Professional Documents
Culture Documents
*Haematology Laboratory, S U M M A RY
Middlemore Hospital, Auckland,
New Zealand These guidelines provide information on how to reliably and con-
University College London sistently report abnormal red blood cells, white blood cells and
Hospitals, London, UK
Universita Cattolica del Sacro important that all countries in the world use consistent reporting of
Cuore, Rome, Italy
blood cells. An international group of morphology experts have
Institute of Cancer Sciences,
University of Manchester, decided on these guidelines using consensus opinion. For some red
Manchester, UK blood cell abnormalities, it was decided that parameters produced
**SEALS Randwick, Prince of by the automated haematology analyser might be more accurate
Wales Hospital, Randwick,
NSW, Australia
and less subjective than grading using microscopy or automated
image analysis and laboratories might like to investigate this fur-
University of Arizona Medical
Center, Tucson, AZ, USA ther. A link is provided to show examples of many of the cells dis-
cussed in this guideline.
Correspondence:
Lynn Palmer, Haematology
Laboratory, Middlemore
Hospital, Private Bag 93311,
Otahuhu, Auckland 1640,
New Zealand.
Tel.: +64 9 2760167;
Fax: +64 9 2704761;
E-mail: Lynn.Palmer@
middlemore.co.nz
doi:10.1111/ijlh.12327
Keywords
Blood, morphology, RBC,
platelets, WBC
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percentage of the cells having a particular morpho- and follow-up of thrombotic thrombocytopenic pur-
logical abnormality. pura (TTP) and haemolytic uraemic syndrome (HUS)
As a general recommendation, the ICSH group rec- [7]. There is wide variation in red cell nomenclature
ommends providing only a qualitative report for those in common use and a table showing the recom-
presenting with RBC abnormalities; however, a schis- mended nomenclature and common red cell syno-
tocyte count may be of clinical value for the diagnosis nyms has been provided (Table 2).
Acanthocyte acanthoid cell, astrocyte, burr cell, prickle cell, Liver disease, vitamin E deficiency,
pyknocyte, star cell, spur cell, thorn cell postsplenectomy, abetalipoproteinaemia,
McLeod RBC phenotype
Basophilic punctate basophilia Lead poisoning, haemoglobinopathies,
stippling thalassaemia, abnormal haem synthesis
Bite cell keratocytes G6PD deficiency
Blister cell puddle cell, eccentrocyte Oxidative haemolysis, G6PD deficiency
Echinocyte berry cell, burr cell, crenated cell, Liver and renal disease, pyruvate kinase
mulberry cell, poikilocyte, pyknocyte, deficiency, storage artefact
spiculated cell, spur cell, sputnik
cell, star cell
Elliptocyte bacillary cell, cigar or rod shaped cell, Hereditary elliptocytosis, iron deficiency
ovalocyte, pencil cell
Howell-Jolly body Hyposplenism, postsplenectomy, haemolytic
anaemia, megaloblastic anaemia
Hypochromic cell anulocyte, pessary form, ring form Iron deficiency, thalassaemia
Irregularly G6PD deficiency, haemoglobinopathies
contracted cell
Macrocyte macronormocyte, megalocyte B12/folate deficiency, liver disease, MDS
Microcyte micronormocyte Iron deficiency, thalassaemia
Ovalocyte bacillary cell, cigar or Hereditary elliptocytosis, iron deficiency
rod shaped cell, elliptocyte
Pappenheimer Sideroblastic anaemia, haemoglobinopathies,,
bodies hyposplenism
Poikilocyte burr cell, irregular shaped
cell, irregularly contracted
cell, pyknocyte, spur cell
Polychromatic cell polychromatophilic cell Haemolytic anaemia, haematinic treatment
RBC erythrocyte, normocyte,
discocyte
Schistocyte burr cell, helmet cell, Microangiopathic haemolytic anaemia,
horn cell, keratoschistocyte, TTP, HUS, DIC,
pincer cell, poikilocyte, renal disease
prickle cell, red cell
fragment, schizocyte,
thorn cell, triangular cell
Sickle cell drepanocyte, holly leaf cell Sickle cell anaemia and other sickle cell diseases
Spherocyte spherical cell Hereditary spherocytosis, ABO and warm AIHA,
Clostridium perfringens sepsis, burns
Stomatocyte cup cell, knizocyte, slit cell Alcoholic liver disease, hereditary stomatocytosis
Target cell codocyte, leptocyte Liver disease, haemoglobinopathies, thalassaemia
Teardrop cell dacrocyte, pear-shaped cell myelofibrosis
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numbers of target cells will falsely lower the MCV mias and mechanical damage to the red cells may
due to their increased surface area to volume ratio produce morphologically identical cells (keratocytes),
[8]. which are formed by the rupture of peripheral
As previously mentioned, the red cells of newborns pseudovacuoles and subsequent fusion of the red cell
and neonates are larger than in adults but the red membrane.
