ANOMALIES OF ERYTHROCYTIC SERIES IN PERIPHERAL BLOOD 51 ed-purpl filament, called Cabor's ring, a faintly in the figure. Basophilic stip. = also found inthe same erythrocyte. Cabos£28. f-Thalassemia major (producing target cells) ‘80. Obstructive jaundice (producing target cell) . Target cells are conspicuous. They stain lightly in this case, looking like a target because there isa bright ringed region between the deeply stained ‘peripheral and central pats. When observed by sean- ‘ing electron microscopy, they look like a cup or salad bowl. When smeared, the central ‘part becomes prominent like @ Mexican hat or target 29. This case is Hb SC disease, one of the hemoglobin anomalies resulting from inheritance of hemoglobin $ and hemoglobin C, one from each parent. Hemolytic anemia develops. 31. LCAT deficiency (producing target cells) 80, ‘Target cells are also conspicuous in jaundice. When obstructive jaundice has been ‘surgically, cells revert to normal. Alterations of lipids, such as an increase in cholesterol level obstructive jaundice, change the iid the red cell membrane and lead tan i ‘rane surface area, resting inthe generation thin erythrocytes. 81. This feature is caused by hereditary lecithin-cholesterol acyltransferase ( Alterations of plasma lipids caused by ‘eficieney affect the lipid composition of the ‘membrane, resulting in generation of target (Courtesy of Dr. Chikayuki Nato, Tokyo. Hospital, Tokyo, Japan.)semia minor is a heterozygous disorder 2 mild hypochromic microeytic anemia, where ells are inconspicuous. Anisocytosis and poikilo- prominent, smear is from the mother (postsplenectomy) of ‘whose smear is shown in Figure 33 above. unstable hemoglobin hemolytic anemia as does ‘because this disease is dominantly inherited. ANOMALIES OF ERYTHROCYTIC SERIES IN PERIPHERAL BLOOD 53 35. Unstable hemoglobin hemolytic anemia (after splenec- tomy) However, the post-splenectomy morphology of erythro- ‘yes is markedly different from that preoperatively. ‘Slightly shrunken erythrocytes containing one large n= clusion body are conspicuous, ‘of hemoglobin appear inthe per they can no longer be removed by the spleen. In the ‘figure, some erythrocytes with Stippling and54 ATLAS OF BLOOD CELLS: 4. An increased number of normal at various maturation stages ate found. Us ‘such circumstances, hemolytic anemia should suspected. v b 2, There are many erythroblasts that are than normal and appear shrunken because of ‘seantier cytoplasm. Suspect iron deficiency 3. Many large polychromatic erythroblasts ‘observed, in which the eytoplasm is mature for stage, Conspicuously, the nucleus isi revealing a delicate nuclear chromatin structure: maturity ofthe nucleus is not balanced by tht. the cytoplasm, These cells are megalobast. ‘an image, as shown ere, is characteristic of loblastic anemia, confirming the diagnosis. te cause: either deficiency of vitamin By, or acid. Mepalobasts at various maturation stages. ‘shown below in Figures 4 to 7 under high fication.ANOMALIES OF ERYTHROBLASTIC SERIES IN BONE MARAOW 55 lic megaloblast lie megaloblasts are larger but often dif- iscriminate from normal basophilic8. The cytoplasm of orthochromatic erythro ‘synthesis. Suspect sideroblastic anemia and iron stain to confirm, Erythrocytes show dim phism. 9, Prussian blue staining revealed that iron gr ‘les surround the nuclear margins of erythrobl (ringed sideroblasts). Although the case here is lead poisoning, ring sideroblasts are also char istic of sideroblastic anemia. ron granules are co tained in the mitochondria. . 10. Characteristically, basophilic stipling is co spicuous and there is hyperplasia of erythrob ‘with anomalous nucle’ in this patient with acute le poisoning. In the previous figure, ring siderobl are demonstrated by iron staining. Lead inhib both decomposition of ribosomes and heme sis, resulting in this image. 11. Hyperplasia of megaloblastoid cells (nm ‘chromatin more clumped than in the megalob is observed. Most of the cells are polychromaic.. binucleate erythroblast containing Howell-Jo ‘bodies (shown by the arrow) is also present, is from a patient with the rare congenit dyserythropoietic anemia (CDA) I. (Courtesy of Dr. Mitsuhiro Omine, Gun University, Gunma, Japan.)ANOMALIES OF ERYTHROBLASTIC SERIES IN BONE MARROW $7. Dyserythropoietic Anemia Vo" | (high magnification) ‘megaloblastoid cell is present. {i (low magnification) ‘mature, binucleate orthochromatic {8 are_more conspicuous than idcellsin CDA I. CDA Iisalso called in Ham's test and negativity in the sucrose test chardéterize this rare disease. sy of Dr. Mitsuhiro Omine, Gunma ‘Gunma, Japan.) Ill (low magnification) large, multinucleated megaloblastoid 9ieuous. The maturity of the cells varies. y of Dr. Nobuo Yamaguchi, Kobe Kobe, Japan.) Il (high magnification) appearance is unique to CDA TIL. It must be sated from erythroleukemia, If hyperplasia is observed, it indicates erythro-58 ATLAS OF BLOOD CELLS 16. A mulinucteate erythroblast and a myelo (lower-eft) are found in the figure, This is fn case oferythroleukemia (acute myelocytic leukt FAB type My). 