LECTURE 1 & 2 (FINALS) HEMATOLOGY 1

Lecturer: Prof. Sherryl Manzon, RMT, MPH

RBC DISORDERS AND MORPHOLOGY B. Pyruvate Kinase Deficiency (PKD)

1. Pathophysiology
C. Pyrimidine-5’-Nucleotidase Deficiency
TOPIC OUTLINE X. RBC Morphology
I. Introduction A. RBC Distribution
A. Erythropoiesis 1. Normal distribution
B. Hematological Parameters 2. Abnormal Distribution
II. Polycythemia a) Rouleaux Formation
A. Absolute Polycythemia b) Agglutination
B. Relative Polycythemia B. RBC - Size
C. Signs and Symptoms a) Normocytes
D. Laboratory Findings b) Microcytes
III. Anemia c) Macrocytes
A. Signs and Symptoms C. RBC - Variation in Color
B. Laboratory Detection Tests a) Hyperchromic Cells
C. Classification of Anemia: According to b) Polychromatophilic
Cause Erythrocytes
1. Decreased or Impaired Production D. RBC - Variation in Shape
2. Increased RBC Destruction a) Spherocyte
(Hemolysis Anemia) b) Stomacyte
3. Blood Loss (Hemorrhage Anemia) c) Acanthocyte
D. Classification of Anemia: According to d) Burr Cell
Morphology e) Ovalocytes
1. Microcytic Hyperchromic f) Elliptocyte
2. Macrocytic Normochromic g) Dacrocyte
3. Normocytic Normochromic h) Schistocyte
IV. Abnormal Red Cell Membrane i) Drepanocyte
A. Hereditary Spherocytosis j) Leptocyte
B. Hereditary Elliptocytosis k) Bite Cell
V. Autoimmune Hemolytic Anemia XI. RBC Inclusion Bodies
A. Cold Agglutinin Syndrome (CAS) A. Basophilic Stippling
B. Paroxysmal Cold Hemoglobinuria (PCH) B. Sideroblastic Granules
VI. Abnormal Hemoglobins C. Howell-Jolly Bodies
VII. Hemoglobinopathy D. Cabor RIngs
A. Beta - Hemoglobinopathies E. Heinz Bodies
1. Homozygous B-Hemoglobinopathy F. Hemoglobin H Inclusion Bodies
2. Heterozygous G. Parasite
B-Hemoglobinopathy XII. Classification of Anemia
B. Examples of Hemoglobinopathy A. Microcytic, Hypochromic Anemia
1. Sickle Cell Anemia B. Normocytic, Normochromic Anemia
2. Hb C C. Macrocytic, Normochromic Anemia
3. Other Hemoglobin Variants LEGENDS
VIII. Thalassemia
I. BLACK TEXT - From Discussion/PPT
A. Alpha Thalassemia
I. RED TEXT - Additional Information from the Book
1. Silent Carrier State
II. VIOLET TEXT - Additional Information from the Manual
2. α-thalassemia Trait
III. BLUE TEXT - Disease Associated/Diagnosis
3. Hemoglobin H Disease
4. Hemoglobin Bart Hydrops Fetalis
Syndrome INTRODUCTION
B. Beta Thalassemia
1. β-thalassemia Silent Carrier State - Anemia - lower than normal number of RBC or reduced
2. β-thalassemia Trait/Minor Hgb
3. β-thalassemia Major - Deficiency in RBCs leading to oxygen-carrying
4. β-thalassemia Intermedia capacity problems
IX. Red Cell Enzymopathy
- Polycythemia - elevated RBCs in the bloodstream
A. Glucose-6-Phosphaste Dehydrogenase
(G6PD) Deficiency - Excess RBCs resulting in increased blood
1. Pentose Phosphate Pathway viscosity and related complications
2. Oxidative Stress - Both conditions involve imbalance in RBC
3. 2 Main variants of G6PD
Deficiency
a) African Variant
b) Mediterranean Variant
4. Laboratory Findings

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

ERYTHROPOIESIS INCREASED POLYCYTHEMIA

- Hemoglobin
- Hematocrit
- RBC count
DECREASED ANEMIA
- Hemoglobin
- Hematocrit
- RBC count

● These factors may cause false increase/decrease

leading to false interpretation due to technical errors or
physiological response

RELATIVE - false increase of Hgb and Hct

ABSOLUTE - true increase of Hgb and Hct

- Production of RBC in the body that takes place in the red POLYCYTHEMIA
bone marrow, ensuring that the body’s oxygen-carrying
capacity is sufficient - A condition characterized by an elevated number of RBC
- Destruction can lead to Anemia or in the bloodstream
Polycythemia 1. Absolute Polycythemia (True)
a. Primary Polycythemia
1. Hematopoietic stem cells (multipotent cells in the BM) b. Secondary Polycythemia
have the ability to differentiate into various blood cells 2. Relative Polycythemia (False)

2. Hematopoietic stem cells differentiate to proerythroblast 1. ABSOLUTE POLYCYTHEMIA

under the influence of erythropoietin
- Erythropoietin - primarily produced by the Absolute Polycythemia (True)
kidney in response to low oxygen in the blood - True increase in the number of RBC wherein the bone
marrow produces too many RBC leading to higher Hct
3. Proerythroblast becomes erythroblast - cell begins to and Hgb levels
accumulate Hgb a. Primary Polycythemia
- Hgb protein that enables RBC to carry oxygen b. Secondary Polycythemia
- As erythroblast mature, the nucleus shrinks and
is eventually expelled from the cell PRIMARY POLYCYTHEMIA SECONDARY
- Polycythemia Vera - Occurs in response to
4. Reticulocytes are formed containing some residual - JAK2 V617 mutation external factors:
organelles and ribosomes, and released to the ❖ High altitude
❖ Chronic Lung Disease
bloodstream circulating for 1-2 days
(Emphysema, COPD)
❖ Heart Disease (CHD)
5. Reticulocytes lose their remaining organelles and mature ❖ Smoking (constant
into fully functional biconcave RBCs exposure to CO2)
❖ Erythropoitein-producing
6. Mature RBCs are released in the bloodstream daily for tumors
about 120 days, carrying oxygen from the lungs to the
Primary Mechanism: Body’s
body tissues and returning carbon dioxide to the lungs for
attempt to increase the
exhalation oxygen-carrying capacity in
response to low-oxygen level
HEMATOLOGICAL PARAMETERS
Happens if chronic (Hypoxia)
- In the initial diagnosis of RBC disorders, it is important to
take note of the
- Polycythemia Vera is a rare, chronic, myeloproliferative
- Medical history
disorder which the BM overproduces RBCs, WBCs, and
- Physical examination
Platelets even in the absence of body’s normal regulatory
- Signs and symptoms of the patient
signals resulting to a true increase of RBC number
- CBC. PBC, and other hematological
- It is often caused by a mutation of JAK2 gene,
examinations
specifically the JAK2 V617 mutation

