Tag Archives: Haematopathology

Toxic Granules in Neutrophils

23 Mar IMG_1153 - Toxic Granules

IMG_1153 - Toxic GranulesGranulocytes have two types of granules primary and secondary. Primary granules are azurophilic, most numerous and prominent at the promyelocyte stage (see morphology of myeloid precursors) and diminish in number with further maturation. As the granulocyte matures the staining characters of the primary granules changes. They initially become violet and then became inapparent because they fail to take up stain. The secondary granules appear in the myelocytes and persist for the rest of the ice of the granulocyte. Neutrophils have fine pink secondary granules.

In conditions of intense stimulation of neutrophil maturation the primay granules may continue to take up stain in mature neutrophil because of a higher concentration of acid mucosubstances. These are called as toxic granules and the change called toxic change. The toxic granules are so called because they were first described in patients with gram negative sepsis and endotoxemia but may be found under conditions of intense stimulation of neutrophil production. The may be seen in

  1. Infection
  2. Inflammatory diseases
  3. Pregnancy
  4. Use of haemopoietic growth factors (G-CSF or GM-CSF)

Photomicrography with a Canon 7D SLR

19 Mar

English: Canon EOS 7D with EF 28mm f/2.8 日本語: ...

English: Canon EOS 7D with EF 28mm f/2.8 日本語: キヤノン EOS 7D レンズ:EF 28mm F2.8 (Photo credit: Wikipedia)

“Necessity is the mother of invention (or actually discovery in this case)”

This blog is developed from a manuscript of a haematology book. No haematology book can be complete without photomicrographs. As I did not have access to a microscope camera I had to look for other ways to photograph peripheral blood and bone marrow slides. The first digital camera I had was the Nikon Coolpix 4500. The lens of this camera had a ring equal to that of a microscope eyepiece and the focusing mechanism, unlike most cameras was internal. These features gave me the confidence that if I hold the camera against the eyepiece of a microscope I will not be damaging either. It worked! I have since then used Canon IXUS 105, Canon 400D and Canon 7D for photomicrography. This post is about photomicrography by holding a camera close to the eyepiece of a microscope.

Nikon Coolpix 4500: Nikon Coolpix 4500 is a 4 megapixel camera that was the first camera I tried for photomicrography. It gave usable photographs but the images had many concentric rings. To overcome the “ring” problem one had to ensure that the area to be photographed was at the periphery, where the rings were absent/less prominent. The image below is that with megaloblastic anaemia where the rings were seen

 002

Photomicrograph of a the bone marrow of a patient with megaloblastic anaemia taken with Nikon Coolpix 4500 showing concentric rings

One could apply post processing to some of the photomicrographs to get images acceptable for displaying on a webpage. The same image with post processing is shown below.

Megaloblasts

Cameras Canon IXUS 105: Canon IXUS 105, a much later model, was free of concentric rings. It gave good photographs but gave six dots (I am not sure if this was an issue with the model or the piece I had). The images were large enough to be cropped and I have used these in the post morphology of myeloid precursors. All the images in this post are taken by holding a Canon IXUS against the eyepiece of a microscope.

Six Dots of Canon IXUS 105 001

The image taken with a Canon IXUS 105. The six dots are evident above and to the right (11 o’clock) of the myeloid cells.

Canon 400D with a 50mm f/1.8 II lens: The images of a digital SLR offers are of a better quality than compact cameras. The SLR also gives images that can be processed better. I had tied to use the 400D with the 18-55 kit lens, before using the Canon IXUS 105, but never succeeded. The photograph never filled the entire frame. Then the internet came to the rescue. The 400D set to manual focus took pictures. The 50mm f/1.8mm lens is an inexpensive lens of extremely good quality. I switched to a 50mm f/1.8 II lens. The 400D allows shooing in the RAW format allowing greater post-processing. The Low ISO of the 400D means shooting a slow sutter speeds (1/20-1/40 seconds) which resulted in blurring of images because of camera shake. The 400D does not have alive view mode. The Canon 7D overcomes these limitations.

