HEMATOLOGY

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Starting my Leukocyte labs next week! Your blog was a great refresher, thank you.

You’re welcome! I’m glad my blog helped you. Good luck!

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Hi! I just finished my third day at my internship for med lab science. I'm on my phlebotomy rotation and start in micro next week. Phleb has definitely become a little easier for me just in the few days I've been drawing in the clinic, but I'm going to have to draw hospital patients in the very early morn once a week for the rest of my internship time. In general, do you have advice on how to succeed in the field? I'm so nervous to finally be in an actual lab and having to learn SO MUCH.

Thanks so much for this question! I, myself, just started rotating in microbiology. Very exciting, finally being in a real lab!

The one thing I always remind myself is that my rotating instructors know I’m a student and that I’m there to learn. Yes, it is a lot of information to learn, but remember this: you are not expected to remember every detail they tell you, and techs that have been working in the lab 30+ years still have to check SOPs and lab procedures. If you’re having trouble learning something in particular, my best advice is to read your lab’s SOPs. I started reading a few today, and I’ve learned so much already.

Also, ASK QUESTIONS. That’s what you’re there for, to get experience and ask questions. If someone explains something to you, try to quickly summarize what they said back to them to make sure you’ve understood them correctly. If you didn’t, they will explain it over again, hopefully in a way that is more helpful.

Don’t be afraid to make mistakes. Today, I broke a glass slide during a gram stain, and I felt like such an amateur and was extremely embarrassed. My instructor looked over at me, asked if I was okay, and laughed after I said yes. She told me not to worry about it, and that it happens to everyone, even techs. When I started cleaning up, I noticed that there were pieces of glass from many broken slides that people missed when cleaning up. I instantly felt better because I knew my instructor wasn’t lying to me, and I remembered that no one is perfect.

Study hard, ask questions and don’t be afraid to make mistakes. You will succeed. Good luck and thanks for following!

[normocytic-normochromic]

When it comes to cell identification during a manual differential, it can be hard differentiating reactive (atypical) lymphocytes and monocytes.

The cell on the left is a reactive lymph that the experienced may not confuse with a monocyte. It has a round to oval nucleus with a fine chromatin pattern and a large, basophilic cytoplasm.

The middle cell, however, looks very similar to a monocyte, and by itself, without an actual monocyte for comparison in the same field, may trick some. It has an indented nucleus with a fine/lacy chromatin pattern, just like many typical monocytes do. The cytoplasm is a little less basophilic compared to the left cell and, if you stare at it long enough, can even have the sort of “ground glass” look that is very characteristic of a monocyte’s cytoplasm.

The cell on the right is a very typical monocyte. It has an oddly-shaped nucleus with a lacy chromatin pattern and a blue-gray, ground glass cytoplasm, as well as vacuoles.

For this particular patient, I knew that the cell on the right was a monocyte and not a reactive lymph because its cytoplasm was blue-gray and vacuolated. No other reactive lymph had these features. They all had more basophilic cytoplasms, especially around the edge of the cell and no vacuoles were present. But here’s the problem - reactive lymphocytes can be vacuolated and the cytoplasm of a monocyte can sometimes be more basophilic than blue-gray. It just wasn’t the case for THIS PATIENT. So what do you do if your patient has reactive lymphs and monocytes with similar cytoplasms and both are vacuolated? Try to find similarities between them to categorize them as two separate populations as I’ve done. For me, it was a basophilic cytoplasm and no vacuoles v.s a blue-gray cytoplasm with vacuoles. For another patient, it may be large sized cells with large azurophilic granules (reactive lymphs) vs. medium sized cells and no azurophilic granules (monocytes). 

Simply look at the details to see if one population has something the other population that is very similar does not. Reactive lymphs and monos can look nearly identical at times, but sometimes you have to forget what you know and simply look at what you see at first, and then go from there.

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The arrow is pointing to a dysplastic monocyte

Wright-Giemsa, 1000X

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A photoset of blasts from a patient with AML. Notice the auer rod in the second photo

Wright-Giemsa, 1000X

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Here, I show the maturation of an eosinophil in a leukemia patient, from a very immature form in the first photo, to an eo that has burst in the last.

Wright-Giemsa, 1000X

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Just by looking at this photograph, can anyone tell me the sex of this patient? How can you tell?

Image courtesy of Jenny Van Mersbergen

[lionessey-blog]

Female. Barr body. Heyyyy. 💁🏻

[normocytic-normochromic]

Yes, you are correct! :)

[hellohiheyhowareya]

Can someone explain?(:

[normocytic-normochromic]

Hi evevoneg!