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- JAK2 gene stands for “Janus Kinase 2” - a gene that

provides instructions for producing kinase LABORATORY FINDINGS
- JAK2 V617F mutation - characterized by a single point
mutation in which the amino acid Valine is replaced by 1. High blood count (Overpopulation)
Phenylalanine (F) at position 617 of the JAK2 2. Low ferritin
3. Decreased ESR
2. RELATIVE POLYCYTHEMIA - RBC number is inversely proportional to the
ESR value
Relative Polycythemia (False) - High RBC count = Low ESR
- The increase in RBC concentration is due to a false 4. High LDH
increase in the number of RBC 5. Hyperuricemia
- The actual number of RBCs is NOT ELEVATED but Hct 6. High Vitamin B12
level is elevated 7. Low EPO
- Result of a decrease in plasma volume due to 8. Hyperplastic BM
dehydration and other functions
- Also known as “Stress Polycythemia or Gaisbock
Syndrome” ANEMIA
- Causes: (All leading to DECREASED plasma volume)
1. Dehydration - Condition characterized by RBC deficiency or a reduced
- Sweating amount of Hemoglobin in the blood
2. Fluid Loss - The decreased ability of blood to carry oxygen
- Diarrhea, vomiting, severe bleeding
3. Burns
4. Diuretic use
- Those with conditions like
hypertension and heart failure with
increased urine output leading to
dehydration
5. Alcohol and Smoking
6. Prolonged application of tourniquet
- Can temporarily obstruct the blood
flow
- (ALL leading to DECREASED plasma volume and
INCREASED RBC concentration)

SIGNS AND SYMPTOMS

SIGNS AND SYMPTOMS
1. Hyperviscosity of the blood
- Once blood is too viscous, prone to clot 1. Fatigue
formation leading to conditions like Deep Vein 2. Pale skin
Thrombosis or Pulmonary Embolism 3. Shortness of breath
- Once blood is increased in viscosity = - The body struggles to get enough oxygen to the
impairment of blood flow in the circulatory muscles and tissues
system leads to inadequate supply of oxygen 4. Weakness
- Spleen can enlarge contributing to - Muscle fatigue and lack of physical stamina
sequestration (trapping of RBCs) 5. Dizziness and Lightheadedness
- Blurred vision or Retinal Vein Thrombosis - Drop in blood pressure
- Headaches and Neurological symptoms - 6. Headache
difficulty in concentrating or confusion or altered - Insufficient supply of oxygen to the brain
mental status = increased thickness of the 7. Cold Hands and Feet
blood - Due to poor circulation
2. Itching or pruritus 8. Chest Pain
- Pruritus - after exposure to hot water, related to 9. Cognitive and Concentration Problems
hyperviscosity 10. Brittle Nails
3. Gouty arthritis 11. Pale or Yellowish Conjunctive
4. Burning pain in the hand accompanied by reddish and 12. Pica
bluish coloration of the hand

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- Eating disorder; consumption of non-nutritive be determined by performing Stained-Prussian

and non-food substances like soap, clay etc. Blue Iron Stain
- More common in children and pregnant women
6. BILIRUBIN
LABORATORY DETECTION TESTS - Indicates increased destructions of RBC found
in Hemolytic Anemias
1. CBC - High Bilirubin = Increased RBC destruction
- Hgb, Hct, RBC Ct. - DECREASED
- Initial and most common test to diagnose 7. SERUM LDH
anemia which tests various blood components - Increased level indicates Hemolytic Anemias
- Using MCV ratio - Microcytic, Normocytic, or and in some cases, ineffective erythropoiesis
Macrocytic based on RBC size such as Megaloblastic Anemia
- Using MCH & MCHC - Determine average - Less specific
amount of concentration of Hgb
CLASSIFICATION OF ANEMIA: ACCORDING TO CAUSE
2. PBS
-Visual inspection of size, shape and 1. DECREASED OR IMPAIRED PRODUCTION OF RBC
appearance of RBCs
- Used to differentiate kinds of Anemia A. Bone Marrow Disorders
3. RETIC COUNT - Aplastic Anemia & Myelodysplastic
- Increased retic count = Increased RBC Syndrome
destruction and blood loss - Characterized by Abnormal Bone
- Assessment of bone marrow’s response to Marrow Function leading to ineffective
Anemia by measuring young & immature RBCs RBC production
- Uses Reticulocyte Production Index Test - a B. Nutritional Deficiencies
relatively accurate reflection of effective RBC - Iron-deficiency Anemia & Folate-Deficiency
production in the bone marrow - Inadequate volume; hinders the
- In cases where defective Hgb synthesis, synthesis of DNA in the RBC
replacement of normal marrow by tumors, precursor reading to Megaloblastic
failure of BM to produce normal cells = Anemia
decreased reticulocyte count C. Decreased Erythropoietin
- Increased reticulocyte count = indicative of - Hormonal balances or conditions affecting the
Anemia - increased RBC destruction or blood endocrine system, that interferes the body’s
loss ability to produce RBC
D. Defect in Globin Synthesis
4. IRON STUDIES - Inherited conditions such as Thalassemia,
- Serum Iron Sickle-cell Anemia, Congenital
- Measures amount of Iron in blood Ayserythropoietic Anemia resulting in
- Total Binding Capacity (TIBC) impaired RBC production
- Assess blood's capacity to bind to iron E. Iron Overload
- Transferrin Saturation F. Ineffective Erythropoiesis
- Dividing the serum iron by TIBC and
indicates how much the iron is bound 2. INCREASED RBC DESTRUCTION (HEMOLYSIS ANEMIA)
to transferrin
- Serum Ferritin A. Intrinsic defects within the RBC
- Measures the body’s iron stores - Involves factors within the RBC that cause it to
be destructed
5. BONE MARROW EXAM - Common cause: Hemoglobinopathies, Enzyme
- Normal: 20-35% NRBC are erythroid Deficiency, and Membrane Disorders
- Myeloid: Erythroid ration (M:E) = 4:1
- When bone marrow biopsies are performed, an B. Extrinsic defects within the RBC
iron stain must be done on a marrow - Can be caused by certain factors such as
concentrate smear to determine the percentage Auto-immune Hemolytic Anemia
of Sideroblasts - Immune system mistakenly produce
- Presence/absence of Ring Sideroblasts must antibodies that attack and destruct
be noted and an estimation of Iron Stores may RBCs that can be:
- Idiopathic: Unknown Cause

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- Secondary to conditions like 2. Decreased Retic