17. PAS stain Many coarse PAS-positive granules are obst in this mulinucleate megaloblastoid cell at several mononuclear erythroblasts. This findi characteristic of erythroleukemia (acute myele leukemia, FAB type Mc). * 18. Cabot's ring ‘The Cabot's ring shown here was observed ‘orthochromatic megaloblast in pernicious an ‘The naked nucleus has been extruded from ferent cell,‘ANOMALIES OF ERYTHROBLASTIC SERIES IN BONE MARROW 59 ie crisis caused by B19 Parvovirus recovery phase of aplastic crisis caused by in the previous case. Hyperplasia of cerythroblastic sevies is marked.1. Peroxidase reaction with diaminot dine (normal bone marrow) ‘ods have been selected. Since benzidine and) chloric benzidine are not available due ‘carcinogenicity, the former two methods are resent. 2. Peréxidase reaction with amine bazole (normal bone marrow) 3-amino-9-ethyl carbazole is used (ISCH 3. Peroxidase reaction with diaminc zidine and Giemsa counter-stain ‘mal bone marrow) (Figures 1-3: Courtesy of Dr. Tadashi Koil | Dr. Akira Shibata, Niigata University, Ni Japan.)CYTOCHEMISTRY OF LEUKOCYTES 61 Alkaline Phosphatase Reaction r Method) and Acid hosp! (by Tomonaga’s or Kaplow's Method) at ‘mal peripheral blood) phosphate as a substrate and fast blue reaction solution are used. This method and y described by Kaplow are recommended by | j ‘The former is superior in ease of calculating 4 but inferior in thatthe reaction time is longer ‘Sours vs 15 minutes). This smear is stained ly (+4). The method is widely used in Japan, king phosphatase reaction in Saupe, Tomonage's method (or Joo Alkaline phosphatase reaction in ‘neutrophils, Kaplow’s method (normal ‘peripheral blood) ‘method is inferior to Tomonaga’s in image ‘Acid phosphatase reaction (T cell Iym- phooytic leukemia) is method is recommended by ICSH. Acid is present in lysosomes. ‘Acid phosphatase reaction (T cell lym- pphocytic leukemia) tion by tartrate is observed. Tis is impor- for diagnosis of hairy cell leukemia,62 ATLAS OF BLOOD CELLS ‘6-2. PAS Resetion, Non-Spocfic Esterase Reaction and f-olucuronidase Reaction | p » ae 7 § 4 8. PAS reaction (acute lymphocyti leukemia) ‘This reaction is useful for diagnostic pur It is used for revealing the presence polysaccharides. Granulocytes ae stained diffuse and positively, while lymphoblasts clearly sl positive granules. In some cases, however, ostivity occurs. Note that erythroblasts are stained intensely in erythroleukemia (see p.58). 9. Non-specific esterase reaction ( cytic leukemia [acute myelocyti leukemia, FAB type M}) ‘naphthyl butyrate as a substrate and aniline asa reaction solution ae used. Cells of monocyte series are stained positively. This is recommended by ICSH. reaction (with conaphthy! butyrate pararosaniline) and chloroacets ‘esterase reaction (with naphthol chloroacetate and fast blue BB! leukemia, FAB type M,]) In this smear, cells of the monocyte series -non-specific-sterase-positive and stain brown, wh cells of the granulocytic series are chloroacetat esterase positive and stain blue. This stain is re ‘mended by ICSH. 11, -Glucuronidase Reaction {Prslucuronidase is an enzyme contained lysosomes. Therefore, the intensity of the sti {is proportional tothe content of lysosomal granulPhagocytosis of ink particles by ‘leukocytes (Monocytic leukemia [acute myelocytic leukemia, FAB type Ms] Peripheral blood) ‘phagocytosis is observed.(64 ATLAS OF BLOOD CELLS 10-1. Anomalies of Neutrophils. (Toxic Granules, Déhle Bodies and Pelger-Huét An 1. Toxic granule and Dahle body in neutrophil Granules in normal neutrophils are relatively ‘and not very conspicuous, while those in s Gnfection) are large and stain intensely. The I are called “toxic granules.” Electron mi shows that they are large azurophilic granules ‘mary granules) and the number of neutrophil ules (secondary granules) is markedly reduced as. result of degranulation. The arrow in the fi indicates a Dohle body (the area of cytoplasm s 1g blu), 2. The margins of the neutrophils are obscured ‘ean been seen thatthe neutrophil inthe upper are observed in infectious diseases, 3. Pelger-Huét anomaly (Pelger anom: ‘These neutrophils are segmented onl lobes. The nuclear chromat a large clu ‘This smear is from a case of autosomal domi trait and did not show any symptoms, (Courtesy of Dr. Tomoski Matsumoto, Dr, Tsuyoshi Yoshioka, Kumamoto University ‘Kumamoto, Japan.)Psoudo-Pelger anomaly Although the morphology of the nucleus i simi- ‘to that in the Pelger anomaly, pseudo-Pelger ly is acquired in diseases such as leukemia myelodysplastic syndrome (MDS). In this smear ‘case of MDS, the nuclear chromatin is not ‘condensed as in Pelger anomaly. Hypersegmented neutrophil In nommal neurophils, the nuclei have two or lobes in most cases, four or five in only few s six oF more lobes are never seen. Tis cell ‘case of mezalobastic anemia has seven or lobes. Such ahypersegmented neutrophil may be observed in the myelodysplastic syndrome 3), infections*and in heavy metal poisoning. ‘May-Hegalin anomaly ‘Dole bodies staining pale blue are presenti the sn of the neutrophils shown by arrows (9). are decreased in number. A giant platelet as shown by the arrow (P). This smear patient with autosomal dominant trait May- in anomaly. In most patients no symptoms ‘but in some there is a bleeding tendency. y of Dr. Hideo Hayashi, the Second Red Hospital of Kyoto, Kyoto, Japan.) ANOMALIES OF LEUKOCYTE SERIES IN PERIPHERAL BLOOD 657. Chédiak-Higashi syndrome, stain) Large blue staining granules are conspi the neutrophil, This disease is inherited in an | (Figures 7-9: Courtesy of Dr. Sumio Miyaz ‘Saga