Canon 7D with 50mm f/1.8 II lens: The Canon 7D allowed fast shutter speed and has a better image capturing device that has given the best images I have taken. The high ISO (unto 3200) allows shutter speeds of 1/100 and eliminates blurring because of camera shake. To take pictures by holding a digital camera close to the eyepiece of a microscope on has to

  1. Set the focus to manual
  2. Set the camera to aperture priority and set the aperture wide open
  3. I prefer setting the exposure to expose such that the histograms is snuggled to the right. This reduces the noise.
  4. Focus the images using the adjustment on the microscope. No focusing is done by the camera. Photographs are taken using one of the eyepieces of a binocular microscope. The two eyepieces may have different focus planes. A slide may appear to be in sharp focus when seen through both objectives but may still not be in sharp focus when through the eyepiece used for photography. Look and focus the slide though the eyepiece you intend to use for photography.
  5. Adjust the white balance. You may use auto white balance, custom white balance or adjust the white balance shift (add blue/green if the microscope lamp is too yellow). you can also adjust the temperature and tint on the image processing software after taking the picture.
  6. Sometimes the image has a bright spot (shown in the picture below). This has happen with the 400D and 7D. Images are framed with the 400D by looking through the viewfinder. The bright spot can not be seen on looking through the viewfinder. It can however be seen in the live view mode of the 7D. It is best to shoot using the live view mode. The spot can be eliminated by slightly tilting the camera. The problem of the bright spot has occurred with all brands of microscopes (local brands to Olympus). I have tried eliminate the spot by adjusting the condenser and changing the illumination but with little success. This has occurred only when seeing the slide under oil immersion objective (100X) never under 40X or 10X.

bright Spot Final

Why the 7D? Photomicrography does not use all the features of a 7D. A 600D or 650D would perform as well. SLR cameras by other manufacturers like Nikon or Sony should give the same results but my experience is limited to Canon SLRs. If you intend to use a camera for photomicrography you need to

  1. Preferably have an SLR – They have a superior image quality than compact cameras. Compact cameras can be used if an SLR is not available.
  2. Those using Canon SLRs may find the 50mm f/1.8 II lens most useful. Some believe this is the best value for money lens Canon has produced. It is incredibly sharp and incredibly inexpensive. ALWAYS USE A UV FILTER. The lens must never touch the eyepiece. I have found the performance better the the kit 18-55 lens.
  3. High ISO capabilities to allow high shutter speeds to eliminate blurring due to camera shake
  4. Live View gives a better view and helps in identifying and eliminating the bright spot.

I have used the 7D because I happen to purchase one for photography which is my hobby. What the 7D offers over a 600D or a 650D is never used in photomicrography. You may use any of the above mentioned cameras and get results.

ISO – The Exposure Triangle

ISO – The Exposure Triangle (Photo credit: abanakas)

Myelocyte and Neutrophils – Band and Segmented

18 Mar Myelo Band Neutro Final

Myelo Band Neutro Final

Neutrophilic Cells. The images shows myelocyte (1), band neutrophils (2), two lobed neutrophil (3) and neutrophils (4)

The image about shows morphology of cells of the neutrophilic series. The first cell to show commitment to a particular granulcoytic series (eosinophilic, basophilic or eosinophilic) is the promyelocyte. The promyelocytes of the three series can however only be differentiated by electron microscopy. The earliest cell showing features of neutrophilic differentiation on staining with Romanowsky staining is the myelocyte. Myelocytes may be neutrophilic, eosinophilic and basophilic. Myelocyte is a round cell with a round to oval nucleus that may be eccentrically placed. The cytoplasm shows two types of granules.

  1. Primary granules: The primary granules are azurophilic (reddish-purple or burgundy color) and are remnants of the granules of  the promyelocyte stage. The myelocyte does not synthesize primary granules. As the cell matures the number of primary granules declines and they disappear by the cells matures to a polymorphonuclear neutrophil.
  2. Secondary granules: The the size and staining of secondary granules are specific to the type of granulocytes. In neutrophils these granules are fine and pink staining

As the myelocyte matures the nucleus becomes more indented and finally becomes lobed.