Lupus or Lymphoma a. Hyperproliferative Anemia
- Can be caused by infections that directly b. Myelopathic Anemia
damages the RBC or triggering an Immune
response against them 3. Hemoglobinopathies
- Exposure to certain drugs, chemicals and a. Renal and Endocrine Disease
toxins can lead to RBC destruction b. Paroxysmal Nocturnal Hemoglobinuria
- Mechanical factors: Heart-valve abnormalities,
Microangiopathic Hemolytic Anemia
C. Non-immune, Acquired Hemolytic Anemia ABNORMAL RED CELL MEMBRANE
D. Immune Hemolytic Anemia
- Due to various conditions including Hereditary disorders
3. BLOOD LOSS (HEMORRHAGE ANEMIA) including Hereditary Spherocytosis, Hereditary
Elliptocytosis, and other acquired conditions like
- Occurs when there is a significant loss of blood leading Autoimmune Hemolytic Anemia
to reduction in the number of RBCs and decrease Hgb
- Results from Acute and Chronic bleeding 1, HEREDITARY SPHEROCYTOSIS
- Acute bleeding: Injurise, SUrgeries, and Gastrointestinal
Bleedings such as Ulcers and Bleeding Disorders Inheritance Pattern:
- Chronic bleeding: Found in conductions such as ● Autosomal Dominant
Inflammatory disease and Bowel disease, heavy
menstrual period and certain types of cancers Deficient Proteins:
● Ankyrin
CLASSIFICATION OF ANEMIA: ACCORDING ● Band 3
TO MORPHOLOGY ● Alpha-spectrin
● Beta-spectrin
1. MICROCYTIC HYPERHROMIC (<80 fl.) ● Protein 4.2
● RBCs are smaller than normal; decrease in MCV
Pathophysiology and Principle:
“TAILS”: ● Defects in proteins that disturbs vertical membrane
1. Thalassemia interactions between transmembrane proteins and
2. Anemia of Chronic Disease underlying cytoskeleton, loss of membrane and
3. Iron-deficiency Anemia decreased surface area-to-volume ratio
4. Lead Poisoning ● RBCs are abnormally permeable to sodium
5. Sideroblastic Anemia ● If there is a deficiency in alpha-spectrin and
beta-spectrin, biconcave disk shaped can’t be achieved
2. MACROCYTIC NORMOCHROMIC (>100 fl.) ● Cell becomes spherical and more fragile leading to their
● RBCs are larger than normal, increase in MCV premature destruction in the spleen
● In a hypotonic solution, the water tends to enter the RBC
1. Megaloblastic Anemia through osmosis and normally, it would swell
a. Vitamin B12 Deficiency ● In Hereditary Spherocytosis, RBCs have a reduced
b. Folic Acid Deficiency surface area and spherical shape that becomes
c. Pernicious Anemia challenging to accommodate the influx of water causing
them to swell and potentially burst in the hypotonic
2. Non-Megaloblastic Anemia environment
a. Hypo proliferative Anemia ○ Natural environment in the spleen: Low pH,
b. Refractory Anemia Low ATP, Low Glucose
c. Liver Disease ○ It swells then bursts, osmotic environment can’t
d. Hemolytic Anemia be tolerated
e. Acute Blood Loss Anemia
Laboratory Findings:
3. NORMOCYTIC NORMOCHROMIC (80-10 fl.) 1. An INCREASE in the MHCH value between 35-39 g/dL
● RBCs of normal size, MCV at normal range (Normal range: 31-37 g/dL)
1. Increased Retic ● Make sure to check if it is only false increase
a. Acute Blood Loss Anemia 2. Peripheral blood morphology: Spherocytes, NRBC
b. Hemolytic Anemia

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

2. HEREDITARY ELLIPTOCYTOSIS 2. PAROXYSMAL COLD HEMOGLOBINURIA (PCH)

● Body also produces antibodies that bind to RBCs and cause
Inheritance Pattern: them to be destroyed at cold temperatures
● Autosomal Dominant ● Secondary to viral infections such as Epstein-Barr virus
(EBV)
Deficient Proteins:
● Alpha-spectrin
● Beta-spectrin ABNORMAL HEMOGLOBINS
● Protein 4.2
HEMOGLOBIN
Pathophysiology and Principle: - protein found in the RBCs that transfers oxygen from the
● Defects in proteins that disturbs horizontal membrane lungs to various tissues and organs; and carries carbon
interactions linkages in the cytoskeleton dioxide back to the lungs for exhalation
● Loss of mechanical stability of membrane
● RBCs are abnormally permeable to sodium 1. HEME (FERROPROTOPORPHYRIN X)
● Reduces the cells’ flexibility making it prone to rupture - Porphyrias
● In hypotonic solution, more rigid and less flexible than - Defective heme synthesis
normal thus when they take in excess water, they - Diseases characterized by impaired
become more distended and undergoes hemolysis or production of heme
fragmentation (but less severe than H. spherocytosis)
● Relatively more stable in osmotic environment compared 2. GLOBIN
to H. spherocytosis - Hemoglobinopathies
● Less prone to hemolysis in both isotonic or hypotonic - Qualitative Globin Synthesis defect
solution.
- Thalassemias
Laboratory Findings: - Quantitative Globin Sytnehsis defect
1. Peripheral blood morphology: Elliptocytes
2. RBC indices: Normocytic, Normochromic
HEMOGLOBINOPATHY

AUTOIMMUNE HEMOLYTIC ANEMIA HEMOGLOBIN - Hb molecule

OPATHY - disease state
Pathophysiology:
- Patient develops antibodies against their own RBCs - collection of diseases where there is a point mutation or
- The immune system mistakenly recognizes the body’s amino acid substitution within the globin molecule
own RBCs are foreign invaders and destroys them - Qualitative Problem on the Globin chains
- AIHA is divided into warm and cold types
- Warm AIHA is the most common type and serological 2 CATEGORIES:
activity is optimal at 37 degrees celsius 1. Qualitative
- Associated with Systemic Lupus - Structural defects in Hb molecule
Erythematosus and other Lympho-proliferative - Ex: Hemoglobinopathies
disorders
- Cold AIHA serological activity is 4 degrees celsius 2. Quantitative
- Associated with Infectious Mononucleosis and - Imbalance in the number of globin chain
other Lympho-proliferative disorders - Thalassemia

2 Types of Cold AIHA: MAJOR GROUPS OF HEMOGLOBINOPATHIES

1. COLD AGGLUTININ SYNDROME (CAS) 1. Alpha-hemoglobinopathies

● The immune system produces cold agglutinins that bind to 2. Beta-hemoglobinopathies
the RBC at low temperature - Most frequently occurring
● These antibodies cause the RBC to clump together and be - Directly affects HbA1
destroyed 3. Gamma-hemoglobinopathies
● Can be primarily idiopathic or secondary to underlying 4. Delta-hemoglobinopathies
conditions like Mycoplasma Pneumonia or Systemic lupus
erythematosus

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

FORMS OF HEMOGLOBIN ● The insolubility of deoxygenated Hb S causes teh

molecule to polymerize into rigid aggregates and assume
HbA1 ● 2 Alpha and 2 Beta a crescent or sickle shape
● Most predominant adult Hgb
HbA2 ● 2 Alpha and 2 Delta
HbF ● 2 Alpha and 2 Gamma

REMEMBER!!: The name of Hemoglobinopathies is the basis of

the globin chain affected
● HgbA1 is made up of 2 alpha chain and 2 beta chain
BETA-HEMOGLOBINOPATHIES ○ 2 beta chain is made up of 146 amino acids
○ On its 6th position of the Beta chain, Glutamic
1. HOMOZYGOUS B-HEMOGLOBINOPATHIES Acid is replaced by Valine
- Both B-genes are mutated
- HbA1 is absent - replaced by predominant Hb Laboratory Findings
- Abnormal Hb becomes predominant Hb type ● Peripheral blood morphology: Marked sickle cells
- EXAMPLES: (Drepanocytes), nRBCs, Polychromasia, Pokilocytosis,
- Sickle Cell Disease Anisocytosis and Macrocytes
- Genotypes: Hb SS ● Howell-Jolly bodies and Pappenheimer bodies
- Hb C Disease ● Bone marrow: Erythroid hyperplasia
- Genotypes: Hb CC ● Indices: MCV = Normal; MCH = Normal; RDW =
Increased
S and C in their genotype are represented by the B-genes ● Reticulocyte count: Increased (5% - 20%)
!! BETA GENES - genes that make us create the Beta globulins
necessary for the construction of HbA1
- They have ABNORMAL Beta genes
- Inherited from the parents - BOTH abnormal