Medical College, Saga, Japan.)ANOMALIES OF LEUKOCYTE SERIES IN PERIPHERAL BLOOD 67 Atypical lymphocyte Atypical lymphocytes are large cells with dim- ‘up to 20 um. The eytoplasm stains deep blue. ‘nucleus is eccentric, There appear to be visible oli. The shape of the cell is similar to the cell. many atypical lymphocytes are found, cease can be diagnosed as infectious mononucle- Atypical lymphocyte ‘Two cells which are similar to but slightly smaller in the previous figure are seen. These are not a cells. Such cells may appear not only in mononucleosis, but also in viral hepatitis, and hypersensitivity to medicaments or ~ ‘Atypical lymphocyte “This cell is much larger than previously ius: Iisa large lymphoid cell having cytoplasm is more basophilic than normal lymphocytes. It thought that B lymphocytes increase in number the intial stage of infectious mononucleosis 1) while T lymphocytes increase during the serious stage (Weeks 2-3). ‘Atypical lymphocyte This is a large lymphoid cell. Bright muceol re {nthe upper part of the nucleus. Tis eel be misclassified as a leukemia cell if viewed = isolation. It is, therefore, important to examine entice smear to assess the other cells present cells, lymphoblasts or monocytes) The structure of atypical lymphocytes is in coarser than that of leukemia cells although is delicate in some cases.[ANOMALIES OF LEUKOCYTE SERIES IN PERIPHERAL BLOOD 67 ‘Acute Myeloid Leukemia (FAB Types My, Ma, M; and Ma Variant) ‘Acute myeloid leukemia (FAB type Mi) atic leukemia, Three myeloblas's show= ‘maturation tendency are found. These are ‘Acute myoloid leukemia (FAB type M.) laste leukemia. These three leukemia cells sna small numberof azurophilie granules."The ‘of these cells is uneven and their nuclei are ‘The cell in the upper part has an Auer rod cells are peroxidase-positive. ” ‘Acute myeloid leukemia (FAB type M:) Promyelocytic leukemia. Two cells inthe figure ‘promyelocytes. The nucle have irregular shapes. cytoplasm is also irregularly shaped. A number “Auer rods are found in the cell atthe center of figure. Acell wth bundles of Auer rods is called oazot cell. The cell at the center is therefore cel, Patients with this disease often present bleeding due to disseminated intravascular ation (DIC). ‘Acute myeloid leukemia (FAB type My variant) “The azurophilie granules are smaller than those ypical promyelocytic leukemia (Ms). The nuclei promyelocytic leukemia cells in the peripheral are kidney-shaped or indented. There are fewer containing Auer rods. The total leukocyte count zenerally normal or decreased i his variant. This ‘might be erroneously diagnosed as mono- je leukemia Ms, when only cells of peripheral fare observed.70 ATLAS OF BLOOD CELLS 10-7. Acute Myeloid Leukemia (FAB Types My, My, Msp and My) — 21. Acute myeloid leukemia (FAB type’ “Myelomonocytic leukemia. Three cells in figure have monocytic characteristics. The cell the upper-right also has azuropilic granules, ing like « promyelocyte. However, its nucleus ‘monocytic characteristics with nucleoli thus been judged as an immature cell of the mo series (promonoeyt). 22, Acute myeloid leukemia (FAB type “Monoeytic leukemia. There are two forms: i mature type Msy, where the majrity of cells ‘monoblass, and Ma, where the majority of cll the peripheral blood are mature monocytes. The in the figure is @ promonocyte, because it has cleoli and is juvenile 23, Acute myeisid leukemia (FAB type Monocytic leukemia Ma, Mature monocytes present in the peripheral blood, Inthe bone the majority of cells are more juve (promonocytes). 24, Acute myeloid loukemia (FAB type. Erythroleukemia, In the ease shown here. ‘multinacleate erythroblasis found in te per blood (as indicated by the arrow).ANOMALIES OF LEUKOCYTE SERIES IN PERIPHERAL BLOOD 71 ‘Acute myeloid leukemia (FAB type M) mia. This smear is from the previ- ‘The appearance of erythroblasts in the blood is marked (—»). A juvenile cell of seties is also present (D>). ‘Acute myeloid leukemia (FAB type My) yeytic leukemia. The cell inthe Figure blast witha 15 um diameter. The mucleat/ rato is high. The nucleus has two or nucleoli. iéchromatn is slightly condensed. -ytopasm is tained slightly deeper blue. This, hs no granules but develops small pseudopo- ‘oF vesicle-ike protrusions (blebs). On mroscopy the cell was found tobe pate ase positive thus confirming the diagno x of Dr. Kiyoaki Watanabe, Keio Uni- ‘Tokyo, Japan.) ‘Acute Lymphocytic Leukemia (FAB ‘type Ly) ae small lymphoblasts of relatively simi- “Although the nuclear chromatin distribu {s relatively even in general, it cannot be as delicate. bright nucleolus is found in ‘middle of the cell An indent is found in the ofthe lowest cel ‘yloplasi is extremely scanty in these cells72 ATLAS OF BLOOD CELLS vw” € 28. Acute lymphocytic leukemia (F 7 " type L:) ‘The size of the cells varies; some are more t twice as large as others. The nuclei have consp cous indents or nicks. The nuclear chromatin st ture is coarser. The cell in the lower left seem have an indistinct nucleolus. The cytoplasm is si and stained blue, having no granules. ‘No example of peripheral blood from FAB | LL is shown but for a bone marrow example pas. 29. Acute lymphocytic leukemia (FAB t L,) PAS Stain PAS-positive granules, which stan as large co ‘granules (blocks) are found. Although suct ‘observation is characteristic