cells of healthy children are physiologically smaller The recommendation is to grade bite cells.
than in adults so it important that red cell size be
interpreted in the context of the age of the subject.
Blister cells
It is recommended that the more accurate analy-
ser generated MCV be used to gauge red cell size Supplementary image S3.
(degree of microcytosis) rather than grading by visual Blister cells are red cells in which the haemoglobin
microscopic examination but grading criteria have appears retracted into one half of the cell to form a
also been included in the table for microcytes for dense mass leaving the remainder of the cell as an
those laboratories that do not have these advanced empty membrane.
analysers. An abnormal RDW or red cell histogram The recommendation is to grade blister cells.
that suggests the presence of microcytes even though
the MCV is normal may also prompt slide review
Echinocytes (burr cell)
and grading of microcytes by visual microscopic
examination. Supplementary image S4.
Echinocytes are red cells that have lost their disc
shape and are covered with 10-30 short blunt projec-
Polychromasia
tions or spicules of fairly regular form.
Polychromasia refers to immature red cells that are The recommendation is to grade echinocytes.
pinkish blue-grey in appearance due to residual ribo-
somal RNA. They are larger in size than normal
Elliptocytes and ovalocytes
mature red cells.
The recommendation is to grade polychromasia Supplementary image S5.
and perform a reticulocyte count if necessary. Elliptocytes are cells with an elliptical shape (the
long axis is more than twice the short axis), while
ovalocytes have an oval shape (the long axis is less
Abnormalities of RBC shape
than twice the short axis). The recommendation is to
grade elliptocytes and ovalocytes.
Acanthocytes (spur cell)
Supplementary image S1.
Irregularly contracted cells
Acanthocytes are round, hyperchromic red
cells with 2-20 irregularly spaced projections or Supplementary image S6.
spicules of variable length, thickness and shape. Irregularly contracted cells are smaller and denser
Some spicules have club-shaped rather than pointed RBC which lack an area of central pallor but are not
ends. as regular in shape as spherocytes.
The recommendation is to grade acanthocytosis. The recommendation is to grade irregularly con-
tracted cells.
Bite cells
Poikilocyte
Supplementary image S2.
Bite cells are RBC with peripheral single or multi- A poikilocyte is a red cell of abnormal shape. Poikilo-
ple arcuate defects (bites) caused by the removal of cytosis is a non-specific abnormality but poikilocytes
Heinz bodies by the spleen and are a feature of oxi- of specific shapes may be associated with a particular
dant haemolysis. Microangiopathic haemolytic anae- disorder e.g. elliptocytes in hereditary elliptocytosis.
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The recommendation is to report the abnormal spe- the stomatocytes may have two stomas per cell which
cific cell shape rather than use poikilocytosis. may be longitudinal, transverse, V or Y shaped.
The recommendation is to grade stomatocytes.
Schistocyte
Target cells
Supplementary image S7.
Schistocytes are fragments of red blood cells pro- Supplementary image S11.
duced by extrinsic mechanical damage within the circu- Target cells are thin cells with an increased surface
lation and are a diagnostic feature of microangiopathic area to volume ratio that have an area of increased
haemolytic anaemia (MAHA). Schistocytes are always staining which appears in the middle of the area of
smaller than intact red cells and can have the shape of central pallor.
fragments with sharp angles and straight borders, small The recommendation is to grade target cells.
crescents, helmet cells or keratocytes. Microspherocytes
may also be a feature of MAHA [7].