2. HETEROZYGOUS B-HEMOGLOBINOPATHIES
- One B-gene: Normal
- Other B-genes: Mutated
- HbA1 >= abnormal Hb
- HbA1 is more abundant, or sometimes equal in Clinical Features:
amount with the abnormal Hb ● Severe Chronic Hemolytic Anemia throughout life
EXAMPLES: ● Vaso-occlusive crises due tot he blockage of trapped
- Sickle Cell Trait sickle cells
- Genotype: Hb AS ○ RBC gets stuck to capillaries - Vaso-occlusion
- A represents the normal B-gene ● Recurrent and painful attacks
- S represents the mutated B gene ● Organ damage, cerebral vascular accidents and
- HB C Trait deteriotration of tissues
- Genotype: Hb AC ● Acute Chest Syndrome
- A represent the normal B gene ● Bacterial Infections
- C represent the mutated B gene ● Retinopathy
● Short life-expectancy
EXAMPLES OF HEMOGLOBINOPATHY
Test for Hemoglobin S:
1. SICKLE CELL ANEMIA
1. Sodium Metabisulfite Method:
Pathophysiology:
● Hb S is formed when Glutamic Acid is replaced by Valine Principle: Whole Blood is mixed with Sodium Metabisulfite, a
at the 6th position of the beta-chain reducing agent which deoxygenates hemoglobin
● When oxygenated, Hb S is fully soluble (normal shape)
● Sickling happens when O2 drops at the tissue level Positive result: Presence of Sickle cell or Holly leaf
● Causes polymerization of globin molecules triggered by - Hgb S crystallizes after deoxygenation
low oxygen tension, dehydration, and acidosis -

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

Negative result: Normal looking RBC or slightly creanted RBC ● Usually, blood periphery morphology of Hgb C has:
● Impossible to differentiate SC trait and anemia (SC ○ Microspherocytes
anemia - more rapid reaction) ○ Target cells
○ Folded RBCs
○ Intracellular Hgb C crystals

● RBC indices are normal

● Reticulocyte count has slight to moderate increase

2. Sodium Dithionite Tube Test

Principle: When RBC are added to the the Sodium Dithionite and
Saponin (hemolytic agent), the red cell immediately lyse

Positive result: Turbid solution

● Hgb S and sickling Hgb in a reduced state forms liquid OTHER HEMOGLOBIN VARIANTS
crystals resulting to Turbid solution
Hb E ● 3rd most common
Negative result: Clear solution ● Structural formula: a2B2
26th GLU-LYS
3. Hemoglobin Electrophoresis (Cellulose Acetate) Hgb O - Arab ● A2B 121 GLU-LYS
● Primary screening to detect variant Hgb Hgb C - Harlem or ● Two Amino Acid
Georgetown substitution
● In Alkaline buffer, Hgb is negatively charges but
● A2B2 6th Glu-Val; A2B2
during Electrophoresis, the Hgb molecule 73rd Asp-An
travels toward the anode because of their net Hgb Gun Hill ● Deletion of 5 amino acids
negative charge on B chain 91 - 95
● Difference between net charge defines its Hgb Constant Spring CS ● Elongation of the Alpha
mobility and reveals itself by the speed by Chain and Additional of 31
which it migrates to the positive pole Amino Acids

4. Hemoglobin Electrophoresis (Citrate Agar)

● Confirmatory Test for variant Hgb M HEMOGLOBINS
● Further differentiates Hgb S from D and G ;
Hb M - Saskatoon ● Associated with
Hgb C from Hgb E
Hb M - Milwaukee - 1 Methemoglobinemia
● Principle: Migration distance of different Hgbs and Cyanosis
Hb M - Milwaukee - 2
are based on Electrophretic charge to the
molecule and absorption to agar compound
ASSOCIATED WITH ASSOCIATED WITH
INCREASED OXYGEN DECREASED OXYGEN
2. Hb C AFFINITY AFFINITY
Hb Hiroshima Hb Agenogi
Pathophysiology: Hb Rainier Hb Beth Israel
● Glutamic acid on the 6th position of the beta chain is Hb Bethesda Hb Yoshizuka
replaced by Lysine
● Structural formula: A2B2 6th GLU-VAL
● The second most common abnormal Hemoglobin THALASSEMIA
● Two HB Crystals related to HB C:
- Quantitative globin synthesis defect
1. Hb SC crystals - 2 main types:
● Characteristic appearance: “Washington - Alpha thalassemia
Monument” - Beta thalassemia
● Found protruding in the RBC membrane
ALPHA THALASSEMIA
2. HB CC crystals
● Characteristic appearance: “Bar of Gold “ - Typically caused by a deletion of 1, 2, 3, or all 4 of the
● Found within the RBC membrane alpha globin chains

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- An inherited blood disorder that results from the mutation

in alpha globulin chains BETA THALASSEMIA
- Classified in various types or severity levels based on the
alpha globulin chains affected - Caused by a mutation that affect the β globin gene
- The number of affected genes determine the clinical complex
manifestation of the condition
Clinical Syndrome Examples of Remarks
Clinical Syndrome # of Genetype Remarks Genotypes
Deleted β-thalassemia silent βsilent / β Asymptomatic
Genes carrier state
Silent carrier state 1 of 4 (-α / αα) Asymptomatic
β-thalassemia trait B+ / β Asymptomatic; mild
(α-thalassemia) genes
Aka: β-thalassemia β0 / β hemolytic anemia,
α-thalassemia trait 2 of 4 (- - / αα) or Mild microcytic, microcytic
Aka: α-thalassemia genes (-α / -α) Hyperchromic MINOR
MINOR anemia Hypochromic RBCs
Hb H disease 3 of 4 (- - / - α) Microcytic, β-thalassemia B+ / β+ Most SEVERE form of beta
Abnormal Hb of 4 β genes Hypochromic B+ / β0B+ / β thalassemia
MAJOR
globin chains: fastest anemia β0 / β0
Aka: Cooley’s Anemia
migrating Hb Severe hemolytic anemia,
Hb Bart Hydrops 4 of 4 (--/--) Most SEVERE microcytic, hypochromic
Fetalis Syndrome genes form of alpha RBCs,
Aka: Hb Bart thalassemia transfusion-dependent
Syndrome or that causes β-thalassemia βsilent/βsilent MODERATE clinical
α-thalassemia MAJOR stillbirth/ Intermedia B+ / βsilent symptoms
hydropfetalis
B0 / βsilent
transfusion-dependent,
SILENT CARRIER STATE mild to moderate hemolytic
anemia, microcytic,
hypochromic RBCs
- Carrier of the mutation and don’t typically display any
symptoms
β THALASSEMIA SILENT CARRIER STATE
- They have 2 functional alpha globin genes and produced
sufficient alpha globin chains
- Genetic condition in which the individual carries a
mutation in one of the beta globin genes but no
α-THALASSEMIA TRAIT
symptoms
- It is called silent because the individual do not typically
- May have mild anemia
experience the symptoms associated with beta
- Conditions are often asymptomatic or associated with
thalassemia
mild symptoms
- They are generally healthy and may not be even aware
- Hgb levels are usually lower but not severe
of their carrier status unless they undergo screening or
testing
HEMOGLOBIN H DISEASE
- Presence of mutation can result in one beta globin chain
can result in reduced production of beta globin chains
- a.k.a. Alpha thalassemia intermedia
- Other normal beta globin gene can compensate for this
- Leads to moderate to severe anemia
deficiency = hemoglobin production and overall health is
- Symptoms are:
normal
- Pallor
- Jaundice
β THALASSEMIA TRAIT/ MINOR
- Enlarged spleen
- Often require medical attention, sometimes blood
- One normal beta gene, one affected gene resulting in
transfusion
MILD beta globin chain deficiency
- The individual has mild or no symptoms
HEMOGLOBIN BART HYDROPS FETALIS SYNDROME
- Slightly lower levels of hemoglobin
- Often discovered incidentally during routine blood tests
- The most severe form, all 4 alpha globin chains are
- Yung infected individuals ay asymptomatic and usually
deleted/non-functional
meron syang mild hemolytic anemia (microcytic,
- Can lead to severe fetal anemia and fluid accumulation in
hypochromic RBCs)
body cavity causing a life-threatening condition in utero
- Most of the individuals don’t survive beyond birth or they
need aggressive medical interventions