Do you see the tiny dot of chromatin that is separate from the normal lobes of the neutrophil? That is called a Barr body and is seen in neutrophils of females. Technically speaking, you can see them in males with Klinefelter syndrome as well. This is a rare genetic condition where a male is born with an extra X chromosome (XXY).

 A Barr body occurs when an X chromosome is inactivated, leaving the pyknotic remnant you see here.

Source: Gulati, G & Caro, J. “Blood Cells: Morphology & Clinical Relevance” Second edition.

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Immature eosinophils

Images courtesy of Jenny Van Mersbergen

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Platelet satellitism around segmented neutrophils

Image courtesy of Jenny Van Mersbergen

[normocytic-normochromic]

Let’s Talk: The Manual Differential

The manual differential is one of my favorite tasks to complete as a medical laboratory science student. Automation has largely taken over the differential, but there will always be a need for completing manual differentials. It’s something students tend to love or absolutely hate. It takes a lot of skill and a ton of practice, but when you’ve gotten good at it, it’s a skill that will set you apart from other scientists and technicians. As a disclaimer, there are many different ways to perform a manual differential, and every hospital’s protocol is going to be a little different. If you do something differently, or learned to do something a different way, I’m not saying your way is wrong; I’m simply saying this is the way I was taught.

1. First, examine your slide macroscopically. Make sure there are no holes, your cells haven’t sloughed off and that your slide has stained evenly. Remember, there will be an area of the slide where the film of blood is thicker, so the staining will appear darker there, which is normal. The stain should have a gradient effect. See image below (source: http://www.medical-labs.net/feathered-edge-of-peripheral-blood-smear-2598/).

Make sure that you have a nice feathered edge. If there is no feathered edge, you may not have a good area to count, known as the monolayer. This is the area of the slide where red blood cells are barely touching each other but are still abundant and have a nice central pallor.

2. If you have a quality slide macroscopically, examine your slide microscopically under the 10X objective. The main things you want to look for are blast/immature cells in the feathered edge, platelet clumping and parasites. Blast and immature cells tend to be larger, so they are pushed into the feathered edge a lot of the time. Catching these abnormal cells is one of the most important parts of performing a manual differential. A lot of the time, this is why you will perform a manual differential in a clinical lab, because a machine flagged it for review due to abnormal cells (as in cells that shouldn’t be in PERIPHERAL blood). If you see platelet clumping, you should not release a platelet estimate. Check your tube for clots. If your tube is clotted, you should request a new sample. Always follow your hospital’s protocol, though. There are many different blood parasites. Microfilariae are large, so they can be seen under the 10X objective, but you may have to wait until you get under the 50X or 100X objectives to see things such as Plasmodium spp. and Toxoplasma gondii.

3. If all is well microscopically, find your monolayer. There are many different ways to move your slide to begin counting. The two most important things are to not leave the monolayer and not count the same field over again by accident. A good way to move your slide can be see in the image below (source: http://www.medical-labs.net/feathered-edge-of-peripheral-blood-smear-2598/).

The typical count is 100 WBCs but some hospitals will require counting 200 WBCs if the WBC count is high. I always count using the 100X objective because I feel it’s far more accurate, but counting using the 50X objective is very common for the experienced. While counting, simultaneously look at RBC and WBC morphology and inclusions, as well as platelet morphology and an estimate. Record all results according to your hospital’s protocol, and you’re done! Another smear under your belt.

Is there something you do differently during a manual differential? Let me know in my ask!

Sources:

http://www.medical-labs.net/feathered-edge-of-peripheral-blood-smear-2598/

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Welcome, new followers!

I’ve just hit 100 followers, and I can’t thank all of you enough!

Right now, I’m working on a large post about performing a manual differential. Hopefully I’ll have it posted soon.

I’m also hoping to get back into the teaching lab to take some more photomicrographs for you all. I’m currently doing an internship in a research lab studying parasites, so I’ve been busy.

Question: If you’ve learned how to complete a manual differential, what are some things that your instructor hounded you on, making sure you did it a certain way? Let me know in my ask box!

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Let’s Talk: Echinocytes

AKA: Burr Cells; Crenated Red Blood Cells

I’d like to start off by saying that when I come across echinocytes in the lab, it’s almost always artifactual, or simply “artifact.” A slide can show echinocytes if it was prepared using old blood or if the drying process was slow. Echinocytes also form when the pH of red blood cells increases, which can happen during slide preparation, called the “glass effect,” when substances from the glass slide diffuse and raise the pH. Excess EDTA in a collection tube (due to an underfilled tube) can also create echinocytes. True echinocytes (non-artifactual) can be referred to as “in-vivo,” and artifactual echinocytes may be referred to as “in-vitro.” In-vitro echinocytes usually cover the slide, while in-vivo echinocytes are less numerous.

