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WBCs Abnormal Morphology

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Abnormal WBC’s

  • White blood cell (neutrophil and lymphocyte) abnormalities include abnormalities of number (leukocytosis or leukopenia) and of function. Leukocytosis and leucopenia may occasionally indicate serious and potentially urgent medical problems. Congenital white cell dysfunction is rare, but acquired dysfunction is associated with common medical problems.

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Normal ranges

  • The normal number of WBCs in the blood is 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 × 109/L).
  • Type of WBC Normal percentage of overall WBC count
  • Neutrophil - 40 to 70 percent
  • Lymphocyte - 20 to 40 percent
  • Eosinophil - 1 to 4 percent
  • Monocyte - 2 to 8 percent
  • Basophil - 0.5 to 1 percent
  • Normal value ranges may vary slightly among different labs. Some labs use different measurements or may test different specimens.

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Causal conditions:

  • Leukocytosis
  • Reactive (e.g., bacterial infection, infectious mononucleosis)
  • Neoplastic (e.g., leukemias)
  • Leukopenia
  • Increased destruction (e.g., bacterial infection, human immunodeficiency virus)
  • Decreased/ineffective production (e.g., marrow suppression)
  • Leukocyte dysfunction (e.g., HIV, chronic granulomatous disease)

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Specific function white blood cells

  • Monocytes: Frontline defenders that attack anything the immune system considers abnormal
  • Lymphocytes: Blood cells that produce immune proteins called antibodies that target and fight specific disease-causing organisms
  • Neutrophils: Blood cells that mainly fight bacterial infections
  • Eosinophils: Blood cells that mainly fight parasitic infections
  • Basophils: Blood cells that help trigger inflammation to fight infections, diseases, or toxins

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High WBC’s in blood

  • A high white blood cell count usually indicates:

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  • An increased production of white blood cells to fight an infection
  • A reaction to a drug that increases white blood cell production
  • A disease of bone marrow, causing abnormally high production of white blood cells
  • An immune system disorder that increases white blood cell production

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  • Specific causes of a high white blood cell count include:
  • Acute lymphocytic leukemia
  • Acute myelogenous leukemia (AML)
  • Allergy, especially severe allergic reactions
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leukemia
  • Drugs, such as corticosteroids and epinephrine
  • Infections, bacterial or viral
  • Myelofibrosis (a bone marrow disorder)
  • Polycythemia vera
  • Rheumatoid arthritis (inflammatory joint disease)
  • Smoking
  • Stress, such as severe emotional or physical stress
  • Tuberculosis
  • Whooping cough

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Shift To The Left

Morphology�Presence of precursor of granulocytes in the peripheral blood

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Found in

  • Normal in pregnancy or neonate.
  • Infections.
  • Bone marrow fibrosis.
  • Bone marrow infiltration by malignancies.

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Hypersegmentation or right shift of neutrophil nuclei

Morphology�Average lobe count increased OR increased % of neutrophils with 5 - 6 lobes OR > 3% neutrophils with 5 lobes or more.��Found in

  • Megaloblastic anaemia
  • Iron deficiency
  • Chronic infection
  • Liver disease
  • Uraemia�

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Causes

  • There are many different causes of white blood cell disorders. Some are due to a severe infection, an autoimmune disease, genetics, or cancers affecting blood cells or bone marrow.

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Leukopenia

  • Some of the white blood cell disorders associated with leukopenia include:
  • Aplastic anemia: A rare condition in which the body stops producing enough new blood cells
  • Autoimmune neutropenia: A condition in which your immune system mistakenly attacks and destroys neutrophils
  • Congenital neutropenia: A genetic disorder in which the body doesn't make enough neutrophils
  • Cyclic neutropenia: A rare genetic disorder in which neutrophil production drops every 21 days or so
  • Chronic granulomatous disease: An genetic disorder that causes certain white blood cells to malfunction and behave abnormally
  • Leukocyte adhesion deficiencies: A group of rare genetic disorders that affect the white blood cells' ability to fight infection