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

β THALASSEMIA MAJOR

- Both beta genes are affected = SEVERE deficiency of

beta globin genes
- Typically present in early childhood
- Causes:
- Responsibility ni G6PD enzyme na i-maintain yung
- Severe life-threatening anemia
adequate levels of NADPH sa loob ng red cell, kasi
- Poor growth
kapag deficient, walang NADPH na mapo-produce.
- Bone deformities
- Ang NADPH ang ginagamit para ma-convert yung
- Organ damage
glutathione in reduced form, so hindi maco-convert ito
- Need a life-long blood transfusion and need iron therapy
kung walang NADPH
- Without treatment = fatal
- Yung reduced glutathione will convert hydrogen peroxide
into water
β THALASSEMIA INTERMEDIA - If yung hydrogen peroxide hindi na-reduced into water, it
can cause formations of free radicals within the red cells,
- Characterized by 2 affected beta globin chains producing denatured hemoglobin = triggers oxidative
- Have a MODERATE reduction of beta globin chain stress
production = more pronounced anemia compared to beta - Eventually mag precipitate yung hemoglobin and is
thalassemia minor called Heinz Bodies
- They may experience symptoms such as: - mag-adhere sa red cell membrane
- Anemia - spontaneously removed by the macrophages of
- Jaundice the spleen na biglang magca-cause ng damage
- Enlarged spleen sa red cell membrane producing bite cells
- Severity can vary widely among individuals leading to acute hemolytic anemia
- Transfusion-dependent
- Moderate clinical symptoms, they can also be PENTOSE PHOSPHATE PATHWAY
characterized as mild to moderate hemolytic anemia
(microcytic, hypochromic RBCs)

RED CELL ENZYMOPATHY

- Group of genetic disorders that affect the enzymes within

the red blood cells
- These enzymes play a very crucial role in the metabolic
process within the red blood cells particularly in the
pathway responsible for generating energy and
maintaining the structural integrity
- One of the most well known is G6PD deficiency - First Step: The G6PD function in catalyzing the
- Another is Pyruvate Kinase deficiency and Hexokinase oxidation of glucose-6-phosphate → 6-phosphogluconate
deficiency while reducing the NADP → NADPH
- Treatments may involved managing symptoms such as
blood transfusions and medications - The G6PD is responsible for maintaining the adequate
- It may include avoiding triggers like certain levels of NADPH inside the cell
foods and drugs - NADPH is used to keep the glutathione in its reduced
form
- Reduced glutathione acts as scavenger for the
GLUCOSE-6-PHOSPHATE DEHYDROGENASE
dangerous oxidative metabolites in the cells
(G6PD) DEFICIENCY
- It converts harmful hydrogen peroxide to water
- There are other metabolic pathways that can generate
- Most common enzymopathy which cause non-immune
NADPH in all cells except in RBC where
hemolytic anemia
NADPH-producing enzymes are lacking
- G6PD enzyme is part of the Pentose Phosphate
Pathway
- G6PD enzyme prevents oxidative damage to red cells
- G6PD deficiency impairs the ability of the RBC to form
NADPH resulting in HEMOLYSIS

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

OXIDATIVE STRESS 7. Urine sample

- Positive with hemoglobin
- Can be caused by:
- Infections PYRUVATE KINASE DEFICIENCY (PKD)
- Drugs or chemicals
- Sulfa drugs - Autosomal recessive disorder of deficiency of pyruvate
- Streptomycin kinase enzyme, leading to hemolytic anemia
- Dilantin - Individuals can be:
- Dapsone - Heterozygous
- Exposure to mothballs - Homozygous - worse prognosis
- Fava beans
- 2nd most common RBC enzyme defect
2 MAIN VARIANTS OF G6PD DEFICIENCY - Most common cause of RBC enzyme-related hemolytic
anemia
1. AFRICAN VARIANT (MILD FORM) - Non-immune hemolytic anemia because it is a defect in
- MILDLY reduced half-life of G6PD an enzyme as opposed to immune system-mediated
- It can still produce NADPH but not as much destructions of the red cells
- Leads to mild intravascular hemolysis with oxidative
stress PATHOPHYSIOLOGY

2. MEDITERRANEAN VARIANT (SEVERE FORM) - Mutation in a gene known as PKLR gene

- MARKEDLY reduced half-life of G6PD - Encodes pyruvate kinase enzyme
- Leads to marked increase in intravascular hemolysis with - Chromosome 1q21
oxidative stress - RBC deficient in ATP production
- Causes cellular dehydration
NOTE: If an individual has G6PD deficiency, they are protected - ALters RBC shape
against Plasmodium falciparum, for the reason that they cannot
stay in the red blood cell because the red blood cell will be lyzed - PKLR gene synthesizes the formation of pyruvate kinase
when exposed to oxidative stress environment. enzyme on the red cell to promote ATP production for
- As mentioned, one cause is an infection, so kung meron energy use
kang infected na RBC na may Plasmodium falciparum it - The lack of ATP due to PK deficiency will cause depletion
can lead to its own destruction of ATP production and will increase in 2,3-DPG synthesis
within the red cells
ADDITIONAL INFO: - The low ATP production may cause membrane instability
- G6PD deficiency is also called Favism and early red cell destruction causing cellular
- Since some of the G6PD deficient individuals are dehydration and it will alter the RBC shapes
allergic to fava beans
- All patients with favism are G6PD deficient, but many TAKE NOTE:
G6PD deficient individuals can regularly eat fava beans - A genetic defect in the PK enzyme results in inefficient
glycolysis
LABORATORY FINDINGS - PK is the enzyme responsible for the final step in
glycolysis in RBCs, which is required for maintaining
1. Abrupt decrease of Hgb and Hct RBC energy (ATP) levels and morphology
2. High reticulocyte count or Polychromasia - Diminished PK enzyme activity in patients with PK
3. Peripheral Blood Smear: deficiency leads to a reduction in ATP and shortened
- Normocytic, Normochromic red cells RBC lifespan, leading to chronic hemolysis
- Normal to marked anisocytosis, poikilocytosis, - Chronic hemolysis results in anemia and potentially
and spherocytosis even schistocytes in severe other serious long-term symptoms and complications,
cases and the presence of bite cells made by like chronic fatigue, jaundice, osteopenia, and iron
macrophages overload
4. Supravital stain:
- Presence of Heinz inclusion bodies PYRIMIDINE-5’-NUCLEOTIDASE DEFICIENCY
5. Blood chemistry:
- Decreased haptoglobin and hemopexin - 3rd most common enzyme abnormality causing
- Increased LDH enzyme, presence of free Hgb hereditary non-spherocytic hemolytic anemia
6. Direct Anti-globulin Test (DAT) - The disease is transmitted as an autosomal recessive
- Negative result trait

