Blood smear

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Blood smear
Peripheral blood smear - stained and unstained.jpg
Two push-type peripheral blood smears suitable for characterization of cellular blood elements. Left smear is unstained, right smear is stained with Wright-Giemsa stain.
ICD-9-CM 90.5
MedlinePlus 003665

A blood smear, peripheral blood smear or blood film is a thin layer of blood smeared on a glass microscope slide and then stained in such a way as to allow the various blood cells to be examined microscopically. Blood smears are examined in the investigation of hematological (blood) disorders and are routinely employed to look for blood parasites, such as those of malaria and filariasis.

Contents

Preparation

A blood smear is made by placing a drop of blood on one end of a slide, and using a spreader slide to disperse the blood over the slide's length. The aim is to get a region, called a monolayer, where the cells are spaced far enough apart to be counted and differentiated. The monolayer is found in the "feathered edge" created by the spreader slide as it draws the blood forward.[ citation needed ]

Unstained peripheral blood smear closeup.jpg
Unstained
Stained peripheral blood smear closeup.jpg
Wright-Giemsa stained
Closeups of the feathered edge of blood smears. The pale middle band of the gradient is the monolayer.

The slide is left to air dry, after which the blood is fixed to the slide by immersing it briefly in methanol. The fixative is essential for good staining and presentation of cellular detail. After fixation, the slide is stained to distinguish the cells from each other.[ citation needed ]

Routine analysis of blood in medical laboratories is usually performed on blood films stained with Romanowsky stains such as Wright's stain, Giemsa stain, or Diff-Quik. Wright-Giemsa combination stain is also a popular choice. These stains allow for the detection of white blood cell, red blood cell, and platelet abnormalities. Hematopathologists often use other specialized stains to aid in the differential diagnosis of blood disorders.[ citation needed ]

After staining, the monolayer is viewed under a microscope using magnification up to 1000 times. Individual cells are examined and their morphology is characterized and recorded. [1] [2]

Clinical significance

Normal Adult Blood Smear.JPG
Chronic Myeloid Leukemia smear 2009-04-09.JPG
The left image shows a microscopic view of a normal adult blood film, while the right image shows a blood film from a patient with chronic myeloid leukemia.
Variations of red blood cell shape on blood film, overall termed poikilocytosis Poikilocytes - Red blood cell types.jpg
Variations of red blood cell shape on blood film, overall termed poikilocytosis

Blood smear examination is usually performed in conjunction with a complete blood count in order to investigate abnormal results or confirm results that the automated analyzer has flagged as unreliable. [3]

Microscopic examination of the shape, size, and coloration of red blood cells is useful for determining the cause of anemia. Disorders such as iron deficiency anemia, sickle cell anemia, megaloblastic anemia and microangiopathic hemolytic anemia result in characteristic abnormalities on the blood film. [2]

The proportions of different types of white blood cells can be determined from the blood smear. This is known as a manual white blood cell differential. The white blood cell differential can reveal abnormalities in the proportions of white blood cell types, such as neutrophilia and eosinophilia, as well as the presence of abnormal cells such as the circulating blast cells seen in acute leukemia. [4] Qualitative abnormalities of white blood cells, like toxic granulation, are also visible on the blood smear. Modern complete blood count analyzers can provide an automated white blood cell differential, but they have a limited ability to differentiate immature and abnormal cells, so manual examination of the blood smear is frequently indicated. [5] [6]

Blood smear examination is the preferred diagnostic method for certain parasitic infections, such as malaria and babesiosis. [7] Rarely, bacteria may be visible on the blood smear in patients with severe sepsis. [8]

Malaria

Blood smears showing various developmental stages of the malaria parasite Plasmodium falciparum, stained with Wright stain and Giemsa stain Synchronsed P falciparum cultures.jpg
Blood smears showing various developmental stages of the malaria parasite Plasmodium falciparum , stained with Wright stain and Giemsa stain

The preferred and most reliable diagnosis of malaria is microscopic examination of blood smears, because each of the four major parasite species has distinguishing characteristics. Two sorts of blood smear are traditionally used. [9]

From the thick smear, an experienced microscopist can detect all parasites they encounter. Microscopic diagnosis can be difficult because the early trophozoites ("ring form") of all four species look identical and it is never possible to diagnose species on the basis of a single ring form; species identification is always based on several trophozoites.[ citation needed ]

The biggest pitfall in most laboratories in developed countries is leaving too great a delay between taking the blood sample and making the blood smears. As blood cools to room temperature, male gametocytes will divide and release microgametes: these are long sinuous filamentous structures that can be mistaken for organisms such as Borrelia. If the blood is kept at warmer temperatures, schizonts will rupture and merozoites invading erythrocytes will mistakenly give the appearance of the accolé form of P. falciparum. If P. vivax or P. ovale is left for several hours in EDTA, the buildup of acid in the sample will cause the parasitised erythrocytes to shrink and the parasite will roll up, simulating the appearance of P. malariae. This problem is made worse if anticoagulants such as heparin or citrate are used. The anticoagulant that causes the least problems is EDTA. Romanowsky stain or a variant stain is usually used. Some laboratories mistakenly use the same staining pH as they do for routine haematology blood films (pH 6.8): malaria blood films must be stained at pH 7.2, or Schüffner's dots and James' dots will not be seen.[ citation needed ]

Immunochromatographic capture procedures (rapid diagnostic tests such as the malaria antigen detection tests) are nonmicroscopic diagnostic options for the laboratory that may not have appropriate microscopy expertise available. [11]

Related Research Articles

<span class="mw-page-title-main">Cytopathology</span> A branch of pathology that studies and diagnoses diseases on the cellular level

Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1928. Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues. Cytopathology is frequently, less precisely, called "cytology", which means "the study of cells".

<span class="mw-page-title-main">Romanowsky stain</span> Family of related stains for examination of blood including the detection of parasites

Romanowsky staining is a prototypical staining technique that was the forerunner of several distinct but similar stains widely used in hematology and cytopathology. Romanowsky-type stains are used to differentiate cells for microscopic examination in pathological specimens, especially blood and bone marrow films, and to detect parasites such as malaria within the blood.

<span class="mw-page-title-main">Complete blood count</span> Routine laboratory test of blood cells

A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and platelets, the concentration of hemoglobin, and the hematocrit. The red blood cell indices, which indicate the average size and hemoglobin content of red blood cells, are also reported, and a white blood cell differential, which counts the different types of white blood cells, may be included.

<span class="mw-page-title-main">Babesiosis</span> Malaria-like parasitic disease caused by infection with the alveoate Babesia or Theileria

Babesiosis or piroplasmosis is a malaria-like parasitic disease caused by infection with a eukaryotic parasite in the order Piroplasmida, typically a Babesia or Theileria, in the phylum Apicomplexa. Human babesiosis transmission via tick bite is most common in the Northeastern and Midwestern United States and parts of Europe, and sporadic throughout the rest of the world. It occurs in warm weather. People can get infected with Babesia parasites by the bite of an infected tick, by getting a blood transfusion from an infected donor of blood products, or by congenital transmission . Ticks transmit the human strain of babesiosis, so it often presents with other tick-borne illnesses such as Lyme disease. After trypanosomes, Babesia is thought to be the second-most common blood parasite of mammals. They can have major adverse effects on the health of domestic animals in areas without severe winters. In cattle, the disease is known as Texas cattle fever or redwater.

<span class="mw-page-title-main">Staining</span> Technique used to enhance visual contrast of specimens observed under a microscope

Staining is a technique used to enhance contrast in samples, generally at the microscopic level. Stains and dyes are frequently used in histology, in cytology, and in the medical fields of histopathology, hematology, and cytopathology that focus on the study and diagnoses of diseases at the microscopic level. Stains may be used to define biological tissues, cell populations, or organelles within individual cells.

<span class="mw-page-title-main">Wright's stain</span> Hematologic stain that facilitates the visual differentiation of blood cell types

Wright's stain is a hematologic stain that facilitates the differentiation of blood cell types. It is classically a mixture of eosin (red) and methylene blue dyes. It is used primarily to stain peripheral blood smears, urine samples, and bone marrow aspirates, which are examined under a light microscope. In cytogenetics, it is used to stain chromosomes to facilitate diagnosis of syndromes and diseases.

<span class="mw-page-title-main">Giemsa stain</span> Stain used for diagnosis of malaria

Giemsa stain, named after German chemist and bacteriologist Gustav Giemsa, is a nucleic acid stain used in cytogenetics and for the histopathological diagnosis of malaria and other parasites.

<span class="mw-page-title-main">Schistocyte</span> Fragmented portion of a red blood cell

A schistocyte or schizocyte is a fragmented part of a red blood cell. Schistocytes are typically irregularly shaped, jagged, and have two pointed ends.

The reticulocyte production index (RPI), also called a corrected reticulocyte count (CRC), is a calculated value used in the diagnosis of anemia. This calculation is necessary because the raw reticulocyte count is misleading in anemic patients. The problem arises because the reticulocyte count is not really a count but rather a percentage: it reports the number of reticulocytes as a percentage of the number of red blood cells. In anemia, the patient's red blood cells are depleted, creating an erroneously elevated reticulocyte count.

<span class="mw-page-title-main">Leishman stain</span> Diagnostic technique

Leishman stain, also known as Leishman's stain, is used in microscopy for staining blood smears. It is generally used to differentiate between and identify white blood cells, malaria parasites, and trypanosomas. It is based on a methanolic mixture of "polychromed" methylene blue and eosin. The methanolic stock solution is stable and also serves the purpose of directly fixing the smear eliminating a prefixing step. If a working solution is made by dilution with an aqueous buffer, the resulting mixture is very unstable and cannot be used for long. Leishman stain is named after its inventor, the Scottish pathologist William Boog Leishman. It is a version of the Romanowsky stain, and is thus similar to and partially replaceable by Giemsa stain, Jenner's stain, and Wright's stain.

<i>Babesia</i> Genus of protozoan parasites

Babesia, also called Nuttallia, is an apicomplexan parasite that infects red blood cells and is transmitted by ticks. Originally discovered by the Romanian bacteriologist Victor Babeș in 1888, over 100 species of Babesia have since been identified.

<span class="mw-page-title-main">Diff-Quik</span>

Diff-Quik is a commercial Romanowsky stain variant used to rapidly stain and differentiate a variety of pathology specimens. It is most frequently used for blood films and cytopathological smears, including fine needle aspirates. The Diff-Quik procedure is based on a modification of the Wright-Giemsa stain pioneered by Harleco in the 1970s, and has advantages over the routine Wright-Giemsa staining technique in that it reduces the 4-minute process into a much shorter operation and allows for selective increased eosinophilic or basophilic staining depending upon the time the smear is left in the staining solutions.

<span class="mw-page-title-main">Tzanck test</span> Skin test for chickenpox and herpes

In dermatopathology, the Tzanck test, also Tzanck smear, is scraping of an ulcer base to look for Tzanck cells. It is sometimes also called the chickenpox skin test and the herpes skin test. It is a simple, low-cost, and rapid office based test.

<span class="mw-page-title-main">Pappenheimer bodies</span> Abnormal iron deposits in red blood cells

Pappenheimer bodies are abnormal basophilic granules of iron found inside red blood cells on routine blood stain. They are a type of inclusion body composed of ferritin aggregates, or mitochondria or phagosomes containing aggregated ferritin. They appear as dense, blue-purple granules within the red blood cell and there are usually only one or two, located in the cell periphery. They stain on a Romanowsky stain because clumps of ribosomes are co‐precipitated with the iron‐containing organelles.

<span class="mw-page-title-main">Elliptocyte</span> Abnormal red blood cell

Elliptocytes, also known as ovalocytes or cigar cells, are abnormally shaped red blood cells that appear oval or elongated, from slightly egg-shaped to rod or pencil forms. They have normal central pallor with the hemoglobin appearing concentrated at the ends of the elongated cells when viewed through a light microscope. The ends of the cells are blunt and not sharp like sickle cells.

The mainstay of malaria diagnosis has been the microscopic examination of blood, utilizing blood films. Although blood is the sample most frequently used to make a diagnosis, both saliva and urine have been investigated as alternative, less invasive specimens. More recently, modern techniques utilizing antigen tests or polymerase chain reaction have been discovered, though these are not widely implemented in malaria endemic regions. Areas that cannot afford laboratory diagnostic tests often use only a history of subjective fever as the indication to treat for malaria.

<span class="mw-page-title-main">Dmitri Leonidovich Romanowsky</span> Russian physician

Dmitri Leonidovich Romanowsky was a Russian physician who is best known for his invention of an eponymous histological stain called Romanowsky stain. It paved the way for the discovery and diagnosis of microscopic pathogens, such as malarial parasites, and later developments of new histological stains that became fundamental to microbiology and physiology.

<span class="mw-page-title-main">White blood cell differential</span> Blood test

A white blood cell differential is a medical laboratory test that provides information about the types and amounts of white blood cells in a person's blood. The test, which is usually ordered as part of a complete blood count (CBC), measures the amounts of the five normal white blood cell types – neutrophils, lymphocytes, monocytes, eosinophils and basophils – as well as abnormal cell types if they are present. These results are reported as percentages and absolute values, and compared against reference ranges to determine whether the values are normal, low, or high. Changes in the amounts of white blood cells can aid in the diagnosis of many health conditions, including viral, bacterial, and parasitic infections and blood disorders such as leukemia.

<span class="mw-page-title-main">Cytocentrifuge</span> Laboratory equipment

A cytocentrifuge, sometimes referred to as a cytospin, is a specialized centrifuge used to concentrate cells in fluid specimens onto a microscope slide so that they can be stained and examined. Cytocentrifuges are used in various areas of the clinical laboratory, such as cytopathology, hematology and microbiology, as well as in biological research. The method can be used on many different types of specimens, including fine needle aspirates, cerebrospinal fluid, serous and synovial fluid, and urine.

Alder–Reilly anomaly, or Alder anomaly, is an inherited abnormality of white blood cells associated with mucopolysaccharidosis. When blood smears and bone marrow preparations from patients with Alder–Reilly anomaly are stained and examined microscopically, large, coarse granules may be seen in their neutrophils, monocytes, and lymphocytes. The condition may be mistaken for toxic granulation, a type of abnormal granulation in neutrophils that occurs transiently in inflammatory conditions.

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