Practice Guidelines on the Reporting of Smudge Cells in

the White Blood Cell Differential Count

Denis Macdonald, MD, MBA, FRCPC, FCAP; Harold Richardson, MBBS, MD, FCCM, FRCPC; Anne Raby, MLT, ART

S mudge cells are a well-described artifact in hematologic

morphology that result from the rupture of fragile
lymphocytes secondary to the process of making the pe-
ripheral blood film (Figure). Although seen in both reac-
tive and malignant lymphocytosis, they are more often
associated with the lymphoproliferative disorders, as the
total lymphocyte counts are usually higher and there may
be acquired membrane defects in these disorders. The is-
sue of either including these cells in the standard man-
ual white blood cell differential count or enumerating
them separately as a proportion of a total differential cell
count has rarely been examined in the literature, as evi-
denced by the dearth of articles on the subject in the MED-
LINE database. Smudge cells are counted accurately as
lymphocytes by modern blood cell analyzers, which com-
monly enumerate 10 000 white cells or more in a 5-cell
differential count. The issue is clinically significant when
comparisons are made between the manual differential
counts and the automated differential counts performed Smudge cells with adjacent lymphocytes in chronic lymphocytic leu-
to monitor the lymphocyte doubling time, which has been kemia (Wright-Giemsa stain of blood, original magnification 3400).
promoted as a prognostic factor in disease progression in
chronic lymphocytic leukemia.1 The smudge cells on the
film will not be included in the manual differential, there- issued.2 This guideline recommends reporting an auto-
by resulting in an undercounting of the actual lympho- mated differential count (even with suspect flags) with an
cytes present and an overstating of the neutrophil count associated qualitative comment that smudge cells are pre-
sent. If an automated count is unavailable, smudge cells
relative to the automated count, the true count.
should be counted as lymphocytes with an associated
The Quality Management ProgramLaboratory Servic-
qualitative comment, or as a separate category within the
es (QMP-LS), a joint initiative of the Ontario Medical As-
total differential cell count.
sociation and the Ontario Ministry of Health and Long-
As QMP-LS communicates with every licensed labora-
Term Care, administers an external quality assessment tory in the province of Ontario, we expect that the appli-
program including periodic hematologic check samples cation of this guideline will lead to a standard pattern of
for all licensed laboratories in Ontario. Participants often practice for the reporting of smudge cells. This will avoid
include smudge cells separately from the manual differ- discrepancies when interchanging the use of automated or
ential count, with a resultant discrepancy with the auto- manual leukocyte differential cell counts, which could
mated differential count. A Good Practice Guideline con- possibly cause confusion among clinicians when following
cerning the reporting of smudge cells has recently been the lymphocyte doubling time as a prognostic factor in
chronic lymphocytic leukemia.

Accepted for publication August 26, 2002. References

From the Quality Management ProgramLaboratory Services, To-
ronto, Ontario.
Reprints: Denis Macdonald, MD, MBA, FRCPC, FCAP, Quality Man-
agement ProgramLaboratory Services, 1510-250 Bloor St E, Toronto,
Ontario, Canada M4W 1E6.
1. Zwiebel JA, Cheeson BD. Chronic lymphocytic leukemia: staging and prog-
nostic factors. Semin Oncol. 1998;25(1):4259.
2. Hematology Committee, Quality Management ProgramLaboratory Servic-
es, Ontario. Broadsheet: Good Practice Guidelines on the Reporting of Smudge
Cells. Toronto, Ontario: QMP-LS; June 26, 2001. Hematology-Morphology Bind-
er: vol 3;sect 1.2:1.

Arch Pathol Lab MedVol 127, January 2003 Reporting of Smudge CellsMacdonald et al 105