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- The degree of hemolysis is generally mild to moderate - Cannot evaluate the cell size and shape, and central
- Lack of this enzyme can cause the accumulation of pallor
precipitated ribosomal RNA within the reticulocyte - Cannot evaluate the morphology
causing the formation of large coarse Basophilic - Characteristic of hyperproteinemia and multiple
Stippling myeloma

- ↑ amount of plasma gamma globulin

- ↑ increased fibrinogen
- They are producing a lot of antibodies and those are not
functional

TAKE NOTE!!!
- 1st or most common is G6PD deficiency
- 2nd most common is Pyruvate Kinase deficiency
- 3rd most common is Pyrimidine-5’-nucleotidase
deficiency

- Based on the Serum Protein Electrophoresis, the pattern

shows that there is a peak of gamma (red)
RBC MORPHOLOGY
- Because of the increase production of
antibodies from the plasma cells
- Anemia can be classified according to the morphology of
- Seen in bone cancer
red blood cells which involves examining the size,
- If the protein is increased such as the antibodies, they
hemoglobin content, and concentration of hemoglobin on
will reduce the zeta potential of the red blood cells
each red blood cells
- This classification is helpful to differetiate various types of
- REMEMBER:
anemia
- RBCs has sialic acid in the membranes
- To identify the RBC morphology, the first thing to do is to
- One of the zeta potentials of the RBC is
perform peripheral blood smear, then stain it using
reduced and they tend to clump, they tend to
Wright’s stain
attract each other forming a rouleaux formation
because of the increase plasma protein or
RBC - DISTRIBUTION
increased fibrinogen or factor 1
NORMAL DISTRIBUTION

2. AGGLUTINATION
- RBCs should be slightly separated from one another
- RBCs clump together forming aggregates or masses
- RBCs are not overlapping and barely touching each
of RBCs when exposed to various red cell antibodies
other
- Normal RBCs are circular with a smooth edge,
- Example: ABO typing particularly in forward typing
reddish-pink cytoplasm with a central pallor
- We are detecting the antigen present in the
- When reading a smear, do not read on the feathery edge
RBC, that is why anti-sera is used containing
of the slide, near the feathery edge lang daw
antibodies or sometimes lectin that could
detect the antigen which will result to
agglutination or clumping

- Autoagglutination
- Individual RBCs agglutinate in their own plasma
or serum that contain no specific agglutinins
- Presence of cold agglutinin IgM antibodies
directed against RBC antigens
ABNORMAL DISTRIBUTION
- Diseases involve auto-immune reaction which
produces antibodies against their own cells
1. ROULEAUX FORMATION
- RBCs resembling “stacks of coins”
- Interferes with automated RBC procedures
- The entire outline of each cell is not visible
- ↑ MCV
- ↓ RBC count

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- These RBCs are actually caused by shape changes such

as that found in spherocytes
- True hyperchromia occurs when MCHC is high

RBC - SIZE
ANISOCYTOSIS
- Refers to increased number of red blood with variation in - Hereditary Spherocytosis
size cell - Spherical shape instead of biconcave disc
shape
1. NORMOCYTES - They appear darker because of the reduced
- Normal RBC surface area
- 7-8 um in diameter - The only disease in which the MCHC is high
- MCV is 80-100 fL (above the reference)
- Symptomatic H5 has 3 clinical manifestations:
2. MICROCYTES 1. Splenomegaly
- Smaller than normal RBCs 2. Anemia
- MCV is <80 fL 3. Jaundice
- Associated with defective Hgb formation
Direct Antiglobulin Test Negative
3. MACROCYTES MCV Normal to low
- Larger than normal MCH Normal
- >8 um in diameter MCHC Slightly increased
- MCV is > 100 fL
- Associated with impaired DNA synthesis NOTE: The immune disorders that have spherocytes also are
usually characterized by positive results on DAT
Normocytes - 7-8 um in diameter
- MCV = 80-100 fL GRADING OF HYPOCHROMIA
- Based on the degree of paleness and amount of
hemoglobin distribution
- Pale than the normal due to the reduction of hemoglobin
Microcytes - <7 um in diameter content and these cells appear lightler in color
- MCV = <80 fL
1+ = Area of central pallor 1/2

Macrocytes - >8 um in diameter

- MCV = >100 fL 2+ = Area of central pallor 2/3

3+ = Area of central pallor 3/4

RBC - VARIATION IN COLOR
ANISOCHROMIA
- General term for a variation in the normal coloration 4+ = Thin rim of hemoglobin
- Often noted in the microscopic examination of blood
smear
- The degree of anisochromia can provide diagnostic Polychromasia - bluish or grayish tint
information about the underlying cause of the disease due to the residual RNA and usually often
associated with the presence of
reticulocytes
1. HYPERCHROMIC CELLS
- They appear as darker than the normal cells
- RBCs that lack central pallor even though they lie in
desirable areas for evaluation

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

2. POLYCHROMATOPHILIC ERYTHOCYTES
- A.k.a Diffusely Chromatophilic Erythrocytes
- Larger than normal red cells with a bluish tinge (Wright’s
stain)
- Bluish tinge - caused by the presence of residual RNA
- Large numbers associated with decreased RBC survival,
hemorrhage or erythroid hyperplastic marrow

3. ACANTHOCYTE
- A.k.a. Spur Cells
- RBCs with irregularly spiculated surface
- RBCs are irreversibly thorny and they have irregular
spicules and various lengths
- Some spicules are bent
- They don’t have a central pallor
RBC - VARIATION IN SHAPE - Associated Conditions:
POIKILOCYTOSIS 1. Abetalipoproteinemia
- Increased number of red blood cells with variation in - a.k.a. Bassen-kornzweig Syndrome
shape 2. Lecithin-cholesterol acyltransferase (LCAT)
deficiency
1. SPHEROCYTE 3. Liver disease
- Spherical in shape 4. Post-splenectomy
- Lacks central pallor 5. Pyruvate Kinase (PK) Deficiency
- Staining intensity is increased
- Only RBC that can be called hyperchromic due to
increased MCHC
- Associated Conditions:
1. Hereditary Spherocytosis
2. Autoimmune hemolytic anemia
3. Burns
4. ABO Hemolytic Disease of Newborn

4. BURR CELL
- A.k.a. Echinocytes or Crenated Cells
- RBCs with regular surface spiculated
- pantay pantay yung spicules nila
- Resemble a hedgehog or sea urchin
- Associated Conditions:
2. STOMACYTE 1. Uremia
- A.k.a. Mouth Cell 2. Pyruvate Kinase Deficiency
- Elongated RBCs with a slit-like central pallor
- Cause is due to the membrane defect causing high
cellular sodium and low potassium
- Abnormal sodium-potassium transport ratio cause the
production of stomatocyte
- Associated Conditions:
1. RH Deficiency Syndrome
2. Alcoholism
5. OVALOCYTE
3. Electrolyte imbalance
- Red blood cells that are oval or egg-shaped
4. Over-hydrated stomatocytes
- Associated Condition:
1. Hereditary ovalocytosis (Southeast Asian
Ovalocytosis)
2. Megaloblastic anemia (macro-ovalocytes)