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Leukocytosis

  • Some of the white blood cell disorders associated with leukocytosis include:
  • Chronic idiopathic neutrophilia: A condition in which neutrophils remain persistently elevated for no apparent reason
  • Hemolytic anemia: A disorder in which red blood cells die faster than they are made, often due to an underlying genetic or autoimmune cause
  • Idiopathic thrombocytopenia: A condition in which your immune system mistakenly attacks and destroys blood-clotting cells called platelets

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Leukocytosis

  • Lymphoma: A group of cancers that start in cells of the lymphatic system
  • Lymphocytic leukemia: A type of blood cancer that starts in lymphocytes
  • Myeloproliferative disorders: Includes six types of slowing-growing cancers that cause the overproduction of white blood cells (chronic eosinophilic leukemia, chronic myelogenous leukemia, chronic neutrophilic leukemia, essential thrombocytopenia, polycythemia vera, and primary myelofibrosis)

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Iron deficiency anemia

  • Iron is very important in maintaining many body functions, including the production of hemoglobin, the molecule in your blood that carries oxygen. Iron is also necessary to maintain healthy cells, skin, hair, and nails.

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IDA

  • Iron deficiency is very common, especially among women and in people who have a diet that is low in iron. The following groups of people are at the highest risk for iron-deficiency anemia:
  • Women who menstruate, particularly if menstrual periods are heavy
  • Women who are pregnant or breastfeeding or those who have recently given birth
  • People who have undergone major surgery or physical trauma
  • People with gastrointestinal diseases such as celiac disease (sprue), inflammatory bowel diseases such as ulcerative colitis, or Crohn disease

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  • People with peptic ulcer disease
  • People who have undergone bariatric procedures, especially gastric bypass operations
  • Vegetarians, vegans, and other people whose diets do not include iron-rich foods (Iron from vegetables, even those that are iron-rich, is not absorbed as well as iron from meat, poultry, and fish.)
  • Children who drink more than 16 to 24 ounces a day of cow's milk (Cow's milk not only contains little iron, but it can also decrease absorption of iron and irritate the intestinal lining causing chronic blood loss.)

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  • Blood loss from the gastrointestinal tract due to gastritis (inflammation of the stomach), esophagitis (inflammation of the esophagus), ulcers in the stomach or bowel, hemorrhoids, angiodysplasia (leaky blood vessels similar to varicose veins in the gastrointestinal tract), infections such as diverticulitis, or tumors in the esophagus, stomach, small bowel, or colon
  • Blood loss from chronic nosebleeds
  • Blood loss from the kidneys or bladder

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  • Frequent blood donations
  • Intravascular hemolysis, a condition in which red blood cells break down in the bloodstream, releasing iron that is then lost in the urine. This sometimes occurs in people who engage in vigorous exercise, particularly jogging. This can cause trauma to small blood vessels in the feet, so-called "march hematuria." Intravascular hemolysis can also be seen in other conditions including damaged heart valves or rare disorders such as thrombotic thrombocytopenia purpura (TTP) or diffuse intravascular hemolysis (DIC).

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Megaloblastic anemia 

  • Megaloblastic anemia is a form of anemia characterized by very large red blood cells and a decrease in the number of those cells. Anemias are blood disorders that occur when the body has fewer red blood cells than normal. Red blood cells carry oxygen throughout the body using a protein called hemoglobin. If there aren’t enough of these cells or this protein, anemia results.
  • Usually, megaloblastic anemia is due to an acquired deficiency in vitamin B12 or folic acid. The deficiency can be related to inadequate dietary intake of these B vitamins or poor intestinal absorption. Rarely, megaloblastic anemias are the result of medications or inherited defects in the transport/metabolism of vitamin B12 or folic acid.

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Drumstick

Morphology�Drumstick shaped nuclear appendage. ± 1,5 µm in diameter and attached to the nucleus by a filament. Inactive X chromosome of the female.

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Found in

  • Neutrophils of females
  • Males with Klinefelter syndrome

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Sessile Nodule

Morphology�Inactive X chromosome found as nodule on neutrophils of females.

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Found in

  • Neutrophils of females

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Ring shaped nuclei

Morphology�Nucleus ring or doughnut shaped.

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Found in

  • Acute myeloid leukemia
  • Chronic granulocytic leukaemia
  • Megaloblastic anaemia
  • MDS

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Detached Nuclear Fragments

Morphology�Detached nuclear material in cytoplasm.