Echinocytes are red blood cells that show evenly distributed projections over the surface of the cell. The projections can be blunt or pointy. Echinocytes are thought to occur when the outer leaflet of the lipid bilayer of an RBC increases in area compared to the inner leaflet. The projections of echinocytes can be removed by the spleen, resulting in spherocytes. Echinocyte formation is reversible, but spherocyte formation is not.

To determine if a patient has in-vivo echinocytes or if the echinocytes are artifact, you can perform a wet preparation by placing a drop of unstained blood between two coverslips and observe the RBCs. If echinocytes are seen, the echinocytes seen on the slide were in-vivo and not artifact.

Clinical conditions associated with echinocytes include severe renal disease (uremia, or urea in the blood), liver disease, vitamin E deficiency, pyruvate kinase deficiency, burns, heparin therapy, GI disorders (peptic ulcers, carcinoma, Crohn’s disease) and myeloproliferative disorders.

“Echinocyte” comes from the Greek word meaning “sea urchin.” Cool, right?

Do you know something clinically significant about echinocytes that I haven’t mentioned? Let me know! I hope this helps.

A picture of echinocytes is below.

Sources:

Gulati, Gene and Caro, Jaime. Blood Cells: Morphology & Clinical Relevance. 2nd Edition.

McKenzie, Shirlyn B. and Williams, J. Lynne. Clinical Laboratory Hematology. 2nd Edition.

https://www.medialabinc.net/spg28876/burr_cells_echinocytes.aspx

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Let’s Talk: Howell-Jolly Bodies

Howell-Jolly bodies are a type of red blood cell inclusion, appearing dark purple (or bluish-purple) and spherical. They range from 0.5 microns to 50 microns in size.Typically, you will only find one Howell-Jolly body per cell, but on rare occasions, you can find multiple bodies per cell. They are typically found in mature red blood cells, but can be seen in reticulocytes and orthochromic normoblasts (a type of nucleated red blood cell), as well.

Howell-Jolly bodies are nuclear (DNA) fragments that are left behind after the nucleus has been extruded from the red blood cell. If the nuclear maturation of a red blood cell is abnormal, Howell-Jolly bodies can result. It is thought that during mitosis, an individual chromosome may not properly attach to the spindle apparatus, resulting in nuclear fragments that are not a part of the nucleus.

Howell-Jolly bodies are usually removed by macrophages in the spleen. Splenic macrophages are able to “pit” an RBC, which is essentially biting off a piece of the RBC, which usually gets rid of RBC inclusions, such as Howell-Jolly bodies. Therefore, if these inclusions are seen in peripheral blood, it may be due to a hypofunctioning spleen. These inclusions are also very typical in a postsplenectomy state. They can be seen in severe hemolytic anemia, megaloblastic anemia and congenital dyserythropoietic anemias, as well. Also, it’s not uncommon to see these in newborns, particularly premature newborns.

When in comes to RBC inclusions and morphologies, I was always taught that you only report out a specific morphology if you see (at a minimum) a few per high-power field, and that there should be many of the same inclusion on the slide for it to be reportable. There are exceptions, and Howell-Jolly bodies are one of them. I was taught that even if you see ONE Howell-Jolly body during a differential, you report it. Of course this will depend on the hospital you are rotating/ working at. Just as an FYI, I’ve never actually encountered a slide with only one Howell-Jolly body. Every time I’ve seen this inclusion during a differential, multiple cells have had it.

Do you know something clinically significant about Howell-Jolly bodies that I haven’t mentioned? Let me know! I hope this helps.

A picture of a Howell-Jolly body is below (a little south of the center of the field).

Sources:

Gulati, Gene and Caro, Jaime. Blood Cells: Morphology & Clinical Relevance. 2nd Edition.

McKenzie, Shirlyn B. and Williams, J. Lynne. Clinical Laboratory Hematology. 2nd Edition.

[normocytic-normochromic]

Hello! I love your blog! It will help me a lot since I'm taking up Medical Laboratory Science! 😂 this isn't a question but yeah. 👍🏻

I’m so glad you like it! MLS is such an exciting field to be in right now, and I can’t wait to share my experience with you. I’m finished classes until the fall, so I’ll be a lot more active in the following months.

[normocytic-normochromic]

What this video demonstrates is a microscopes "depth of field." As you can see, as you move the fine focus, whatever you're viewing under the microscope (in this case, D. latum eggs) will go in and out of focus as you move into different planes.

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A comparison of a reactive lymphocyte (left) and a large granular lymphocyte (which can sometimes be considered reactive as well) Wright-Giemsa, 1000X

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A comparison of a normal lymphocyte (bottom), a reactive lymphocyte (right, arrow) and a monocyte (top) Wright-Giemsa, 1000X