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

9. DREPANOCYTE
6. ELLIPTOCYTE - A.k.a Sickle Cells or Meniscocyte
- Elliptical or cigar-shaped RBC - Sickle or crescent-shaped RBCs
- Slightly oval to sausage-like form - Elongated or crescent shape
- Hemoglobin is concentrated at both ends kaya meron pa - RBC with pointed ends; S, V, L configuration yung
rin silang central pallor makikita sa pointed ends
- Formation is assumed to be involved in the alteration of - Cause is due to polymerization of hemoglobin S due to
RBC membrane skeleton decreased oxygen and also irreversible
- Associated Conditions: - Associated Conditions:
1. Hereditary elliptocytosis 1. Sickle cell anemia
2. Thalassemia 2. Hemoglobin SC disease

7. DACRYOCYTE 10. LEPTOCYTE

- A.k.a. Tear Drop Cell - A.k.a. Codocyte, Platycyte, Greek Helmet Cell,
- Tear-drop shaped or pear-shaped RBC Mexican Hat cell, Bull’s eye cell, Target cell
- Results when the RBCs with rigid inclusions try to pass - RBC which shows a centrally stained area with a thin
through the splenic sinuses outer rim of hemoglobin
- Associated Conditions: - Cause is due to increase membrane surface due to
1. Primary myelofibrosis increase membrane cholesterol and phospholipids
2. Megaloblastic anemia - Associated Condition:
1. Hemoglobinopathies
2. Liver disease
3. Thalassemia
4. Lecithin-cholesterol acyltransferase (LCAT)
Deficiency

8. SCHISTOCYTE
- A.k.a. Schizocyte
- Fragmented RBCs
- Appear in a variety of shapes
11. BITE CELL
- They are microcytic
- Hallmark of MAHA - where cells nag-attempt to pass - A.k.a. Degmacyte
through the fibrin stands, and when they pass through - Demonstrate a semi-circular defect in the edge of the
various narrow blood vessels, na-dadamage yung red RBCs
cell kaya nagiging fragmented - Resembles a bite mark
- Parang kinagat, kasi ayaw ni spleen sa mga
- Associated Conditions: pangit!!! so lahat ng pangit pinapatay nya, we
1. Artificial heart valves call it culling or splenic sequestration
2. Uremia - 2 lang ang di pinapatay ni spleen:
3. Severe burns 1. Microcytic, hypocritical RBC
4. Microangiopathic hemolytic anemia (MAHA) 2. G6PD RBC with Heinz bodies

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- ang ginagawa lang dito,

bina-bite nya lang yung
merong Heinz bodies pero
di pinapatay
- Associated Condition:
1. G6PD deficiency

3. HOWELL-JOLLY BODIES
- Appears singly in a cell (only one per cell)
- Round and <1um in diameter
- Blue to purple in color
- Content: Remnants of nuclear chromatin (DNA)
- Associated Conditions:
NOTE: SUMMARY ON THE LAST PART 1. Megaloblastic anemia
2. Thalassemia

RBC INCLUSION BODIES

- They are usually inside the RBC because the RBC

doesn’t normally contain particulate inclusions
- There are certain inclusions associated with diseases

1. BASOPHILIC STIPPLING 4. CABOT RINGS

- A.k.a. Punctate Basophilia - Thread-like structures that appear as purple-blue loops
- Irregular dark blue to purple granules evenly distributed or rings
within an RBC - Content: Mitotic spindle remnants
- Content: Aggregated RNA - Associated Conditions:
- Associated Conditions: 1. Megaloblastic anemia
1. Lead poisoning 2. Refractory anemia
- A.k.a Plumbism 3. Lead poisoning
- Arsenic poisoning
2. Pyrimidine-5-nucleotidase deficiency
3. Refractory anemia
4. Alcoholism
5. Megaloblastic anemia
6. Thalassemia

5. HEINZ BODIES
- Appear eccentrically along the inner RBC membrane
- Large, round, blue to purple materials
- Cannot be seen using Wright’s stain
- Supravital stain is used instead
- Content: Denatured and precipitated hemoglobin
- Associated Conditions:
1. G6PD deficiency
2. SIDEROBLASTIC GRANULES 2. Drug-induced hemolytic anemia
- A.k.a. Pappenheimer Bodies 3. Unstable hemoglobin disease
- Described as multiple dark blue irregular granules in
Prussian blue iron staining
- Content: Pappenheimer bodies
- Associated Conditions:
1. Sideroblastic anemia
2. Thalassemia
3. Hemochromatosis or Hemosiderosis 6. HEMOGLOBIN H INCLUSION BODIES
- Small multiple, evenly distributed throughout the red cell
- Granular, greenish-blue bodies
- Content: Precipitated Hgb H
- Associated Condition:

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

1. Hemoglobin H disease - A group of inherited disorders that

- a subtype of Alpha thalassemia affect the production of hemoglobin

3. Sideroblastic anemia
- A rare genetic or acquired condition
that affects iron utilization with red
blood cell precursor leading to
abnormal hemoglobin production

7. PARASITE 4. Lead poisoning

- Associated Conditions: - Exposure to lead that can interfere
1. Malaria with hemoglobin production
- Schuffner’s dots
- Seen in Plasmodium vivax and 5. Anemia of chronic disease
Plasmodium ovale - There are certain chronic conditions
- A.k.a. Eosinophilic stippling like chronic inflammation or infection
2. Babesia spp. that can destruct the body’s ability to
- Maltese cross use iron effectively resulting in this
type of anemia

NORMOCYTIC, NORMOCHROMIC ANEMIA

(MCV = 80-100 fL)

NOTE: SUMMARY ON THE LAST PART

CLASSIFICATION OF ANEMIA
- According to MCV and MCHC - Red blood cells are normal
- Normal in size
MICROCYTIC, HYPOCHROMIC ANEMIA - Normal amount of hemoglobin
(MCV = <80 fL) - Overall red blood cells may be decreased but the
individual RBCs are within the normal range in terms of
size and hemoglobin content

A. Normal or decreased retic ct.

1. Renal disease
- Chronic kidney disease - retic count
- ↓ MCV may be in the normal range
- ↓ MCHC - This happens when the kidney is still
able to produce or release
- Abnormally small red blood cells and low hemoglobin erythropoietin
content - Normal EPO production will help
- This condition typically results from impaired hemoglobin maintain the stable reticulocyte count
synthesis leading to decreased ability of the RBC to carry - Pero may mga advance stages ng
oxygen CKD and their kidney may not
produce sufficient EPO due to
- Associated Conditions: impaired functions of the kidney and
1. Iron deficiency anemia can results to low retic count =
- Most common cause anemia can develop
- Insufficient dietary iron
- Poor iron absorption 2. Aplastic anemia
- Chronic blood loss - There is a failure of bone marrow to
produce an adequate number of
2. Thalassemia blood cells