of leuke lymphoblasts not only in L; but also other lympl last leukgmias, not every case shows PAS-| tive granules. Even if granules are PAS-negat) ‘can not be concluded that the case is not on ‘acute lymphocytic leukemia, 30. Adult T-cell leukemia (ATL) This disease is not included in the PAB el fication. Although itis so acute that patients | ie within one year, it progresses chronicall some cases. This disease is frequently found i ‘West of Japan (Kyushu). The siz of cells is ung CCharacterstcally, the nuclei have projections look like brains oF flowers with open petals, nuclear chromatin structure is slightly co ‘Marked splenomegaly, anemia, and skin infil. characterize this disease.ANOMALIES OF LEUKOCYTE SERIES IN PERIPHERAL BLOOD 72 Hairy coll leukemia figure shows many linear projections ex- ‘out from the periphery of a lymphoid eel, ell has @ marker for B lymphocyte. Another feature is a tartrate-resistant acid reaction (not shown here). Marked galy is found but lymph node enlargement very conspicuous. Mast cell leukemia is a rare disease. In the figure, relatively ‘granules that resemble those found in mast ‘or azurophilic granules are conspicuous. The vas confirmed by metachromasia revealed ine staining and the presence of character ‘mast cell granules on electron microscopy of cells Marked splenomegaly was found sy of Dr. Tsukasa Abe, Tsukuba Univer- ‘baraki, Japan.) Plasma cell leukemia picture represents an exfoliating myeloma ‘many myeloma cells in the peripheral blood. ‘cells have characteristics of plasma cells: the @ are eccentric and the juxtanuclear light area ‘The cells shown here seem to be relatively the nuclear chromatin is condensed, while fare obscured. These cells originate from B Macroglobulinemia (Waldenstrém's ‘macroglubulinemia) this disease, the plasma monoclonal IgM level remarkably. The cell shown here origi- ‘rom the B lymphocyte. While there is re- to the plasma cell, no osteolytic lesions ‘sbserved radiologically. Splenomegaly and ode enlargement are often found. In some the cells appear morphologically closer to74 ATLAS OF BLOOD CELLS F__ 35. Chronic myeloid leukemia Leukocytes are markedly increased in num! Granulocytes in various maturation stages are s In addition, basophils are prominent (>). Ae nophilie myelocyte is seen in the upper right ( ‘These are characteristic of the peripheral bloo! the chronic phase of this disease. Typically, mat splenomegaly is found. A markedly decreased < tent of neutrophil alkaline phosphatase and presence of the Philadelphia (Ph!) chromos (translocation of material from Chromosome 2 Chromosome 9) confirm the diagnosis. 36. Blastcrisis in chronic myeloid leuke (myeloblastic) In the terminal phase the blood morpholog similar to that in acute myeloid leukemia. ‘majority of cells are myeloblasts. An Auer re also visible, as shown by the arrow. * 37. Blast crisis in chronic myeloid leuke (lymphoblastic) In the terminal phase the majority of cell small iymphoblass. These are peroxidase-nes and a myeloid cell is stained positively, Acute phoblastic transformation occurs in about one Of patents with chronic myeloid leukemia. 38. Chronic lymphocytic leukemia Tn the majority of cases of this disease Teukemia cells are of the B cell variety. The are relatively small and look like normal : lymphocytes. At the top ofthe figure a smeare (basket cel) is present. These cells are freq present in chronic lymphocytic leukemia.|ANOWALIES OF LEUKOCYTE SERIES IN PERIPHERAL 8LOOD 75 Malignant lymphoma here are non-Hodgkin’s lymphoma cells exfoliated into the peripheral blood. Marked ism may be present. Large nucleoli are ‘Malignant lymphoma ww cell shown here is a non-Hodgkin's Iym- cell having an extremely atypical nucleus. i are present. Cancer cell ‘carcinomatosis from bladder carcinoma. cell shown here is large (over 20 jum in diam- lis cytoplasm is plentiful and has inregular This 1s clearly not a cell of hemopovetic Lymphocyte in Niemann-Pick disease lymphocyte shown here is characterized by inthe cytoplasm. A similar phenomenon seen in othe lipidoses. Niemann-Pick dis- an autosomally recessive inherited disease, sphingomyelins accumulate in cells,platelet observed in a patient with myelodysplastic syndrome (MDS) platelets observed in a patient with ibocythemia ‘noua plaiclets also can be seen. (Cour: ‘of Dr. Tatsuo Abe, Kyoto Prefectural Univer- ‘of Medicine, Kyoto, Japan) platelet observed in a patient with karyécytic leukemia (acute myeloid ikemia, FAB type M;) ikaryocyte observed in peripheral Blood ‘nucleus is almost naked. The platelet count alter splenectomy in a patient with kinase deficiency. blast observed in megakaryo- leukemia (acute myeloid leukemia, type Mr) Hs is a relatively small blast characterized by pseudopodium-like or vesicl-like protrusions ‘The diagnosis was confirmed by subsequent microscopic findings that the platelets were idase-postive. ‘of Dr. Kiyoaki Watanabe, Keio Uni- Tokyo, Japan.)76 ATLAS OF BLOOD CELLS 12. ANOMALIES OF LEUKOCYTIC SERIES IN BONE MARROW 12-1. Acute Myeloid Leukemia (M;, M2 and M,) Its important to recognize the principal morpho- logic features of the different types of leukemic cells. It is also important to discriminate my- ¢eloma (multiple myeloma) cells from malignant Iymphoma cells. 