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Found in

  • Dysgranulopoiesis
  • Patients on anti cancer chemotherapy
  • HIV

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Toxic Granulation

Morphology�Increased granulation. Granulation more basophilic and larger than normal.

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Found in

  • Severe bacterial infection.
  • Non specific finding - seen in tissue damage of various types.
  • Normal pregnancy.
  • Therapy with cytokines

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Hypogranulation

Morphology�Reduced granulation in neutrophil cytoplasm.

��Found in

  • Myelodysplastic syndromes

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Dohle Bodies

Morphology�Small pale blue cytoplasmic inclusions, often in the periphery of the cell.

Consist of ribosomes and endoplasmic reticulum

Found in

  • Infective and inflammatory states.
  • Severe burns
  • Tuberculosis
  • Post chemotherapy
  • Pregnancy
  • May-Heggling Anomaly

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Russell bodies 

Morphology

are eosinophilic, large, homogenous immunoglobulin-containing inclusions usually.

Found in

a plasma cell undergoing excessive synthesis of immunoglobulin; the Russell body is characteristic of the distended endoplasmic reticulum

This is one cell variation found in multiple myeloma.

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Phagocytosed Parasites

Morphology�Malaria - Plasmodium falciparum

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Found in

  • Severe malaria infection

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Phagocytosed Platelet

Morphology�Platelet in vacuole in neutrophil cytoplasm

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Found in

  • Infection

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Phagocytosed Red blood cell

Morphology�Red cell in vacuole in cytoplasm of neutrophil

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Found in

  • Infection
  • Auto immune haemolytic anaemia
  • Incompatible blood transfusion

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Auer Raods

Morphology�Small azurophil rods in the cytoplasm of myeloblasts and promyelocytes. Sometimes found in mature neutrophils.

��Found in

  • Acute myeloblastic leukemia.
  • Myelodysplastic syndromes.

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Macro Neutrophils

Morphology�Twice the size of a normal neutrophil with tetraploid DNA content.

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Found in

  • Occasionally in the blood of healthy subjects.
  • Inherited
  • Administration of G-CSF
  • Megaloblastic anaemia
  • Chronic infection

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Necrobiotic / Apoptotic neutrophil

Morphology�Dense homogenous nuclei (pyknotic)

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Found in

  • Occasionally in healthy subjects�In vitro artifact.
  • AML

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Pseudo Pelger Huet Anomaly

Morphology�Bilobed neutrophils with more condensed chromatin

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Found in

  • Inherited Myelodysplastic syndromes.
  • Idiopathic myelofibrosis.
  • Chronic granulocytic leukemia.
  • Therapy with colchicine, ibuprofen.
  • Infectious mononucleosis, malaria, myxedema.
  • CLL

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Neutrophil aggregation

Morphology�Small clumps of neutrophils. Happens in vitro if EDTA anticoagulated blood is allowed to stand. May lead to incorrect WBC.

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Found in

  • In vitro finding.
  • Infectious mononucleosis.
  • Bacterial infections.
  • Auto immune disease.

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Atypical Lymphocytes

Morphology�Pleomorphic. Large with diameter of 15 - 30 µm. Abundant, strongly basophilic cytoplasm. Basophilia may be confined to the cytoplasmic margins.

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Found in

  • Viral infections - EBV, CMV, Hep A, Measles.
  •  Bacterial infections - brucella, tuberculosis.
  • Protozoa – malaria.
  • Immunization.
  • SLE.

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Plasmacytoid Lymphocyte

Morphology�Lymphocyte with basophilic cytoplasm and eccentric nucleus.

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Found in

  • Reactive phenomenon

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Mott cell

Morphology�Plasmacytoid lymphocyte with globular inclusions composed of immunoglobulin.

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Found in

  • Reactive changes in peripheral

blood.

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Large Granular Lymphocyte

Morphology�Small eosinophilic granules in the cytoplasm of large lymphocytes.

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Found in

  • Natural killer cells.
  • Lymphokine activated T cells.

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Monocyte Vacuolization

Morphology

Vacuoles in the cytoplasm of monocytes.

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Found in

  • Infections

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References

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