The image above captures these changes

  1. Cells labels (1) are myelocytes. These show a pink cytoplasm with few primary (azurophilic) and many secondary (fine pink) granules and have a oval eccentrically placed nucleus with clumped chromatin without a nucleolus.
  2. The myelocyte develops and indentation of the nucleus and matures to a metamyelocyte. The metamyelocyte matures to a band neutrophil (cells labeled 2). which is called so because the nucleus is band shaped. With maturation the nucleus develops lobulation. The differentiation between a band neutrophil and a two lobed neutrophil is arbitrary and of little practical importance. A band cell becomes a two lobed neutrophil when its nucleus develops a constriction that is more than half to two third of the nuclear width (cell labeled 3).
  3. A neutrophil usually has 2-5 nuclear lobes (cells labeled 4)

Microcytic Hypochromic Anaemia

13 Mar hypochromic Micro Anaemia

hypochromic Micro Anaemia

Hypochromic Microcytic Anaemia

Shown above is an image of hypochromic microcytic anaemia. This patient had iron deficiency anaemia. Microcytosis is presence of small erythrocytes and hypochromia presence of erythrocytes that are poorly haemoglobinized. The nucleus of a small lymphocyte, the cell in the centre of the image, is a good guide to the size of erythrocytes on a peripheral smear. The nucleus has a diameter of 8.5 µm and a normal erythrocyte a diameter of 7.5 µm. The erythrocytes in in the image are substantially smaller than the lymphocyte nucleus. Erythrocytes have a central pale staining area which occupies about one third of erythrocyte diameter. As the cells get less haemoglobinized the central pale staining area increases. Many of the erythrocytes in the image above have a pale staining area occupies all but a thin rim at the periphery. In others, the pale staining area is increased. The erythrocyte sizes vary. Anisocytosis, increased variation in erythrocyte size, a feature of iron deficiency anemia, is evident in the image.

 

Lymphocytes

11 Mar Lymphocytes

Lymphocytes

Lymphocytes – Large and Small

There are two types of lymphocytes small (10-12µm) and large (12-16µm).

Most of the lymphocytes in the peripheral blood are small. The nucleus of he lymphocytes is small, round, usually indented. The chromatin of the lymphocyte nucleus

  1. Deep purple, small, round, usually indented
  2. Has no nucleoli
  3. Has a densely clumped deep chromatin

The cytoplasm of the lymphocyte is

  1. Moderately basophilic (blue)
  2. Scanty forming a thin rim around the nucleus
  3. Devoid of granules

Large lymphocytes have a more abundant cytoplasm with a few azurophilic granules. Some of these are T supressor lymphocytes (Cd3+ Cd8+) while others are NK cells (Cd3 – CD8+). The picture above shows a large granular lymphocyte

Monocyte

11 Mar Two Monocytes

Two Monocytes

Figure 1. Two Monocytes

Monocytes are the largest leucocytes. They vary considerable in size and shape and may measure about 12-20 µm in diameter. The have a lobulated nucleus that is centrally placed with a fine chromatin. The nucleus has been classically described as kidney shaped but may take other lobulated forms. The cytoplasm is abundant, grey or light-blue grey.  Fine azurophilic granules that are seen on staining on wright’s stain giving the cytoplasm a ground glass appearance (evident in the monocyte on the left in figure 1). The granules may become prominent in patients with marrow stimulation (bacteraemia, marrow recovery from aplasia or following the use of G-CSF)

Monocytes show typical granules in some inherited disorders. They are phagocytic and may show ingested red cells, malarial pigment or microorganisms.

Myelocyte and Metamyelocyte

Figure 2. Neutrophilic Myelocyte and Metamyelocyte- The cell on the left is a myelocyte and the right is a metamyelocyte. Compared to a monocyte (figure 1) a metamyelocyte has a coarser chromatin and pink cytoplasm with fine pink granules. The monocyte nucleus is lobulated and that of a metamyelocyte indented.

The monocyte needs to be differentiated from a neutrophilic metamyelocyte, a cell with a similar size and indented nucleus. The monocyte has a fine chromatin. The chromatin of the metamyelocyte is coarser and clumped. The cytoplasm of a monocyte is grey or light grey blue cytoplasm and fine azurophilic granules whereas the cytoplasm of a metamyelocyte has is pink with fine pink granules.

Normoblast Maturation

7 Mar Normoblast Maturation

IMG_0354 Maturing Normoblast

The image above shows three polychromatophilic normoblasts. The one on the left is the least mature and the one on the right the most mature. Maturation is associated with

  1. Decrease in the size of the cell and nucleus: This is obvious.
  2. Clumping of chromatin: This is obvious.
  3. Increasing cytoplasmic acidophilia and decreased basophilia: The cells are flanked on each side by erythrocytes. The cytoplasm of the least mature cell (left most cell) is basophilic compared to that of the adjacent erythrocyte. The cytoplasm of the most mature cell (the right most cello) has lost basophilia and is almost the colour of the cytoplasm of the erythrocyte. 

