pathognomonic.

23. Stomatocytes
 Stomatocytes are red cells
that, on a stained blood film,
appear to have a slit-like
mouth or stoma. In three
dimensions they are cup-
shaped.
 Common causes of
stomatocytosis are liver
disease and alcohol excess.
 Less common causes include
myelodysplastic syndromes
and hydroxyurea therapy.
 Congenital stomatocytosis is
a rare cause of
stomatocytosis.

24. Target cell
 Target cells are erythrocytes
that, in stained blood films,
resemble a target. They have
an area of increased staining
in the centre of the normal
area of central pallor. In three
dimensions, target cells are
found to be bell-shaped.
Target cells are a feature of
hyposplenism, obstructive
jaundice, liver disease and
various
haemoglobinopathies.

25. Teardrop poikilocyte
 Teardrop poikilocytes or
dacrocytes are pear-
shaped or teardrop-
shaped red cells. They
are a feature of
idiopathic myelofibrosis
(this case), secondary
myelofibrosis,
megaloblastic anaemia
and congenital or
acquired
dyserythropoiesis

26. Keratocyte
 Keratocytes or horned cells
are erythrocytes with a pair of
spicules or 'horns'
surrounding a gap in the cell
outline. There may be a
single pair of spicules [red
arrow] or two pairs of
spicules [blue arrow].
Keratocytes can result from
removal of a Heinz body from
a cell (this case) or from red
cell fragmentation.

27. Elliptocytes in hereditary elliptocytosis
 Elliptocytes are cells of
elliptical shape. This film
also shows ovalocytes
which have an oval
outline and are
intermediate in shape
between elliptocytes and
discocytes.

28. RBC INCLUSIONS (alpha Chain
precipitates)
 When synthesis of b globin
chain is reduced excess
alpha chains may precipitate
in erythroblasts or mature
erythrocytes. a chain
precipitates [blue arrow] have
the same staining
characteristics as
haemoglobin and appear as
an irregular mass within a
hypochromic red cell. They
are seen in patients with b
thalassaemia major.

29. Basophilic stippling
 Basophilic stippling [arrows]
or punctate basophilia refers
to the presence of numerous
small basophilic inclusions
scattered through red cells.
They differ from
Pappenheimer bodies in
being present in larger
numbers within an individual
red cell and being scattered
through the cytoplasm rather
than being peripherally sited

30. Haemoglobin C crystal
 Haemoglobin C is prone
to crystallize, forming
crystals with straight
parallel edges [arrows].
They are usually
rhomboidal or
hexagonal. Usually all
the haemoglobin in the
cell crystallizes so that
the cell appears
otherwise empty of
haemoglobin.

31. Heinz body
 Heinz bodies are red cell
inclusions that are seen only
after a specific vital stain, a
Heinz body stain, has been
performed. They stain pale pink
or purple, are attached to the red
cell membrane and sometimes
protrude through the membrane.
Heinz bodies cannot be seen on
a routinely stained blood film.
However when they are present
the routine blood film usually
shows irregularly contracted cells
and keratocytes. Sometimes
there is a protrusion of the red
cell membrane

32. Glucose-6-phosphate dehydrogenase
(G6PD) deficiency
 The commonest cause of
congenital haemolytic anaemia is
glucose-6-phosphate
dehydrogenase (G6PD)
deficiency which affects millions
of people world-wide. Most
individuals with G6PD deficiency
suffer only intermittent
haemolysis. The blood film then
shows irregularly contracted cells
[deep red arrows] and
sometimes hemighosts [deep
blue arrow] in which all the
haemoglobin appears to have
retracted to one side of the
erythrocyte.

33. Howell-Jolly body
 Howell-Jolly bodies
[arrow] are small nuclear
fragments within
erythrocytes. Their
staining characteristics
resemble those of the
nucleus of a mature
erythrocyte. They are
round in shape and are
sited closer to the edge
of the cell than the
centre.

34. Irregularly contracted cells
 Irregularly contracted
cells are rounded
cells lacking central
pallor but with
irregular outlines.
This image also
shows large cells
that are likely to be
young red cells.

35. Acquired haemoglobin H disease
 Acquired haemoglobin H
disease occurs in
myelodysplastic
syndromes and
erythroleukaemia. This
patient also has
sideroblastic
erythropoiesis.
 The film is dimorphic
and shows target cells,
other poikilocytes,
hypochromia and
Pappenheimer bodies.

36. Pappenheimer bodies
 Pappenheimer bodies
[arrows] are small
basophilic inclusions
sited near the periphery
of red cells. They are
smaller than Howell-
Jolly bodies, stain deep
blue rather than purple
and are more likely to be
multiple..

37. Siderotic granules (Perls' stain)
 Siderotic granules
[arrow] are cytoplasmic
granules composed of
haemosiderin. The term
'siderotic granule' is
used when an iron stain
is employed.
 The same red cell
inclusions on a routinely
stained film are referred
to as 'Pappenheimer
bodies'.

38. Variation of RBC (Anisochromasia)
 Anisochromasia
 This film from an iron
deficient patient shows
anisochromasia, i.e.
there is increased
variation in staining from
cell to cell. Some cells
are normally
haemoglobinized while
others show only a thin
rim of haemoglobinized
cytoplasm.

39. Dimorphic blood film
 The term dimorphic indicates
that there are two distinct
populations of red cells. Most
often the term is used, as in
this case, to refer to a mixture
of normal cells and
hypochromic microcytes.
 This film is from a
heterozygous carrier of
sideroblastic anaemia. The
photograph also shows three
cells of abnormal shape.

40. Variation of RBC (Hypochromic)
 Hypochromia
 Hypochromia refers to
reduced staining of red
cells, indicative of a
reduced haemoglobin
concentration. Cells that
are hypochromic are
often also microcytic.
 In this film, from a
patient with
haemoglobin H disease,
the great majority of
cells are hypochromic.

41. Hyperchromia caused by spherocytosis
 Hyperchromia. The term
hyperchromia can be used to
indicate the presence of
increased numbers of cells
lacking central pallor.
However it is more useful to
state specifically why cells
lack central pallor.
 This film shows hyperchromia
consequent on
spherocytosis, i.e. the
presence of cells which are
more spherical than normal
cells. In this case they are
consequent on autoimmune
haemolytic anaemia.

42. Rouleaux and increased background staining
 Rouleaux and increased
background staining often
occur together since both are
consequent on increased
concentration of plasma
proteins.
 Rouleaux are stacks of red
cells, arranged like a pile of
pennies.
 Increased background
staining means that there is a
basophilic background
between the red cells.

43. Red cell agglutination
 Red cell agglutination is the
clumping of red cells into
irregular masses. It is caused
by the presence of an
antibody, usually a cold
antibody, which bridges red
cells.
 Agglutination can be
distinguished from rouleaux
formation by the irregularity
of the clumps of cells, in
contrast with the stacks of
red cells in rouleaux.

44. Red cell rosetting
 Red cell rosetting is
an uncommon
phenomenon of
uncertain
significance in which
erythrocytes are
rosetted around
leucocytes.