Cell Inclusions

Cell Inclusions John Santangelo

Auer rods are elongated, bluish-red rods composed of fused lysosomal granules, seen in the cytoplasm of myeloblasts, promyelocytes and monoblasts and in patients with acute myelogenous leukemia. (AML)

Lysosomes contain many hydrolytic enzymes, soluble at an optimum acid pH.

Howell-Jolly bodies are basophilic nuclear remnants (clusters of DNA) in circulating erythrocytes. During maturation in the bone marrow erythrocytes normally expel their nuclei, but in some cases a small portion of DNA remains. It is named after William Henry Howell and Justin Marie Jolly.

Appearance This DNA appears as a basophilic (purple) spot on the otherwise eosinophilic (pink) erythrocyte. These inclusions are normally pitted out by the spleen during erythrocyte circulation, but will persist in individuals with functional hyposplenia or asplenia. Description: Round, dense red cell inclusions of variable size, usually single with a staining characteristic of the nucleus.

A Howell-Jolly body is a nuclear remnant that results from incomplete nuclear expulsion as the orthochromic normoblast exits the bone marrow. Might also form as a result of karyorrhexis (nuclear rupture). Small numbers normally are released into the peripheral blood from the bone marrow, but are not seen on a peripheral blood smear if the splenic function is normal or near normal. Howell-Jolly bodies are also seen in: Severe hemolytic anemia, Megaloblastic anemia, Hereditary spherocytosis Myelodysplastic syndrome( MDS). If a small accessory spleen is present following splenectomy in an otherwise normal patient, Howell-Jolly bodies usually are not present.

Spleen Accessary Spleen

Howell Jolly Bodies

Red Circle Pappenheimer Bodies

Pappenheimer bodies Pappenheimer bodies appear as violet staining granules usually found along the periphery of the red cells, often in clusters.

They must be confirmed with an iron stain. These iron-staining granules are found in sideroblastic and megaloblastic anemias, alcoholism, following splenectomy, and in some hemoglobinopathies. They are smaller than Howell-Jolly bodies. Pappenheimer bodies are distinctive granules found in a blood stain that can indicate an excess of iron. They can interfere with platelet counts in electronic counters

Pappenheimer Bodies

Toxic Granulation Toxic granulation refers to changes in granulocyte cells seen on examination of the peripheral blood film of patients with inflammatory conditions. They are commonly found in patients with sepsis. Toxic granulations are dark coarse granules found in granulocytes, particularly neutrophils. Along with Dohle bodies and cytosolic vacuolation, which are two other findings in the cytoplasm of granulocytes, toxic granulations are a peripheral blood film finding suggestive of an inflammatory process. Cytosolic Pertains to or relates to the fluid component of the cytoplasm excluding the organelles and other suspended intracellular structures.

Toxic granulation neutrophils (TGNs), which have prominent azurophilic cytoplasmic granules in blood smears stained by the Wright or May-Grünwald-Giemsa technique, appear in blood when inflammation occurs. Serum levels of C-reactive protein (CRP) are also increased in inflammation as is the ESR.

Toxic Granulation

Toxic Granulation

Dohle Bodies The presence of Döhle bodies in mature and immature neutrophils on a blood smear can be normal if they are present only in small numbers. They are also normally more abundant in cats and horses. Döhle bodies are intra-cytoplasmic structures composed of agglutinated ribosomes; they will increase in number with inflammation and increased granulocytopoiesis. Döhle bodies often are seen together with toxic granulation.

Dohle Bodies Toxic Lymphocyte EBV (Ebstein Barr Virus)

PUNCTATE BASOPHILIA (BASOPHILIC STIPPLING) Seen in:

1. a- and b-thalassaemia. 2. chronic lead poisoning. 3. severe B12 deficiency (megaloblastic anaemias). 4. pyrimidine 5-nucleotidase deficiency. 5. congenital dyserythropoietic anaemias.* 6. acquired Sideroblastic Anaemias. 7. other myelodysplasias.

Hereditary pyrimidine 5'-nucleotidase deficiency is the most frequent enzymopathy of red blood cell nucleotide metabolism that causes hereditary nonspherocytic haemolytic anaemia. The disease is usually characterized by mild-tomoderate haemolytic anaemia, reticulocytosis and hyperbilirubinemia. To date, diagnosis ultimately depends upon demonstration of a reduced level of pyrimidine 5'nucleotidase type-I (P5'N-1) activity in red cells and detection of mutations in the P5'N-1 gene.