1. Acute myeloid leukemia (FAB type M.) ‘Myeloblastic leukemia (acute), Myeloblasts showing no maturation tendeney are seen. In thi figure, one or two large bright nucleoli are found. 2. Acute myeloid leukeria (FAB type Ma) ‘Myeloblastic leukemia (acute). Myeloblasts show: ‘8 maturation tendency. Promyelocytes are present (in the bottom and upper-right). 3. Acute myeloid leukemia (FAB type M) Promyelocytic leukemia. The majority of cells ‘are promyelocytes that are quite atypical and have: inmegularly shaped nucle. A bleeding tendency due to disseminated intravascular coagulation (DIC) = ‘often the presenting feature in this type of acute leukemia.[ANOMALIES OF LEUKOCYTIC SERIES IN BONE MARROW 73 myeloid leukemia (FAB type M,) sytic leukemia. There isa cell contain- of Auer rods (faggot cell), as shown by ‘Acute myeloid leukemia (FAB type M,) ‘myelomonocytic leukemia, In this exam- appear tobe differentiating along two lines. in the upper left part, which is slightly smaller has round azurophilic granules, seems to be of granulocytic series, while the other cells seem fof the monocytic series. Discrimination is ple sing only the May-Giemsa stained ‘serum lysozyme content is increased. ‘Acute myeloid leukemia (FAB type M,) esterase reaction of acute myelomonocytic cells. This method consists of the esterase with cenaphthyl butyrate to stan cells of ‘monocyte series brown, and a second esterase on with naphthyl AS-D chloroacetate to stain ‘ofthe granulocytic series blue. This technique two series of leukemia cells. ‘Acute myeloid leukemia (FAB type M,) le esterase reaction on acute myelomono- leukemia cells in the previous case. The cell ‘middle has features of both monocytic and yc series, being therefore stained by both10 ATLAS OF 8L000 CELLS 18. Acute myeloid leukemia (FAB type ‘This variant is subclassified into two types (poorly differentiated) and Ma (well dif Tn Ms, 80% or more of monocytes are inthe Bone marrow. In May less than 80% of m cells are monablasts, Ms, is closely related anomaly of Iq” chromosome. ‘9. Acute myeloid leukemia (FAB type Double esterase reaction of acute m leukemia M, cells All the leukemia cell the mature neutrophil in the mide (Dive) are rmonoeytic series. The reaction solution used forthe esterase reaction with d-naphihy! bs is fast gamet GBC not pararossnilin. 10, Acute myeloid leukemia (FAB type! ‘Wel-differeniated acute monocytic leu ‘The majority of the cells are promonacytes monocytes 11. Acute myeloid leukemia (FAB type! Esterase reaction with cenaphthyl but _well-ifferentiated acute monocytic leukemis & “The reaction solution used here is as in 9. leukemia cells are stained positively, whic cates that they are of the monocyte series. (Figures 6-11: Courtesy of Dr. Tadashi ‘and Dr Akira Shibata, Niigata University, NiANOMALIES OF LEUKOCYTIC SERIES IN BONE MARROW 81 Acute myeloid leukemia (Mc) hroleukemia. Two large multinucleated blasts are seen in the figure, The cel inthe left in which the margin of the cytoplasm is seems tobe a myelobast (because maclol ‘clearly visible). Acute myeloid leukemia (M,) stained erythroleukemia cells. As shown “Anomalies of Erythroblastic Series in ipheral Blood,” PAS-positive material ig as blocks or coarse granules are found in abnormal cells of the erythroblast series. In this, ‘one PAS-negative cell, which may be a ‘with a round nucleus, is seen t0 the left of the multinucleate erythroblast. Acute myeloid leukemia (Mc) As erythroleukemia progresses, myeloblasts be- conspicuous, as shown by the arrows. Other in the figure, with dark blue cytoplasm, are4 ATLAS OF BLOOD CELLS 15. Acute myeloid leukemia (M,) overlying the megakaryocyte cytoplasm. There three cells which are thought tobe blasts with nuclei and one cell in which small, like or vesicl-like protrusions (blebs) ae ‘ous, The diagnosis was confirmed by el ‘microscopic findings that the platelets were dase-positive. 16. Acute myeloid leukemia (M,) ‘Megakaryoytic leukemia. Same case as 15 under high magnification. The blasts are uneven: size. Nucleoli are visible. Pseudopodium-like ‘tusions are conspicuous in these cells, (Figures 15-16: Courtesy of Dr. Kiy: ‘Watanabe, Keio University, Tokyo, Japan.) * 17. Acute lymphocytic leukemia (ALL; type Li) As in the peripheral blood, the cells are small. less uneven in size. The cytoplasm is scanty virtually absent making the nucleus ook naked. round nuclei are deeply stained and the nucleoli ‘obscured. Some of the nuclei are indented. A basket cell is seen in the lower left comer. 18. Acute lymphocytic leukemia (FAB type L) As in the peripheral blood, the cells are uneven in ize and have indented nuclei. The cytoplasm and. nuclei have small vacuoles. No granules are visible in the cytoplasm. To determine whether they are of Tor B-lymphocyte origin, immunophenotypic analysis is necessary.Acute lymphocytic leukemia (L;) ‘The cells shown here are uneven in size but in large. The nuclear chromatin structure is ly delicate, There are one or two nucleoli cytoplasm is seanty in some cells but relatively ‘in others. Ly is defined as Burkit’'s Iym- Ls cells are B cells. Although detailed clini- findings are unknown, this case can be diagnosed. sgically as Ls. This variant is rare in Japan, Chronic myeloid leukemia (CML) ‘The features are almost the same a in the periph- ‘blood, except tha, as shown here, an increased ‘of megakaryocyte is seen. Another ditfer- is that exythroblasts are