Orthochromatophilic Normoblast

7 Mar IMG_0286 - Orthochromatophilic Normoblast

Image

Orthochromatophilic normoblast

An orthochromatophilic normoblast is the most mature of nut;elated red cell precursors. The cytoplasm has lost almost all it’s basophilia and is the same colour as that of the erythrocyte. The nucleus is small pyknotic with densely condensed chromatin.

Case 2 – Thrombocytopenia Due to Large Platelets

3 Nov Large-Platelets-600px

A 52 year old patient presented with thrombocytopenia discovered on a haemogram performed about 2 years before presentation. The first haemogram performed as a part of a health checkup showed a platelet count of 81 X 109/L with an MPV of 13.1fl. The haemogram had been performed on multiple occasions since then and the platelet count has been reported by different laboratories to be between 63 X 109/L and 103 X 109/L. The haemoglobin, red cell indices, total and differential WBC count was normal.

The patients had no personal or family history of bleeding. He had undergone an appendicectomy and a tooth extraction without excessive bleeding.

The first step in the evaluation of a patient with thrombocytopenia is to confirm if the platelet count is really low. The causes of pseudothrombocytopenia include

  1. Presence of large platelets
  2. Platelet satellitism
  3. EDTA (or rarely other anticoagulant) induced platelet aggregation

The figure below shows the peripheral smear and the platelet histogram of the patients compared to a normal individual.

The platelet count performed manually was 130 X 109/L. The patients was a native of North India. Mild thrombocytopenia (platelet count between 100 X 109/L and 150 X 109L) is found in 26% of blood donors from eastern India and 18% blood donors from northern india (HVK Naina et al. Journal of Thrombosis and Haemostasis 2005; 11:2581-2).

Automated counters have limitations in evaluation of thrombocytopenia. The peripheral smear must be examined in every patient with thrombocytopenia to exclude giant platelets, platelet aggregation and platelet satellitism that may cause thrombocytopenia.

Megaloblasts

25 Jul Megaloblasts

Development of erythrocytes involves coordinated changes in the nucleus and the cytoplasm of erythroid processors (see Morphology of Erythroid Precursors) . The proerythroblast is a large cell with a fine chromatin, the earliest forms not being different from other blasts. As the cell matures the chromatin becomes more clumped and the nucleus reduces in size and the cytoplasm becomes acidophilic. Finally a dark pyknotic nucleus is extruded from the orthchromatophilic normoblast to give a reticulocyte.

Figure 1. Basophilic Normoblast

A group of basophilic normoblast are shown above. The cytoplasm is basophilic and the chromatin more clumped than a proerythroblast. The two cells on the right are less mature than the two on the left.

Figure 2. A group of orthochromatophilic normoblasts

The figure above show a group of  orthochromatophilic normoblasts. The cells of the left are more mature. The nucleus is reduced to a dense body in the more mature forms. The cytoplasm still has a blue tinge. which contrasts from the megaloblasts shown below.

Figure 3. Basophilic, polychromatophilic and orthochromatophilic normoblasts

The figure above shows three stages of erythroid maturation. The cell on the top right is a basophilic normoblast, bottom right is a orthochromatophilic normoblast and the bottom right is an orthochromatophlic normoblast. Note the evolution of nuclear and cytoplasmic changes.

Figure 4. Megaloblasts

The figure above shows a group of megaloblasts. Cells in the right lower corner have a cytoplasm which is fully haemoglobinized and resembles the mature erythrocyte. These cell still have a nucleus. The cell on the left upper corner has a cytoplasm resembling a orthochromatophilc normoblast (see figure 2 and 3) but nuclear features resembling a basophilic normoblast (figures 1 and 2). Megaloblastic anaemia results from conditions that hamper DNA synthesis (B12 deficiency, folate deficiency, Chemotherapy drugs). The nucleus of a megaloblast thus matures slower than the cytoplasm resulting in cells having a nuclear morphology resembling a previous stage. This, known as nucleo-cytoplasmic dissociation, is the characteristic feature of megaloblastic anaemia.

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