Red Blood Cell morphology and indices

Evaluation of RBC morphology

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. Erythrocytes show only slight variation in size and shape.

Normal RBC morphology

Size-7-10 microns
Shape: discocytic (bi-concave disk)
Color- red (depending on stain)

SIZE
Anisocytosis: this is a variation in size of RBCs. The nucleus of a small lymphocyte (
8m) is a useful guide to the size of a red cell.
Macrocytosis: large RBCs that may be due to a vitamin B12 or folate deficiency. They
are seen in pernicious anemia, chronic alcoholism, and megaloblastic anemia.
Microcytosis: this is the presence of small RBCs that may be due to an iron deficiency
anemia or to an inherited disorder such as thalassemia.

SHAPE

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 Poikilocytosis is a variation in the shape of an RBC and may include several different
abnormalities at the same time.
Acanthocytes (spur, thorn or spiculated cells): irregular shaped cells with 5-10 spicules.
May be present in the blood of post splenectomy patients and in chronic alcoholism.
Echinocytes (burr, crenated or berry cells): may have 10-30 spiny projections and often
seen in patients with renal failure or iron deficiency. May be an artifact something
caused during sample preparation.
Elliptocytes (ovalocyte): elliptical-shaped RBC seen in hereditary elliptocytosis and
various anemias.
Stomatocytes are erythrocytes with an elongated (mouth-like) area of central pallor. An
occasional cell of this type might be seen as a non-specific finding in a variety of
situations, such as regenerative anemias, liver disease, and lead poisoning. Stomatocytes
can also be an artifact in a blood smear that is too thick.
Keratocyte (horn cell): A half-moon or spindle shaped RBC that may be seen in patients
with disseminated intravascular coagulation (DIC) or a vascular prosthesis.
Rouleaux: RBCs that appear as a stack of coins and seen in patients with multiple
myeloma or macroglobulinemia.
Sickle cells: crescent shape RBCs that are characteristic of sickle cell anemia.
Target cells (leptocytes or codocytes): RBCs that resemble a bull's-eye. Commonly seen
in patients with hemoglobinopathies (abnormal inherited forms of hemoglobin),
thalassemia and various anemias.
Teardrop cells (dacrocytes): RBCs that resemble a teardrop. Often seen in patients with
myelofibrosis and thalassemia.
Schistocytes: fragments or broken pieces of RBCs. This may be due to a disorder that is
causing the red blood cells to be especially fragile or due to mechanical hemolysis as seen
sometimes with devices such as artificial heart valves, or in severely burned patients.
Spherocytosis: sphere-shaped RBCs that are often present in hereditary spherocytosis or
due to an immune hemolytic anemia.
Spicule (crenated): scalloped or serrated perimeter due to loss of water from the cell or to
liver disease.

COLOR
Hypochromasia: this may be seen in a variety of disorders including thalassemia and
iron deficiency. The RBC is pale in color due to insufficient hemoglobin and contains a
large, hollow middle (central pallor) of the cell.
Hyperchromasia: the RBC is darker in color that normal; this may be due to
dehydration.
Polychromasia: blue-staining RBCs, indicating that they are immature due to early
release from the bone marrow.

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RBC INCLUSIONS
Nucleated RBCs (normoblasts): a very immature form of RBCs seen when there is a
severe demand for RBCs to be released by the bone marrow. May be seen in severe
anemia, myelofibrosis, thalassemia, miliary tuberculosis, cancers that involve the bone
marrow, and in chronic hypoxemia (low oxygen levels). Nucleated RBCs can be normal
in infants for a short time after birth.
Reticulocytes: these are immature RBCs that are usually polychromatic in color. A few
of these young red blood cells are normal in the circulation. Elevated numbers may be
seen with acute blood loss, hypoxia, RBC destruction, sickle cell disease, glucose-6-
phosphate dehydrogenase (G6PD) deficiency, and autoimmune hemolytic anemia. A
lower than normal percentage of reticulocytes may indicate: bone marrow failure (for
example, from drug toxicity, tumor, or infection), iron deficiency, radiation therapy.
Basophilic stippling (dark blue dots inside the RBC): due to the precipitation of nuclear
material (ribosomes) and may be present in heavy metal poisoning (such as lead),
nutritional deficiencies, or myelofibrosis.
Heinz bodies: large inclusion bodies (granules) in the RBCs when stained with crystal
violet. May be due to an enzyme (G6PD) deficiency, unstable hemoglobin variant,
thalassemia, and autoimmune hemolytic anemia.
Howell-Jolly bodies (small round remnants of nuclear DNA inside cell): present in sickle
cell anemia, hemolytic or megaloblastic anemias, and may be seen after a splenectomy.
Cabots Rings: threadlike inclusions that form a ring within the RBC. May be seen in a
variety of anemias.

RBC indices
MCV (Mean Corpuscular Volume) defines the mean size of the red blood cells and is
expressed as femtoliters (fl).
MCV is measured directly using an automated analyzer, or is calculated as follows:
MCV =Hematocrit (l/l)/ Erythrocytes (106/l)
The ref. values for MCV are 82 -96 fl.
MCV< 82 fl Microcytosis (chronic iron deficiency, thalassemia, anemia associated
with various chronic diseases (uremia, rheumatoid-collagen diseases, severe chronic
infection, etc.)
MCV>100 flMacrocytosis (Folat or B12 deficiency, alcoholism with or without
cirrhosis, myelodysplastic syndromes, reticulocytosis, normal newborn)

MCH (Mean Corpuscular Hemoglobin)

MCH quantifies the amount of hemoglobin per red blood cell.
The ref. values for MCH are 26-32 pg.

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 MCH (in picograms per erythrocyte) is calculated using the following formula:
MCH (pg) =Hb (g/l)/RBC (106/l)
MCH=26-32 pg Normochromia
MCH<26 pgHypochromia (iron deficiency, thalassemia, anemia in chronic diseases)
MCH>32 pg Macrocytic anemia

MCHC (Mean Corpuscular Hemoglobin Concentration)

The measurement of the average concentration of hemoglobin in a red blood cell
MCHC is determined using this formula:
MCHC (g/dl) =Hb(g/dl)/Hematocrit (l/l).
The ref. values for MCHC: 300-360 g/l

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 MCHC < 300 g/l chronic iron deficiency, sideroblastic anemia, anemia of chronic
diseases)
MCHC > 360 g/l Hereditary spherocytosis, cold agglutination;

RDW (Red cell Distribution Width)= standard deviation of MCV

The RDW is calculated to provide a measure of the anisocytosis, or variation in size of
the RBC's.
Normal reference range in human red blood cells is 11 - 15%.
RDW>15%- chronic iron deficiency, reticulocytosis, two erythrocyte populations

Clinical significance:
Red cell indices are valuable in the morphologic classification of anemias.
Anemias are classified, according to the size of the red cell, as being normocytic
(normal MCV), macrocytic (increased MCV), or microcytic (decreased MCV).
MCHC as measured by the electronic machines is mostly normal in microcytic
anemias, however, and the value of MCH closely parallels the value of MCV.
There are no hyperchromic anemias. In spherocytosis, the MCHC is increased due to
loss of membrane and the consequent spherical shape assumed by the cell.