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

- Retic count is low because the bone certain triggers like foods, drugs, or
marrow’s ability to generate new infection
blood cells is severely impaired - In response to ongoing hemolysis, the
bone marrow increases the
B. Increased retic ct. reticulocyte production to replaced the
- As a response to ongoing hemolysis or loos of the red blood cells
destruction of red blood cells
- An attempt of the body to compensate for the NOTE: In all these increased conditions of retic count is a sign of
loss of red blood cells the body’s effort to maintain a sufficient number of red blood cells
despite their premature destructions
1. PNH (Paroxysmal Nocturnal Hemoglobinuria)
- RBCs are more susceptible to MACROCYTIC, NORMOCHROMIC ANEMIA
destruction due to the deficiency of (MCV = 80-100 fL)
certain proteins on their surface
- This results in chronic hemolysis, so - Abnormally large RBCs that contain normal amount of
to compensate for the loss of red hemoglobin
blood cells, the bone marrow - This condition indicates disruption in the RBC production
increases the production of leading to production fewer buy larger RBC than the
reticulocytes and releases them into normal
the bloodstream
- These reticulocytes mature in the red - Increased MCV
blood cells more quickly than the - Normal MCHC
usual
- Kaya increased yung retic count ng FACTORS MEGALOBLASTIC NON-MEGALOBLAST
may mga cases of PNH ANEMIA IC ANEMIA
Absence of non-
2. PCH (Paroxysmal Cold Hemoglobinuria) megaloblastic changes
- It is a rare auto-immune hemolytic Causes 1. Vitamin B12 1. Liver disease
deficiency 2. Alcoholism
anemia where the antibody attach to
2. Folate 3. Bone marrow
red cells leading to destruction failure
especially when exposed to cold deficiency
temperatures Presence of
- In response to this hemolysis, the hypersegmented Present Absent
bone marrow increases the neutrophils
production of reticulocytes to (≥ 6 lobes)
replenish the loss of the red blood Normal = 3-5 lobes
cells Shapes of Oval Round
macrocytes
3. Sickle cell disease Presence of Present
- Characterized by the red blood cells megaloblast in the Absent
that take the characteristics of a sickle BM As a result of DNA
shape synthesis that is
- They can easily rupture causing impaired, they become
chronic hemolysis more larger and more
- The body’s response by increasing immature, appearing as
the reticulocyte production to maintain megaloblast
an adequate number of red blood
cells and compensate for their short
life span

4. Enzyme disease
- G6PD deficiency
- Pyruvate Kinase deficiency

- They can make RBCs more

susceptible to oxidative damage
leading to hemolysis when exposed to

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

VARIATIONS IN SHAPE
FEATURES ASSOCIATED CONDITIONS
Spherocytosis - Spherical in shape 1. Hereditary Spherocytosis
- Lacks central pallor 2. Autoimmune hemolytic anemia
3. Burns
4. ABO HDN

Stomacyte - A.k.a. Mouth Cell 1. RH Deficiency Syndrome

- Elongated RBCs with a slit-like central 2. Alcoholism
pallor 3. Electrolyte imbalance
4. Over-hydrated stomatocytes

Acanthocyte - A.k.a. Spur Cells 1. Abetalipoproteinemia

- RBCs with irregularly spiculated surface - a.k.a. Bassen-kornzweig
Syndrome
2. Lecithin-cholesterol acyltransferase
(LCAT) deficiency
3. Liver disease
4. Post-splenectomy
5. Pyruvate Kinase (PK) Deficiency
Burr Cell - A.k.a. Echinocytes or Crenated Cells 1. Uremia
- RBCs with regular surface spiculated 2. Pyruvate Kinase Deficiency
- Resemble a hedgehog or sea urchin

Ovalocyte - Red blood cells that are oval or 1. Hereditary ovalocytosis (Southeast
egg-shaped Asian Ovalocytosis)
2. Megaloblastic anemia
(macro-ovalocytes)

Elliptocyte - Elliptical or cigar-shaped RBC 1. Hereditary elliptocytosis

2. Thalassemia

Dacryocyte - A.k.a. Tear Drop Cell 1. Primary myelofibrosis

- Tear-drop shaped or pear-shaped RBC 2. Megaloblastic anemia

Schistocyte - A.k.a. Schizocyte 1. Artificial heart valves

- Fragmented RBCs 2. Uremia
3. Severe burns
4. Microangiopathic hemolytic anemia
(MAHAs)

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 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
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Drepanocyte - A.k.a Sickle Cells or Meniscocyte 1. Sickle cell anemia

- Sickle or crescent-shaped RBCs 2. Hemoglobin SC disease

Leptocyte - A.k.a. Codocyte, Platycyte, Greek 1. Liver disease

Helmet Cell, Mexican Hat cell, Bull’s 2. Thalassemia
eye cell, Target cell 3. Lecithin-cholesterol acyltransferase
- RBC which show a centrally stained area (LCAT) Deficiency
with a thin outer rim of hemoglobin

Bite Cell - A.k.a. Degmacyte 1. G6PD deficiency

- Demonstrate a semi-circular defect in the
edge of the RBCs
- Resembles a bite mark

RBC INCLUSION BODIES

FEATURE ASSOCIATED CONDITIONS
Basophilic Stippling - A.k.a. Punctate Basophilia 1. Lead poisoning
- Irregular dark blue to purple granules - A.k.a Plumbism
evenly distributed within an RBC - Arsenic poisoning

- Content: Aggregated RNA 2. Pyrimidine-5-nucleotidase deficiency

3. Refractory anemia
4. Alcoholism
5. Megaloblastic anemia
6. Thalassemia
Sideroblastic Granules - A.k.a. Pappenheimer Bodies 1. Sideroblastic anemia
- Described as multiple dark blue irregular 2. Thalassemia
granules in Prussian blue iron staining 3. Hemochromatosis or Hemosiderosis

- Content: Pappenheimer bodies

Howell-Jolly Bodies - Appears singly in a cell (only one per cell) 1. Megaloblastic anemia
- Round and <1um in diameter 2. Thalassemia
- Blue to purple in color

- Content: Remnants of nuclear chromatin

(DNA)

Cabot Rings - Thread-like structures that appear as 1. Megaloblastic anemia

purple-blue loops or rings 2. Refractory anemia

20 | GARCIA, M., MONTANO, K., SALITA, G., & TANI, Y. (2023)

 LECTURE 1 & 2 (FINALS) HEMATOLOGY 1
Lecturer: Prof. Sherryl Manzon, RMT, MPH

3. Lead poisoning
- Content: Mitotic spindle remnants

Heinz Bodies - Appear eccentrically along the inner RBC 1. G6PD deficiency
membrane 2. Drug-induced hemolytic anemia
- Large, round, blue to purple materials 3. Unstable hemoglobin disease
- Supravital stain is used instead

- Content: Denatured and precipitated

hemoglobin

Hemoglobin H Inclusion Bodies - Small multiple, evenly distributed 1. Hemoglobin H disease

throughout the red cell
- Granular, greenish-blue bodies

- Content: Precipitated Hgb H

Parasite 1. Malaria 1. Malaria

- Schuffner’s dots 2. Babesia spp.

2. Babesia spp.
- Maltese cross

21 | GARCIA, M., MONTANO, K., SALITA, G., & TANI, Y. (2023)