What Do I Do When Red Cell Inclusions Have Been Misidentified?
A 36-year-old chronic alcoholic with liver disease and pneumonia was admitted to the hospital. Her admission was for treatment of the pneumonia. Routine CBCs including differential were ordered daily to monitor her white count during the treatment process. During evaluation of her peripheral smear, a shift to the left was observed. This is a term used to describe the presence of younger white cells from the bone marrow in response to infection and inflammation. On the second day after admission, the patient's smear was being examined on the evening shift by a new laboratory graduate. She noted red cell inclusions and identified them as Howell-Jolly bodies, but she felt insecure about the identity of the inclusion and no one was available to observe the inclusion. After consulting with the lead technologist, they reviewed the smear together to try to identify which inclusion was present. The student preliminarily identified the inclusions as Howell-Jolly bodies, which are single inclusion, DNA in origin, and usually located in the periphery of the red cell. Basophilic stippling was another possibility, but stippling is RNA in origin and seen throughout the red cells; the new employee noted that the inclusion was located toward the periphery of the cell. The next possibility was Pappenheimer bodies, small inclusions that look like grape clusters. Pappenheimer bodies are usually iron deposits either in the form of ferritin or hemosiderin. If they are suspected, an iron stain (Prussian blue) will confirm the presence of iron. A Prussian blue stain was performed, and the inclusions were confirmed to be siderocytes, iron-containing inclusions. These inclusions can be found in hemochromatosis, alcoholism, hemolytic anemia, and post splenectomy.
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