Teardrop cells
The recommendation is to grade schistocytes. A
schistocyte count may be of value when schistocytes Supplementary image S12.
are the dominant feature ( polychromasia, NRBC, Teardrop cells are red cells that are pear or teardrop
thrombocytopenia) for the diagnosis and follow-up of in shape.
MAHA. The recommendation is to grade teardrop cells.
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Metamyelocyte Basophil
The metamyelocyte is smaller than the myelocyte A basophil is 1016 lm in diameter with pale blue
with an indented or kidney-shaped nucleus. Nucleoli cytoplasm containing purple-black secondary gran-
are not observed. The cytoplasm is usually clearly ules. These granules are water soluble and may dis-
pink and contains granules that are clearly differenti- solve on staining leaving clear areas in the cytoplasm.
ated as neutrophilic, eosinophilic or basophilic. The nucleus is segmented but is often obscured by
N.B. Immature granulocytes (promyelocytes, myel- basophilic granules which may vary in number, size
ocytes and metamyelocytes) are not usually seen in and shape.
normal peripheral blood.
Monocyte
Band neutrophil
Monocytes are the largest cell in the peripheral blood,
Band neutrophils are 1014 lm in diameter and have variable in size but usually 1522 lm in diameter.
a nucleus that is nonsegmented or has rudimentary The nucleus is irregular in outline (often kidney
lobes that are connected by a thick band rather than a shaped), and the chromatin is arranged in fine strands
thread. Cytoplasm is abundant, pink and contains with sharply defined margins. The cytoplasm is light
many small violet-pink neutrophilic or secondary blue-grey and contains numerous fine dust-like gran-
granules distributed evenly throughout the cell. ules. Some cells may contain a small number of red-
Many laboratories do not report band neutrophils violet granules. Vacuolation may be present.
on adult patients or children due to interobserver var-
iation in band neutrophil classification; this is a well
Normal lymphocyte development and morphology
recognized and acceptable practice.
It is recommended that band neutrophils be
Lymphoblast
counted as segmented neutrophils in the differential.
Appropriate comments may be made if increased The lymphoblast has a diameter of 820 lm. The
numbers are seen in the blood film. nucleus is round or oval with fine granular chromatin
and one or more indistinct nucleoli. The cytoplasm is
scanty and basophilic, and cytoplasmic granules are
Segmented neutrophil
absent. It cannot be reliably distinguished from some
A granulocyte that is 1014 lm in diameter with a types of undifferentiated or minimally differentiated
lobulated nucleus (usually 34 lobes, but small myeloblasts and therefore should be counted as a blast
numbers of 2 and 5 lobed neutrophils may also be cell.
seen) connected by a thin thread of chromatin. The
chromatin is coarse, stains violet and is arranged in
Prolymphocyte
clumps. Small nuclear appendages may be seen. There
is abundant pink cytoplasm with many small second- The nucleus is round and contains a single prominent
ary granules. nucleolus. It has more cytoplasm than a lymphoblast
and the chromatin is more condensed.
N.B. Lymphoblasts and prolymphocytes are not
Eosinophil
usually seen in the normal peripheral blood.
The diameter of the eosinophil is 1217 lm. The
nucleus usually only has 2 lobes with coarsely
Lymphocyte
clumped, violet-staining chromatin. There is abundant
cytoplasm containing many eosinophilic (orange) sec- Lymphocytes seen in the peripheral blood are pre-
ondary granules that are larger than neutrophil gran- dominantly small (1012 lm), or, less frequently large
ules and more uniform in size. (1216 lm).
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Small lymphocytes are usually round in outline, Each laboratory should establish their own refer-
and the nucleus is round with coarse, densely staining ence ranges as these will vary depending on popula-
chromatin. Cytoplasm is scanty. tion, laboratory, instrumentation and methods used.
