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Basic evaluation in anaemia includes the microscopic examination of the red blood cells. These may show features suggestive of the underlying cause of the anaemia
RBC Morphology | Associated Conditions |
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Microcytic RBCs | Fe deficiency, thalassaemia trait and syndromes, congenital sideroblastic anaemia, anaemia of chronic disorders |
Macrocytic RBCs | Alcohol/liver disease (round macrocytes), MDS, pregnancy and newborn, haemolysis, B12 or folate deficiency, hydroxyurea and antimetabolites (oval macrocytes), acquired sideroblastic anaemia, hypothyroidism, chronic respiratory failure, aplastic anaemia |
Dimorphic RBCs | Fe deficiency responding to Fe, mixed Fe and B12/folate deficiency, sideroblastic anaemia, post-transfusion |
Polychromatic RBCs | Response to bleeding or haematinic Rx, haemolysis, BM infiltration |
Spherocytes | HS, haemolysis, e.g. warm AIHA, delayed transfusion reaction, ABO HDN, DIC, and MAHA, post-splenectomy |
Pencil/rod cells | Fe deficiency anaemia, thalassaemia trait and syndromes, PK deficiency |
Elliptocytes | Hereditary elliptocytosis, MPD, and MDS |
Fragmented RBCs | MAHA, DIC, renal failure, HUS, TTP |
Teardrop RBCs | Myelofibrosis, metastatic marrow infiltration, MDS |
Sickle cells | Sickle cell anaemia, other sickle syndromes (not sickle trait) |
Target cells | Liver disease, Fe deficiency, thalassaemia, HbC syndromes |
Crenated red cells | Usually storage or EDTA artifact. Genuine RBC crenation may be seen post-splenectomy and in renal failure |
Burr cells | Renal failure |
Acanthocytes | Hereditary acanthocytosis, a-β-lipoproteinaemia, McLeod red cell phenotype, PK deficiency, chronic liver disease (esp. Zieve’s) |
Bite cells | G6PD deficiency, oxidative haemolysis |
Basophilic stippling | Megaloblastic anaemia, lead poisoning, MDS, haemoglobinopathies |
Rouleaux | Chronic inflammation, paraproteinaemia, myeloma |
i reticulocytes | Bleeding, haemolysis, marrow infiltration, severe hypoxia, response to haematinic therapy |
Heinz bodies | Not seen in normals (removed by spleen), small numbers seen post-splenectomy, oxidant drugs, G6PD deficiency, sulfonamides, unstable Hb (Hb Zurich, Köln) |
Howell–Jolly bodies | Made of DNA, generally removed by the spleen, dyserythropoietic states, e.g. B12 deficiency, MDS, post-splenectomy, hyposplenism |
H bodies | HbH inclusions, denatured HbH (β4 tetramer), stain with methylene blue, seen in HbH disease (− −/− α), less prominent in α thalassaemia trait, not present in normals |
Hyposplenic blood film | Howell–Jolly bodies, target cells, occasional nucleated RBCs, lymphocytosis, macrocytosis, acanthocytes |