cresyl blue. Methyl alcohol destroys ribonuclear protein; and hence, it cannot be seen in Romanowsky stained preparation. In Romanowsky stained films, they appear as

 

Segmented granulocyte 6.0–12.0 12.9 3.6

Neutrophilic 7.0–30

Contd...

Clinical Hematology 233

Increased megakaryocytes: Acute hemorrhage, aging,

chronic myeloid leukemia, hypersplenism, idiopathic

thrombocytopenia, infection, megakaryocytic myelosis,

myelofibrosis, pneumonia, polycythemia vera and

thrombocytopenia.

Increased plasma cells: Agranulocytosis, amyloidosis,

aplastic anemia, carcinomatosis, collagen disease, hepatic

cirrhosis, Hodgkin’s disease, hypersensitivity reactions,

infection, irradiation, macroglobulinemia, malignant tumor,

multiple myeloma, rheumatic fever (acute), rheumatoid

arthritis, serum sickness, syphilis and ulcerative colitis.

Increased granulocyte: Hypoplasia of the bone marrow,

infections, myelocytic leukemia, myelocytic leukemoid

reaction and myeloproliferative syndrome.

Increased normoblasts: Anemia (iron deficiency, hemolytic, megaloblastic), blood loss (chronic), erythema,

erythroid-type myeloproliferative disorders, hypoplasia of

the bone marrow and polycythemia vera.

Increased M:E ratio above 7:1 Decreased hematopoiesis,

erythroid hypoplasia, infection, leukemoid reactions, and

myeloid leukemia.

Increased diffuse bone marrow hyperplasia: Myeloproliferative syndromes and pancytopenia reactions.

Decreased megakaryocytes: Anemia (aplastic, pernicious),

bone marrow hyperplasia (with carcinomatous or

leukemic deposits), cirrhosis, irradiation (excessive),

and thrombocytopenia purpura. Drugs include benzene,

chlorothiazides, and cytotoxic drugs.

Decreased granulocytes: Agranulocytosis, hyperplasia of

the bone marrow, and ionizing radiation.

Decreased normoblasts: Anemia (aplastic, hypoplastic),

folic acid or vitamin B12 deficiency.

Decreased M:E ratio below 2:1 Agranulocytosis, anemia

(iron deficiency, normoblastic, pernicious, posthemolytic,

posthemorrhagic), erythroid activity (increased), hepatic

disease, myeloid formation (decreased), polycythemia

vera, sprue, and steatorrhea.

Decreased diffuse bone marrow hypoplasia: Aging, cellular

infiltrations, dengue fever, myelofibrosis, myelosclerosis,

myelotoxic agents, osteoporosis, rubella, and viral

infections.

Description: Bone marrow is the soft, organic, sponge-like

material contained in the medullary cavities, long bones,

some haversian canals, and within the spaces between

trabeculae of cancellous bone. It is composed of red and

Contd...

Adult

(%)

Child

(%)

Infant

(%)

Eosinophilic 0.2–4.0

Basophilic 0–0.7

Band cells 9.5–15.3 0 14.1

Neutrophilic 10–35

Eosinophilic 0.2–2.0

Basophilic 0.3

Erythroid series

Normoblasts, total 25.6 23.1 8.0

Pronormoblasts 0.2–4.0 0.5 0.1

Basophilic normoblasts 1.5–5.8 1.7 0.34

Polychromatophilic

 normoblasts 5.0–26.4 18.2 6.9

Orthochromic normoblasts 3.6–21 2.7 0.54

Promegaloblasts 0

Basophilic megaloblasts 0

Polychromatic megaloblasts 0

Orthochromic megaloblasts 0

M:E ratio: (Myeloid:Erythroid is the ratio of WBCs to

nucleated RBCs.)

 Adult 6:1–2:1

 Birth 1.85:1

 2 weeks 11:1

Usage: Helps to distinguish primary and metastatic

tumors. Assists in the identification, classification, and

staging of neoplasias. Aids evaluation of the progress

and/or response to the treatment of neoplasias. Assists

in the definitive diagnosis of blood disorders. Culture

of an aspirated sample can aid in the identification

of infections such as histoplasmosis or tuberculosis.

Histologic examination aids in the diagnosis of carcinoma,

granulomas, lymphoma, or myelofibrosis. Iron stain

showing decreased hemosiderin levels may indicate iron

deficiency and SBB stain differentiates acute granulocytic

leukemia from acute lymphocytic leukemia.

Increased eosinophils: Bone marrow carcinoma, eosinophilic leukemia, lymphadenoma, myeloid leukemia and

pernicious anemia (relapse).

Increased lymphocytes: Aplastic anemia, hypoplasia of the

bone marrow, infectious lymphocytosis or mononucleosis,

lymphatic leukemoid reactions, lymphocytic leukemia

(B-cell and T-cell), lymphoma, macroglobulinemia,

myelofibrosis and viral infections.

234 Concise Book of Medical Laboratory Technology: Methods and Interpretations yellow marrow, with the chief function being production

of erythrocytes, leukocytes, and platelets. Only the rusty,

red marrow produces blood cells. The yellow marrow

is formed of connective tissue and fat cells, which are

inactive. During infancy and childhood, bone marrow is

primarily red marrow, and in the adult, 50% is red marrow.