Large lymphocytes are usually irregular in outline, It is recommended that the automated analyser
and the nuclear chromatin is not as coarse as in small WBC differential count be reported in patients with
lymphocytes. Cytoplasm is abundant and tends to be normal cell populations in the absence of analyser flags
light sky blue in colour. or abnormal cell populations that cannot be reliably dif-
Large granular lymphocytes (LGLs) are of the same ferentiated and classified by automated instruments.
appearance as large lymphocytes but the cytoplasm The automated differential may also be reported after
contains prominent small red-violet granules. These viewing a blood film due to flags or other indicators
cells can comprise up to 1020% of the peripheral where the automated values are found to be accurate.
blood lymphocytes in normal subjects. LGLs are not
routinely counted as a separate lymphocyte popula-
Qualitative abnormalities in myeloid cells
tion.
Supplementary image S17.
Cytoplasmic abnormalities
It is recommended that LGLs be counted as lym-
phocytes but may be commented on if they are pres- Auer rod. Supplementary image S18.
ent in increased numbers. This may prompt further A sharply defined red rod or needle-like cytoplas-
investigations such as flow cytometry. mic inclusion formed by abnormal primary granule
N.B. Lymphocytes predominate in the blood films development. Found mainly in leukaemic myeloblasts
of infants and children until 4 years of age. These or abnormal promyelocytes, they stain positively for
lymphocytes are more pleomorphic than those seen in myeloperoxidase and are a specific marker for myeloid
normal adult blood films. lineage neoplasms. There may be several in a cell and
may be arranged in bundles (faggots).
The recommendation is to report the presence of
Quantitative abnormalities
Auer rods when seen.
Neutrophilia, neutropenia, lymphocytosis, lymphope-
nia, monocytosis, monocytopenia, eosinophilia, eosin- Dohle body. Pale light blue or grey, single or multiple,
openia, basophilia, basopenia. cytoplasmic inclusions found near the periphery of
WBC differential counts can be performed by auto- the neutrophil. D ohle bodies are a non-specific
mated analysers or manual microscopic visual exami- reactive change but may also indicate May-Hegglin
nation of a blood film. Automated analysers use anomaly if associated with thrombocytopenia and
multiple parameters and methods such as impedance giant platelets. D
ohle bodies may also be seen in
technology and fluorescence flow cytometry to differ- patients on growth factor therapy such as granulocyte
entiate and count the 5 major white cell types found colony-stimulating factor (G-CSF).
in the peripheral blood neutrophils, lymphocytes, The recommendation is to grade D ohle bodies
monocytes, eosinophils and basophils. Many modern when seen.
analysers also now provide a 6 part differential with
the enumeration of immature granulocytes (promyel- Hypergranulation neutrophil, (toxic granulation).
ocytes, myelocytes and metamyelocytes). Supplementary image S19.
The automated WBC differential count is less time- Coarse, purple staining primary (azurophilic) neu-
consuming and expensive than the manual method trophil cytoplasmic granules which occur as a
and as an analyser counts thousands of cells compared response to infection and inflammation. A non-spe-
to the usual 100200 WBC by the microscopic cific reactive change, it is a result of abnormal primary
method, it will also be more precise in the absence of granule maturation with retention of their azurophilic
abnormal cell populations. Very low or high white cell staining properties.
counts may also cause the manual differential to be The recommendation is to grade hypergranulation
less accurate and reproducible. when seen.
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L. PALMER ET AL. | NOMENCLATURE AND GRADING OF PERIPHERAL BLOOD CELL MORPHOLOGY 299
tinctive morphology and confirmed by immunophe- cytes and some cells may appear blastic with cleft
notyping), and plasma cells in plasma cell myeloma or or irregular nuclei and a prominent nucleolus.
other plasma cell dyscrasias be included in the differ- Burkitt lymphoma These lymphoma cells are
ential as that cell class. Other abnormal lymphoid cells large with dispersed nuclear chromatin, one or
can be described in the film comment and counted as more prominent nucleoli and moderately abun-
a separate population of abnormal lymphocytes in dant, deeply basophilic and vacuolated cytoplasm.
the differential if present in significant numbers. Sezary syndrome S ezary syndrome is a mature T-
The use of this nomenclature underlines the limited cell lymphoma with neoplastic T lymphocytes in
diagnostic value of morphology in the lymphoprolifer- the peripheral blood. The cells are present in vari-
ative neoplasms where the final diagnosis is deter- able numbers ranging from a few cells to a frankly
mined by immunophenotyping by flow cytometry. leukaemic picture with a marked leucocytosis. The
cells may be large or small but the nuclear mor-
Hairy cells phology, classically described as cerebriform, is the
characteristic cytological feature of both cell types.
Supplementary image S28. The nucleus has deep narrow clefts with superim-
Hairy cell leukaemia is a chronic B cell lineage leu- posed and folded lobes giving it a very convoluted
kaemia with morphologically distinctive neoplastic appearance.
cells. Hairy cells are larger than normal lymphocytes Adult T-cell leukaemia/lymphoma (ATLL) ATLL
and have abundant pale blue-grey cytoplasm with is characterized by a broad spectrum of cytological
fine hair-like projections. The nucleus varies in shape features but the characteristic ATLL cells have been
and may be round, oval, bean-shaped or bilobed. described as flower cells with many nuclear con-
It is recommended that hairy cells are counted as volutions and lobules.
abnormal lymphocytes on first presentation with a It is recommended that lymphoma cells are
detailed description of the cells included in the film counted as abnormal lymphocytes on first presenta-
comment. After immunophenotyping, the cells may tion with a detailed description of the cells included
be counted as hairy cells in the WBC differential. in the film comment. After immunophenotyping,
the cells may be counted as lymphoma cells in the
Lymphoma cells WBC differential.
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L. PALMER ET AL. | NOMENCLATURE AND GRADING OF PERIPHERAL BLOOD CELL MORPHOLOGY 301
electron microscopy. The cytoplasm is weakly baso- Peripheral Blood Cell Morphology Nomenclature and
philic. Cytoplasmic vacuolation and variable numbers Reporting in accordance with the basic aim of the ICSH
of granules may be present, and there may also be to achieve reliable and reproducible results in laboratory
small cytoplasmic protrusions or blebs. Platelets may analysis and, in particular, diagnostic haematology. The
appear to be budding from the surface. existence of traditional and geographical differences in
It is recommended that a comment about the pres- nomenclature is recognized and accepted, thus favouring
ence of megakaryoblasts, megakaryocytes and micro- some flexibility in the suggested methods of reporting for
megakaryocytes be made if seen in the PB film. a number of parameters.
Links for examples of cells discussed. (i) http://
www.morphology.mmu.ac.uk, (ii) www.icsh.org.
CONCLUSION
These recommendations deal with the need for a glo-
AC K N OW L E D G E M E N T S
bal standard in naming, grading and reporting abnor-
mal cells or morphological abnormalities which are We would like to thank the Morphology Workshop
observed at the time of the PB film review and man- Sponsors: Abbott Diagnostics, Beckman Coulter, Hori-
ual differential count. ba Medical Diagnostics, Mindray, Nihon Kohden, Sie-
Their primary goal is to produce clear guidelines mens, Sysmex Corporation. We would like to thank
for scientists who perform analysis of haematology John Burthem and Michelle Brereton at Central
samples. This issue is becoming more important as Manchester and Manchester Childrens University
hospitals and laboratories join with others, forming Hospital, UK for compiling the images. Images have
large hospital and laboratory systems, with physicians been provided by John Burthem, Michelle Brereton,
practicing at multiple sites and with patients able to Gina Zini and Gillian Rozenberg. Gillian Rozenbergs
gain access to the healthcare system from multiple images have been reproduced by permission from
sites. There are also laboratories which are crossing Elsevier Australia from Gillian Rozenberg; Microscopic
international borders. Laboratory services can now haematology: a practical guide for the laboratory 3e
span multiple countries. The need for consistent 2011, Sydney, Elsevier Australia.
nomenclature and appropriate grading standards are
therefore more important than ever.
CONFLICT OF INTEREST
This document is the result of an exhaustive and com-
prehensive review, analysis and consensus agreement by All authors declare that they have no conflict of inter-
the ICSH ad hoc Committee on Standardization of ests.
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APPENDIX
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