also found (to the right the megakaryocyte in the figure), although the ion is small. Two basophils are seen in the i. Myeloma This disease is also called multiple myeloma, atypical plasma cells having one or more ‘nucleoli, ic, myeloma eels, ae found. The are uneven in size and the chromatin struc- is more delicate than in normal plasma cells. cells resemble normal plasma cells in that the sm is stained dark blue and has a large clear light area andthe nucleus is eccentic. ANOMALIES OF LEUKOCYTIC SERIES IN BONE MARROW 89 am 5] | ia ee {23. Malignant lymphoma "Non-Hodgkin’s lymphoma, The cells shown are large and very uneven in size. The nuclei ‘extremely anomalous, having large nucleoli. ‘These are grossly atypicaeels. Non-Hodgkin Aymplioma and Hodgkin's disease are usually nosed histologically following lymph node ‘Recently, however, cel surface marker studies {ng monoclonal antibodies have been used toc sify the forme plasm and even in the nucleus.MEGAKARYOCYTE ABNORMALITIES 85 Idiopathic thrombocytopenic purpura BSP) flow cower magrthontin) Se ee a en ss cbeerviton sce inficuce an in, apse cerca os ne in peicious anemia patient asa mani- of dyshematopoiesis. Despite the small 1nd stlntnsely blue cytoplasm, drombop- seta tcracascri: terara on Pstic) appears to bo budding fom his cel ‘The cell above the night arrow (>) i a giant yte, classic feature of the perici a myelogram. permet‘The one in the center is binucleate and exhibit ‘thrombopoiesis. Dyshematopoiesis was observed. Nucleoli are apparent in this polynucteatemeg- skaryocyte, a leukemic cell, Platelet peroxidase reaction was postive on electron microscopy. (Courtesy of Dr: Kiyoaki Watanabe, Keio Uni versity, Tokyo, Japan.)PERIPHERAL BLOOD ABNORMALITIES IN MYELODYSPLASTIC SYNDROME 87 ‘erthrocyte with basophilic6. Giant platelet (large platelet)MARROW ABNORMALITIES IN MVELODYSPLASTIC SYNDROME 69, = Polychromatic megaloblastoid cells ‘Nuclear maturation clearly lags behind cyto- je maturation. This patient has vefiactory with excess of blasts (RAEB), Erythroblast abnormalities Assingle small, condensed nucleus surrounded ‘many small spheres of the same color as the (similar to Howell Jolly bodies). Tis is process of karyomtexis. Examples (+) of abnormal erythro- blasts, the large erythrocyte having a Howell-Jolly body (>) This is an example of a ringed sidero- blast seen in a patient with RAEB.90 ATLAS OF BLOOD CELLS ‘11. Multinucleate (4 nuclei) megalob! cell and binucleate leukocyte (neut myelocyte?) 12. Polychromatic erythroblast with clo shaped nuclear abnormality binucleate giant band neutrophil 1. Agranular neutrophil ‘The example is the somewhat small neutrop ‘onthe right side. Such cell ae peroxidase neg: (RAEB). 14, Neutrophil with ring-shaped nucl (doughnut-shaped nucleus) (RAEB).MARROW ABNORMALITIES IN MYELODYSPLASTIC SYNDROME 91 45. Giant metamyelocyte Large cell at top (RAEB). power magnification) eo ecere nee laa pees @ +47. Megakaryocyte abnormalities (medium power magnification) ‘This field includes atleast three megakaryocytes. “The one the right has undergone endomitosis, while ‘other two nuclei remain circular and regular. power magnification) ‘The cytoplasm is in a stage of prolific granule jon, but the nucleus is nearly circular and not have the iregular nuclear shape seen typi- in the mature megakaryocyte.92 ATLAS OF BLOOD CELLS 1. Foam cells ‘This name arises because of the soap bubble-ike appearance of the macrophage cytoplasm, Cases ‘marked by an increase in these cells are collectively termed “foam cell syndrome” ‘2. Gaucher's disease This isa genetic disorder in which large amounts of glucocerebroside accumulate in ysosomes dt Beslucocerebrosidase deficiency. Cells become e=- largd, the nicl are eccentric, andthe eytoplsse exhibits characteristic appearance (Courtesy of De Teruo Kitagawa, Nihon Univer sity, Tokyo, Japan) 3. Niemann-Pick cells seen in Niems Pick disease Thisisa genetic disorder in which large: of sphingomyelin accumulate in lysosomes duc sphingomyclinase defcincy. Cells become and the cytoplasm presents a foamy appearance (Courtesy of Dr. Toshiyuki Yanase) 4. Histiocytic medullary reticulosis ‘There is a dramatic proliferation of histi with a remarkable ability to phagocytose: neutrophils and erythrocytes. The disease is nant and progresses rapidly.MARROW CANCER CELLS 99 . MARROW CANCER CELLS ‘with all marrow examination by microscopy, metastatic cancer i suspected is imperative frst examive under low power, to look for three- nal clumps of cells. Bone marrow metastatic cancer (carci- nomatosis of the bone marrow) Aspiration is best performed at any easily punc- area where there is spontaneous or compression This photomicrograph was taken at low power shows that metastatic cancer cells (aiger that «i cells in marrow) have formed nests (clumps). Carcinomatosis of the bone marrow High power view of the previous case: Among | ‘atypical large cells, the cellular margins have indistinct. The primary focus is unknown, Carcinomatosis of the bone marrow ‘Metastatic gastric cancer: Large cells are joined and the cytoplasmic margins are indistinct. ruecleol are visible. Since the peripheral blood of carcinomatosis of the bone marrow certain distinctive features, observers should familiar with the section on peripheral blood Bone marrow metastases from neuro- blastoma ‘The disease cannot be diagnosed definitively this cellular appearance alone, however, the rosette formation is suggestive.‘94 ATLAS OF BLOOD CELLS 18. ARTIFICIAL DEFORMATION OF BLOOD CELLS 18-1. Echinocytes, Doughnut-Shaped Erythrocytes, Pseudo-Elliptocytes: 1. Echinocytes (crenated cells) for when blood is kept to0 long before ‘The cells become dehydrated and their ‘concentration declines. Elution of alkaline ‘contained ina glass slide can also cause this.Ferrata Cell ‘This is a ruptured promyelocyte, also called @ cel.Malaria parasites breed within erythrocytes in- side the human body and consequently the diagnosis of malaria roqures a blood test ‘When the number of parasites is small, exami- nation ofa thick peripheral blood film i efficient, but this does not show the parasites as distintly as 4 regular smear sample unless the observer is ex- Petienced. ‘The important points in smear preparation are: preparation of a smear in which atleast 1/3 ofthe sample is a monolayer of blood cells, rapid drying carried out using ahair dryer, and th use of a buffer solution of pH 7.2 (7-7.2) during Giemsa staining. ‘This pH is particularly important. In routine hematology laboratory buffer solution of pH 6.4— 66 is used. However, such acidity will thin the basophilic protoplasm of malaria parasites, making staining difficult. Ths tenders immature ring forms ‘ar to se, particularly the fine ring of Plasmodium falciparum. Schitiner’s dots can also remain un- stained, ‘When a buffer solution of pH 7.2 is used malaria ‘parasite protoplasm and Schifner’s dots are stained vividly, making detection and classification of the ‘malaria parasite 25 ‘Types of malaria include vivax malaria (tertian ‘malaria), malariae malaria (quartan malaria), falciparum malaria, and ovale malaria. The most ‘common is vivax malaria, followed by fap ‘malaria. The malaria parasite reproduces sexual ‘within the mosquito but asexually within the hum ‘body. The reproductive patter (developmental. ofthe different varieties is much the same, but th forms at each developmental stage and the ti required for development differ, allowing the v ties to be distinguished. ‘When the mosquito bites, a sporozoite (a sick {form with a central nucleus) enters the human bo ‘The organism then transits through ‘becomes an immature reproductive trophozite, centers erythrocytes as @ ring form trophozoite. ‘wophozoite matures gradually (often described ‘both a semi-mature reproductive form and lage i form, amoeboid [trophozoite), and produces eral merozoites that Weave the erythrocyte ‘merozoites re-enter erythrocytes and repeat t above-mentioned asexual reproduction. ‘Inadition to this asexual reproduction, a port of the parasites produce reproductive gametoc distinguished as male and female. The cytoplasm the female reproductive form appears deeper than that of the male, and its chromatin ranula material within vacuoles. The mae dctive form generally appears pale and has chromatin including «number offi cleavages “Thering forms lo casfid as citer youn ‘ring form (early trophozoite), or an older ring (ate trophozcit)isa vivid blue, and the nucleus isa vivid 4, Plasmodium falciparum (ing form) 3, 4. Plasmodium falciparum (ring form) ‘Maurer's dots are visible in Figures 3 and 4. Figure 4 is a high power magnification of the falciparum malaria ring form in which Maurer's dots stain brilliantly. Maurer’s dots are larger than the Schiffner’s dots seen in vivax and ovale ma- laria, Maurer’s dots stain ed.(98 ATLAS OF BLOOD CELLS 5. Plasmodlum falciparum (ing frm) = 7. Plasmodium faliparum (schizont) '8. Plasmodium falciparum (crescentic (6. Plasmodium faleiarum (immature schizont) 19-2. Plasmodium falciparum 8. Plasmodium falciparum (cres¢ seamen ace 5. Plasmodium falciparum (ring torm) tion of falciparum malaria she ere indetes the ng fs Beloy his slaia(creseentegametoytes) (hick dep: and tothe right isa trophozoite with distinct large He Tower lft of center is a cresentc Maurer’ dos. Broad bands are a distinctive feature 8ametocyte unique to falciparum malaria. " i finding is clear evidence of fale of Plasmodivan malariae wophozoites (not illustrated 1 iparum in this volume. : infection. The arrow indicates a ring form, but type of ring form cannot be distinguished 6. Plasmodium falciparum (immature foe ie een pee rer) ce Since athick drop is useful forthe rapid and diagnosis of malaria parasites, profci 7. Plasmodium falciparum (schizont) this preparation technique is desirable, Group of schizonts.Plasmodium falciparum (immature gametocyte) The immature gametocyte retains red cell ghost, 12. Plasmodium falciparum (immature gametocyte) ‘11. Plasmodium falciparum (immature gametocyte) A female gametocyte. 12. Plasmodium falciparum (immature gametocyte) A male gametocyte. Crescentic gametocyte dis- tinctive in faleiparum malaria,18, Plasmodium vivax (thick drop) 15. Plasmodium vivax (hick drop) 114, Plasmodium vivax (schizont) (thick drop) 16. Plasmodium vivax (thick drop) 19-4. Plasmodium vivax 15. Plasmodium vivax (thick drop) ‘A sehizont is visible below and left of 19. Plasmodium vivax (thick drop) “Many ring forms can be seen. az Fray oot tid ness of 46. Plasmodium vivax (thick drop) fs ‘Two gametocytes are visible. A leukocyte is Vis 14. Plasmodium vivax (schizont) (thick —* ‘he lower left. ‘rop)18. Plasmodium vivax (“ing form and trophozoite) 20. Plasmodium vivax (schizont) 419. Plasmodium vivax (schizont) 19-5. Plasmodium vivax 19. Plasmodium vivax (schizont) Merozoites are numerous. Merozoites stan a deep blue. The brown colored material is malaria pig- 17. Plasmodium vivax (ring form) = Pink colored and fine Schiffner's dots are visible Jn the ring form of Plasmodium vivax. oa t Same sample as Figure 17. Brown malaria ‘ments visible andhas the appearance of mulberries. [Although the schizont of Plasmodium malariae does ‘ot appear in this volume, it resembles a chrysan- themum, witha central grouping of malaria pigment and merozoites around it. 18. Plasmodium vivax (ring form and trophozoite) Double infection ofa single erythrocyte with rng form and trophozoite. Schlfner's dots are striking.102 ATLAS OF BLOOD CELLS 23. Plasmodium ovale (wophozote) 19-6. Plasmodium vivax, Plasmodium ovale 21. Plasmodium vivax (gametocyte) ‘A male gametocyte, 22. Plasmodium vivax (gametocyte) ‘Due to delay in specimen preparation, consider- able artificial deformation is apparent and prevents distinguishing the male from the female gameto- cyte.Plasmodium ovale (immature schizont) 28. Plasmodium ovale (schizont) 27. Plasmodium ovale (immature schizont) 28. Plasmodium ovale (schizont) ‘The number of merozoites is not distinct, but a scarcity is considered a distinctive feature of ovale ‘malaria, (A portion of the malaria specimens were pro- vvided by Dr. Tsutomu Ebizawa, Toho University, ‘Tokyo, Japan.)#. 31. Wucherera bancroft (peripheral blood) ‘32. Wuchereria bancrof (peripheral blood) | | | | @ - ~~ ‘19-8. Filariasis (Wuchereria ‘in the circulating blood. The size of these bancroft) an be judged by comparison with leukocytes. worm forms are 4-8 jim wide and 150 jum lo ‘These are microfilaria of Wuchereria bancrofti, 29-32. Wuchereria bancrofti (peripheral etiologic agent of filariasis. In the Giemsa stain. blood) center portion of the worm form, is readily ‘Various stages (peripheral blood). Figures 29 and guishable. 30 are Giemsa stain, and Figures 31 and 32 areazure (Courtesy of Dr. Hiroshi Tanaka and Dr. To | ‘stain, Microfilaria of Wuchereria bancroftiobserved Shibutani, Tokyo University, Tokyo, Japan.)49-9. Trypanosoma cruzi (Chagas’ disease), kala-azar (leishmaniasis) 33, 34. Trypanosoma cruzi, etiologic agent of Chagas’ disease (American trypanosomiasis) Giemsa stain of Trypanosoma crici observed in ‘he peripheral blood. This specimen was obtained from mouse. Chagas’ disease occurs widely in South and Central America and is transmited 10 ‘worm from the foeces of a reduviid bug in which the trypanosomas have a cycle of development be- ‘ore becoming infective to worm. The acute phase marked by fever, hepatosplenomegaly, and myo~ cardial dysfunction and is frequently fatal. Diagnosis is by peripheral blood smear. Trypanosoma gambiense iste etiologic agent of, [BLOOD PARASITE DISEASES 105, ‘96. Kala-azar (visceral leishmaniasis) [African trypanosomiasis, caused by the bite of the tsetse fly and also termed sleeping disease. 35,36. Etiologic agent of kala-azar (visceral leishmaniasis) ‘This specimen is a smear taken from a hamster spleen. The 2-4 um elliptical bodies are Leishmania donovani, the etiologic agent, found in large aggregations in macrophages. ‘The illness is transmitted by the bite ofthe sand fly and is distributed in China, India, Aftica, and South America. The ate phase presents with fever, later with splenomegaly, hepatomegaly anemia, and hhypergammaglobulinemia, Diagnosis i by spleen ‘oF marrow smears. (Courtesy of Dr. Yoshitake Wada, Tokyo ‘Women's Medical College, Tokyo, Japan.)Suggested steps in the analysis of a BM aspirate to reach a diagnosis of AML (M1 to M6) or MDS » BM Aspiration Hypocalar BM on fms iu i ‘CELLULAR Bt eu bopay = ‘. sewn acim son rt t eon tnons ae, [AN a ncioated bone marrow cate, bone marron ‘als exclcing non pomatopote cole ecenonerthvat ct. bone matron cle ‘excluding anrvebiaats Gasims) ‘Summary of the Quantitative Bone-Marrow Criteria Propased for the Diagnosis of Acute Myeloid Leukemia Subtypes!” Bone Marrow Cells ML M2 M4 = MS M6 FSS Blasts ‘All nucleated cells, 330330 <30 or >30 Nonerythroid cells 90+)? >30 >30 >80” >30 Erythroblasts, all nucleated cells _ <0 <5 50 Granulocytic components®, nonerythroid cells] <10 >10.- 320” <20.—Variable Monocytic component, nonerythroid cells <10 20-320 >80” Variable 1) Lysceye extn and cytochemical ess re ogre if the peripheral od monocyte counts 5097 or more bat the mar ‘sogges M2 anf th maw sggests MA but he peripheral od macy conn ss than S197 2) Blass type Tanda pevouly deseo, 3) Monoblas in MS; in MSP the predominant cells ae prmonocye nd noc, 4) Promyeocyes, metamyeloeyts, and neotopis 5) May node myeabast, 6) Promennsye and note. (AB, 1985)Classification of Myeloid Leukemic Cells Myeloid leukemic cells PO + SB (postive biasts = 3% + +, < 3% + -) Eee ° ra) onan er ae | | ohne {3 M1, M2, M3, M4 eNBE (-) NB (4) @NBE (44) sozyme T NAB) GENAB() NAB (4) NB + GNAE (4) ACP) AcPies) SPB igs) 013+ cons cst onw) (2) ‘CD33+ CD14 + f—co4e + 1 inhibited Cots ele by NaF ‘locton microscopy an SeaysisMPO CS) ysczyme antyis PPO () shox (serum, urine)? * monof (PB) 5,000) 7 * mononuctearphagooyie systom (+) inv (16) wk = £ (9:22) (8:21) oO i) S bd 105317) ‘Suporisor, Kenichi Anam, Manager of incl Laborato, Nakatu National Hospital, Japan