This topic is a constant feature of CICM Fellowship SAQs. The questions usually take the shape of "Here's a blood film; it's abnormal. What's wrong with the patient? Give differentials." Probably the most favourite topic is macrocytosis (i.e. "what are the different causes of macrocytosis"). Nucleated red cells, rouleaux formations and inclusion bodies have also made several appearances.
Representative SAQs include the following:
This is a finding usually reported on the basis of a strongly bimodal red cell volume histogram which is produced by automated blood cell analysers (Constantino, 2011). The term is somewhat misleading, as the histogram may have more than two discrete red cell populations sharing the bloodstream. However, usually there's only two cell populations; typically a group from before some sort of illness or treatment, and a group from after that event. Examples include:
Following from this, numerous possibilities exist to explain the concurrent presence of several morphologically distinct red cell variants, some of which are totally predictable. This representative list is cut-and-pasted from Constantino (2011):
This is defined (at least in our laboratory) as a mean corpuscular volume (MCV) of over 100fl.
There are several common causes:
There are also a few uncommon causes:
One can find a discussion of the many causes of macrocytosis in this article.
Nucleated red cells are an immature subtype, and their abundance in a blood sample reflects that either the bone marrow s struggling to keep up with the losses of red cells, or that there are insufficient resources to complete the normal maturation process. Thus, any nutritional hematinic deficiency and any stimulus for erythropoisesis can cause their appearance.
A review article from Laboratory Medicine lists several causes of nucleated red cells in the peripheral blood:
This article from which this list is derived appears to be important, because the CICM question writers have drawn upon it in the past. In fact, their official answer is a word-for-word facsimile of the table on page 225, "Mechanisms and Conditions Associated With Normoblastemia".
This is a form of reversible RBC aggregation, and it seems to be a cause of some altered blood rheology. The rouleaux are stacks of red blood cells which form due to macromolecule bridging between their surface molecules. In 1926 Eric Ponder published on the subject, and his paper contains beautifully drawn diagrams of his experimental design. In short, anything which might increase your ESR will cause rouleaux formation, and thus the differentials include a broad range of conditions:
These are bell-shaped cells in vivo; when processed for microscopy they assume the characteristic "mexican hat" shape. The target cell has too much membrane for a given small amount of hemoglobin content; it is essentially the "reverse" of a spherocyte (which has too little membrane, and is therefore spehrical). The typical reason for this abnormality is some sort of hemoglobinopathy, or at least a failure to clear the normal (usually small) proportion of abnormal red blood cells.
You will see lots of target cells in
Fewer target cells are seen in
Literally "lots of colour", this is a disorder of erythrocyte maturation whereby numerous abnormally coloured (blue-grey) red cells are released into the circulation prematurely. The term applies only to the giemsa stain, in which all such immature forms stain blue-grey, whereas the mature red cells either stain orange or not at all. The blue-grey colour is due to the affinity of the giemsa stain for the phosphate groups of RNA, and reveals the fact that these red cells still have genetic material inside them.
Polychromasia and reticulocytosis are not synonymous. However, most reticulocytes are polychromophilic, and most polychromophilic erythroid cells are reticulocytes. The difference between them is the presence of RNA clumps in the cytplasm, which appear as a mesh-like pattern in the reticulocyte. In contrast, the entire cytoplasm of the polychromophilic cell will be abnormally stained.
Polychromasia can be interpreted as either a non-specific marker of bone marrow stress, or as a marker of impaired erythrocyte quality control (like Howell-Jolly bodies). In polychromasia, the RBC count will be high indicating that numerous immature forms have been released from the marrow.
Possible causes of polychromasia include: