Central Philippine University
College of Medical Laboratory Science
Laboratory Activity No. 5
RBC Indices and Morphology
Learning Outcomes:
At the end of this activity the student must be able to:
1. perform accurately a red cell morphology evaluation on a stained peripheral blood smear.
2. describe, illustrate and grade correctly the normal and abnormal red cell morphology.
3. correlate correctly the RBC indices to RBC morphology.
4. apply correctly the formula in solving problem related to blood indices and constants.
5. perform correctly laboratory safety and waste management at all times.
Contents
01 Introduction
RBC Indices
Normal RBC Morphology
RBC Morphology Variation
Peripheral Blood Smear Examination
02 for RBC Morphology
Materials and Equipments
Specimen
Principle
Procedure
QA/QC
03 Reference Values
Physiologic and Pathologic Variations of RBC
04 Indices
Conditions with Increased or Decreased levels
Introduction
RBC indices are commonly used as an aid in diagnosing and differentiating anemia.
1. Mean Corpuscular Volume (MCV)
2. Mean Corpuscular Hemoglobin MCH
3. Mean Corpuscular Hemoglobin Concentration (MCHC)
4. Red cell distribution width (RDW)
Red cell morphology is observed and described by light microscopy in the optimal area of a
properly prepared and stained blood film.
Introduction
Mean Corpuscular Volume (MCV)
• Indicates average volume of a single RBC
• Unit: femtoliter (fL)
• 1 fL = 10−15 L = 1 μm 3
• Interpretation:
a. Normocytic RBC (80-96 fL)
b. Microcytic RBC (<80fL)
c. Macrocytic RBC (>96 fL)
MCV = Hct (%) × 10
RBC (×1012/L)
Introduction
Mean Corpuscular Hemoglobin (MCH)
• Average weight of Hb per RBC
• Unit: picogram (pg)
• 1 pg = 10−12 g
• Interpretation
a. Normochromic: 27.5 – 33.2 pg
b. Hypochromic: <27.5 pg
c. Hyperchromic: >33.2 pg
MCV = Hb (g/dL) × 10
RBC (×1012/L)
Introduction
Mean Corpuscular Hemoglobin
Concentration (MCHC)
• Average concentration of hgb in the RBC in g/dL
• Unit: % (g/dL)
• Interpretation:
a) Normochromic: 33.4-35.5%
b) Hypochromic: <33.4%
c) Hyperchromic: >35.5%
MCHC = Hb (g/dL) × 100
Hct (%)
Introduction
Red Blood Cell Distribution
Width (RDW)
• Indicates degree of anisocytosis (variation
in size)
• Determined from the RBC histogram
• Normal value: 12-17%
RDW = SD of MCV × 100
Mean MCV
www.vetclinpathimages.com
Introduction
Normal RBC Morphology
1. Biconcave disk (“discocyte”)
2. Circular with a smooth edge
3. Central pallor fades into reddish-pink cytoplasm
4. Diameter of 7-8 μm, MCV of 80-100 fL and thickness of 2.5 μm
5. RBCs should be slightly separated from one another; barely
touching without overlapping
6. Do not normally contain particulate inclusions
RBCs should be examined for deviation in size, shape,
distribution, hemoglobin concentration, inclusions
Introduction
RBC SIZE VARIATIONS
Microcytes Macrocytes Anisocytosis
Introduction
RBC STAINING (Hb CONCENTRATION) VARIATIONS
Anisochromia
Hypochromia Hyperchromia Polychromatophilia
Introduction
RBC DISTRIBUTION VARIATIONS
Rouleaux
formation Agglutination
Introduction
RBC SHAPE VARIATIONS
Elliptocytes/
Acanthocytes Codocytes Dacryocytes Drepanocytes Echinocytes Ovalocytes
Keratocytes Schistocytes Spherocytes Stomatocytes
Introduction
RBC INCLUSIONS
Basophilic Howell-jolly Pappenheimer
Stippling Cabot Rings Hb H Inclusions Heinz Bodies Bodies Bodies
Peripheral Blood Smear Examination
for RBC Morphology
Reagents and Equipments
1. Microscope
2. Immersion oil
3. Prepared slides
4. Automated count report 1
Specimen
Capillary blood or venous whole blood collected with
EDTA
Principle
4
An appropriately prepared and stained blood film is
systematically scanned microscopically to identify
erythrocyte morphology. RBC morphology 2
assessment should be congruent with the information 3
given by the automated hematology analyzer.
Procedure
1 Check slide identification. Ensure that
film and automated count report
identification match.
2 Perform patient specimen orientation. Review
the automated count report, noting the MCV,
MCH, and MCHC of red cells. The above
information is compared to the actual findings
on the blood film. Any extreme discrepancy
should be investigated immediately and
resolved.
Procedure
3 Observe in thin portion of the smear
adjacent to feather edge. The examination
area should represent at least 1/3 of the
entire film and RBCs should be slightly
separated from one another.
4 Perform low-power scan. RBC
morphology is observed first
under low-power scan for major
abnormalities.
Procedure
5 Perform oil-immersion examination of the blood film.
Evenly spread a thin layer of immersion oil over the
blood film in the examination area toward the feather
edge. RBC inclusions (e.g. malaria, basophilic
stippling, Howell-Jolly bodies, etc.) can be visualized
with certainty only by using oil immersion microscopy.
6 Appropriate OIFs composed of approximately 200
red cells should be examined with 1000×
magnification. Evaluate at least 10 fields to identify
size, shape, hemoglobin content, and distribution
pattern of red cells.
Procedure
7
GRADING SCALE FOR ANISOCYTOSIS
Report erythrocyte morphology
AND POIKILOCYTOSIS
using the provided grading scale.
% of RBCs that vary in size or
Grading
shape from normal RBCs
Normal 5%
Slight 5 – 10%
1+ 10 – 25% (few)
2+ 25 – 50% (moderate)
3+ 50 – 75% (many)
4+ >75% (marked)
QA/QC
1. Blood samples are best analyzed within 2 hours of blood collection.
2. Blood film should be interpreted alongside patient’s clinical details
(history and physical examination).
3. The head of the smear should be avoided as the cell density is twice
that seen at the tail
4. Reports are generated in duplicates and stored in a retrieval system
(electronic or manual or both).
5. Films/ slides should also be stored and preserved for a minimum
length of time for possible retrieval or review.
6. Slides are stored in shelves away from light exposure.
Reference Values
Conventional units Factor SI units
MCV 80 - 96 um3 1 80 - 96 fL
MCH 27.5 - 33.2 pg 1 27.5 - 33.2 pg
MCHC 33.4 - 35.5 % 0.01 0.334 - 0.355
RDW 12 - 17 % 0.01 0.12 - 0.17
Physiologic and Pathologic Variations
Decreased MCV Increased MCV
• Megaloblastic anemia
• IDA,
• Hemolytic anemia with
• Thalassemia
reticulocytosis
• Sideroblastic anemia
• Liver disease
• Lead poisoning
• Normal newborn
Increased RDW
IDA, post-transfusion, post-treatment (e.g. iron, B12, or folic acid therapy),
idiopathic sideroblastic anemia, in the presence of two concurrent deficiencies
(iron and folic acid deficiency)
Physiologic and Pathologic Variations
Decreased MCH and Increased MCH and
<22% MCHC
MCHC MCHC
should not • Chronic blood loss • Macrocytic anemia
>38%
occur; lipemic
• Lead poisoning • >35.5% MCHC seen in the MCHC
plasma or presence of spherocytes. should not
abnormal Hb • IDA
occur.
(Hb S or C) • Thalassemia
• Sideroblastic anemia
Sample Problem
What is the MCV, MCH and MCHC (in S.I. units) if the
hemoglobin is 130 g/L, hematocrit is 0.39 L/L and the RBC
count is 4.1 × 1012/L?
MCV = (Hct/RBC) × 10 = 95.1 fL
MCH = (Hb/RBC) × 10 = 31.7 pg
MCHC = (Hb/Hct) × 100 = 33.3%
References
Textbooks
• Brown, B. A. (1993). Hematology: Principles and procedures (6th ed.). Estados Unidos:
Lea & Febiger.
• Keohane, E. M., Smith, L. J., Walenga, J. M., Rodak, B. F. (2016). Rodak's hematology:
Clinical principles and applications (5th ed.). St. Louis, MO: Elsevier.
• Lo, R. W., Liu, E. B., Orillaza, M. A., Faundo, A. C., & J., D. C. (2012). PCQACL'S
Standardization and harmonization of complete blood count in the Philippines (1st ed.).
Quezon City: C & E Publishing.
• McPherson, R. A., & Pincus, M. R. (2011). Henry's Clinical Diagnosis and Management by
Laboratory Methods E-Book. Saunders.
• Stiene-Martin, E. A., Lotspeich-Steininger, C. A., & Koepke, J. A. (1998). Clinical
Hematology: Principles, procedures, correlations. Philadelphia: Lippincott-Raven.
Online Resources
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415389/