Basophilic Stippling

Basophilic Stippling

Basophilic Stippling

Malaria

Four species of human Plasmodium protozoa:

Plasmodium vivax P.falciparum P.malariae P.ovale

Heinz Bodies Heinz bodies appear as small round inclusions within the red cell body, though when stained with Romanowsky dyes they may appear as projections from the cell. They appear more clearly when supravitally stained (e.g., with methylene blue or bromocresyl green). Heinz bodies can be suspected if bite cells (degmacytes) are seen on Wright's stained smears. On the next slide are three bite cells, indicated by the arrows. The cells appear to have had a bite taken out of them. Heinz bodies are membrane-bound and bite cells are caused by their removal. The patient was receiving aspirin-phenacetin-caffeine (APC) tablets for relief of pain.

Heinz Bodies (Bite Cells)

Platelets overlying erythrocytes sometimes may be mistaken for inclusions. Platelets generally have a halo around them if they are seen over a red cell

Siderocytes Red cells that have iron-containing, bluish-green granules are called siderocytes. Siderocytes are seen in anaemia's with disordered haemoglobin synthesis, which include: sideroblastic anaemia's, thalassemia, refractory anaemia, dyserythropoiesis, leukaemia, and preleukemia. The iron is in the form of ferritin or hemosiderin. They are particularly evident in any of these diseases after splenectomy.

Siderocytes

Cabot Rings Cabot rings are thin, red-violet staining, threadlike strands in the shape of a loop or figure-8 that are found on rare occasions in erythrocytes. They are believed to be microtubules that are remnants from a mitotic spindle. Cabot rings have been observed in a handful of cases in patients with megaloblastic anaemia, lead poisoning and other disorders of erythropoiesis. They were first described in 1903 by American physician, Richard Clarke Cabot (1868-1939).

Cabot Rings

Cabot Rings

Dimorphic film

Reticulocytes Reticulocytes are immature red blood cells, typically composing about 1% of the red cells in the human body. Reticulocytes develop and mature in the red bone marrow and then circulate for about a day in the blood stream before developing into mature red blood cells. Like mature red blood cells, reticulocytes do not have a cell nucleus. They are called reticulocytes because of a reticular (mesh-like) network of ribosomal RNA that becomes visible under a microscope with certain stains such as new methylene blue. (Supravital Stain) The normal range of values for reticulocytes in the blood depends on the clinical situation and the lab, but broadly speaking is 0.5% to 1.5%.

Supravital Staining of Reticulocytes

Reticulocytes

Acute Myeloid leukaemia with Auer Rods AML

Auer Rods

Giant Platelets Giant platelet syndrome (Bernard-Soulier syndrome): This condition is a primary problem of platelets in which the platelets lack the ability to stick adequately to injured blood vessel walls and as a result of this problem there is abnormal bleeding. The giant platelet syndrome usually presents in the newborn period, infancy, or early childhood with bruises, nose bleeds (epistaxis), and/or gum (gingival) bleeding. Later problems can occur with anything which can induce bleeding such as menstruation, trauma, surgery, or stomach ulcers.

Giant Platelets

Platelet

Pelger Huet Anomaly Pelger-Huët anomaly (PHA) is a benign dominantly inherited defect of terminal neutrophil differentiation secondary to mutations in the lamin B receptor (LBR) gene. Characteristics observed on blood smears include leukocytes with dumbbell-shaped bilobed nuclei; a reduced number of nuclear segments; coarse clumping of the nuclear chromatin in neutrophils, lymphocytes, and monocytes. Pelger-Huët cells survive normally in circulation. They have normal leukocytic function and can phagocytize and kill micro-organisms.

Examination of a peripheral blood smear in an individual heterozygous for Pelger-Huët anomaly (PHA) is remarkable for neutrophils with a predominance of bilobed, spectacleshaped nuclei.

Cells that contain twin, joined, and plump nuclei resembling dumbbells are predominant. A thin bridge, which is thinner than that observed in a normal band neutrophil, joins the 2 lobes.

About 69-93% of the neutrophils show nuclear segmentation that is arrested at the bilobe level. A small population of neutrophils that possess a nonlobulated oblong or peanut-shaped nucleus is often present.

Pelger Huet