The bone marrow aspiration procedure obtains a sample

of bone marrow by needle. A stained blood smear of the

sample is evaluated for bone marrow morphology and

examination of blood cell erythropoiesis, cellularity,

differential cell count, bone marrow iron stores, and M:E

ratios.

Indications for Bone Marrow Aspiration

Absolute Indications

¾ Megaloblastic macrocytic anemia

¾ Aleukemic or subleukemic leukemia.

Diagnostic Importance

¾ Multiple myeloma

¾ Aplastic anemia

¾ Gaucher’s disease.

Confirmatory Importance

¾ Leukemias of all types

¾ Hemolytic anemia

¾ Idiopathic thrombocytopenic purpura

¾ Idiopathic granulocytopenia

¾ Leishmaniasis

¾ Disseminated lupus erythematosus (LE cells)

¾ Metastatic disease

¾ Myeloproliferative disorders

¾ Lipid storage

¾ Sideroblastic anemia

¾ Iron deficiency anemia

¾ Lymphoma (staging).

Therapeutic Importance

Bone marrow may be obtained from one person for

transplantation into another.

In many cases, one may just obtain blood (blood tap)

or nothing at all (dry tap). Under these conditions, a bone

marrow biopsy has to be performed. It can be obtained

with Jamshidi’s needle or with Sacker-Nordins bone biopsy

trephine.

Bone biopsy may be needed in:

¾ Malignant lymphoma

¾ Metastatic carcinoma

¾ Sarcoidosis

¾ Tuberculosis

¾ Brucellosis.

MORPHOLOGICAL TYPES OF

RED BLOOD CELLS (FIG. 9.17)

Usually anemias are described on two grounds:

¾ The average cell volume (MCV)

¾ The average hemoglobin concentration (MCHC).

Three main types of anemias are recognized:

1. The normocytic anemias, in which MCV is within

normal range (76–96 fl). Most normocytic anemias are

also normochromic (i.e. MCHC is between 30–35 g%)

but in some, mild hypochromia may occur. For size of an

RBC, compare its size with that of a small lymphocyte.

As for hemoglobinization normally only a small area of

central pallor is seen (central 1/3 rd).

2. The hypochromic, microcytic anemias, in which the

MCV is reduced (less than 76 fl) and MCHC is also

reduced (less than 30 g%).

3. The macrocytic anemias in which the MCV is increased

(greater than 96 fl). Most macrocytic anemias are

normochromic; but in some, a mild hypochromia may

occur.

RBC Morphology

Normal Values

Microscopic interpretation is required.

FIGS 9.17A TO I: Morphological alterations in RBCs: (A) Anisocytosis,

(B) Poikilocytosis, (C) Target cells, (D) Sickle cells, (E) Basophilia,

(F) Cabot’s rings, (G) Howell-Jolly bodies, (H) Reticulocytes (large

basophilic), (I) Normoblasts

Clinical Hematology 235

Color Uniformly normochromic

Size 6–8 μ only slight size variation

Shape Round, biconcave disc

Stained appearance Mature erythrocytes stain uniformly and

contain a normal concentration of hemoglobin with an area of central pallor

Nucleus Absent

Nuclear remnants Absent

Cellular inclusions Absent

Acanthocytes Absent

Crescent bodies Absent

Drepanocytes Absent

Echinocytes Absent

Leptocytes Absent

Poikilocytes Absent

Schizocytes Absent

Spherocytes Absent

Stomatocyte Absent

Cabot rings Absent

Heinz bodies Absent

Siderocytes Absent

Classification of Variation from Normal

Abnormal RBCs/HPF Score Interpretation

3–6 l+ Slight

7–10 2+ Moderate

11–20 3+ Marked

>20 4+ Very marked

Usage

Detection of blood dyscrasias; and differentiation of

anemias, leukemia, and thalassemia (Table 9.2).

Reticulocyte Count

Reticulocytes: These are immature red cells which still

contain the remains of ribonuclear protein. Their number

in peripheral blood increases following increased

erythroid activity in the bone marrow. This may occur

when there is reduction in number of red cells in the

peripheral blood, e.g. by hemorrhage or abnormal

hemolysis. The reticulocyte count is of value in pernicious/

megaloblastic anemias, for improvement is indicated by a

rise in reticulocytes in the peripheral blood.

Normal Values

Comprises 1–2% of the total RBC count.

SI Units

Adult females 0.5–2.5% 0.005–0.025 × 10–3

Adults males 0.5–1.5% 0.005–0.015 × 10–3

Cord blood 3.0–7.0% 0.030–0.070 × 10–3

Newborn 1.1–4.5% 0.011–0.045 × 10–3

Neonates 0.1–1.5% 1.010-0.015 × 10–3

Infants 0.5–3.1% 0.005–0.031 × 10–3

Children >6 months 0.5–4.0% 0.005–0.040 × 10–3

Staining

Ribonuclear protein is a living material, which requires

special staining, using a supravital stain such as brilliant

cresyl blue. Methyl alcohol destroys ribonuclear protein;

and hence, it cannot be seen in Romanowsky stained

preparation. In Romanowsky stained films, they appear as

larger cells showing polychromasia.

Stain

 1% Brilliant cresyl blue

 Brilliant cresyl blue 1 g

 Sodium chloride 0.7 g

 Sodium citrate 0.6 g

 Distilled water 100 mL.

 Store in dark bottle under refrigeration, filter before

use (new methylene blue can also be used instead of

BCB).