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CC BY-NC-ND 4.0 · J Lab Physicians 2023; 15(03): 437-442
DOI: 10.1055/s-0043-1764481
Original Article

Traversing Their Path to the Peripheral Smear: The Journey of Traumatized Red Blood Cells

Chethana Mannem
1   Department of Pathology, Kempegowda Institute of Medical Sciences (Affiliated to Rajiv Gandhi University of Health Sciences), Bangalore, Karnataka, India
,
Tuba Saher
1   Department of Pathology, Kempegowda Institute of Medical Sciences (Affiliated to Rajiv Gandhi University of Health Sciences), Bangalore, Karnataka, India
,
Gayathri Bilagali Ramdas
1   Department of Pathology, Kempegowda Institute of Medical Sciences (Affiliated to Rajiv Gandhi University of Health Sciences), Bangalore, Karnataka, India
› Institutsangaben Funding Nil.
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Abstract

Background Thrombotic microangiopathy encompasses a wide range of conditions, of which thrombotic thrombocytopenic purpura being a medical emergency requires prompt intervention, with schistocytes being a reliable morphological indicator of microvascular injury. However, there are conditions other than thrombotic microangiopathic anemia where schistocytes can be seen in large numbers. These nonthrombotic microangiopathic conditions are broadly grouped under cytoskeletal abnormalities, mechanical damage, and thermal injuries. Automated methods in schistocyte evaluation have shown varied reproducibility requiring manual identification. International Council for Standardization in Hematology (ICSH) recommends standardized morphological criteria and quantitative assessment as a percentage after counting at least 1,000 red blood cells in optimal areas of smear to reduce interobserver variability.

Objectives The aim of this study was to evaluate and quantitate schistocytes in thrombotic microangiopathic and nonthrombotic microangiopathic groups using ICSH guidelines and to evaluate interobserver reproducibility of manual schistocyte count.

Materials and Methods Overall, 157 peripheral blood smears showing schistocytes were studied by two independent observers using ICSH recommendations on light microscopy. The hematological findings were correlated with clinical diagnosis and other relevant investigations.

Results Schistocytes were observed in five cases of thrombotic microangiopathic anemia and 152 cases of nonthrombotic microangiopathic anemia. Schistocyte count in thrombotic microangiopathic anemia and nonthrombotic microangiopathic anemia groups with mean (±standard deviation) value was 2.28 ± 2.65% and 0.76 ± 0.67%, respectively (p < 0.001). The correlation coefficient between the two observers was 0.59 (confidence interval = 0.966–1.346) showing an excellent agreement on the reproducibility of schistocytes by application of ICSH guidelines.

Conclusion Percentage of schistocytes more than 1% is a robust morphological indicator for diagnosis of thrombotic microangiopathic anemia in adults. Strict application of ICSH guidelines reduces interobserver bias.

Keywords

ICSH - schistocytes - thrombotic microangiopathy - thrombotic - thrombocytopenic purpura

Ethical Approval

Ethical clearance was obtained from the Institutional Ethics Committee, Kempegowda Institute of Medical Sciences, dated 10/7/2021, bearing the reference number KIMS/IEC/A049/M/2021.


Details of Earlier Presentation

Presented as online oral paper in Karnataka Chapter-Indian Association of Pathologists and Microbiologists—KCIAPM—annual state conference held in September 2021.


Authors' Contributions

T.S. helped in conception and design of the study, acquisition of data, interpretation of data, and drafting of the article. C.M. was involved in conception and design of the study, analysis and interpretation of data, critical revision of the draft, and final approval of the version. G.B.R. helped in conception and design of the study, analysis and interpretation of data, critical revision of the draft, and final approval of the version.




Publikationsverlauf

Eingereicht: 26. Juli 2022

Angenommen: 28. Dezember 2022

Artikel online veröffentlicht:
27. März 2023

© 2023. The Indian Association of Laboratory Physicians. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Zini G, d'Onofrio G, Briggs C. et al; International Council for Standardization in Haematology (ICSH). ICSH recommendations for identification, diagnostic value, and quantitation of schistocytes. Int J Lab Hematol 2012; 34 (02) 107-116
    CrossrefPubMedGoogle Scholar
  • 2 Schapkaitz E, Mezgebe MH. The clinical significance of schistocytes: a prospective evaluation of the International Council for Standardization in Hematology schistocyte guidelines. Turk J Haematol 2017; 34 (01) 59-63
    CrossrefPubMedGoogle Scholar
  • 3 Jameson JL, Kasper DL, Longo DL. et al. Harrison's Principles of Internal Medicine. 20th ed.. New York: McGraw-Hill, Health Professions Division; 2022: 2148-2165
    Google Scholar
  • 4 Huh HJ, Chung JW, Chae SL. Microscopic schistocyte determination according to International Council for Standardization in Hematology recommendations in various diseases. Int J Lab Hematol 2013; 35 (05) 542-547
    CrossrefPubMedGoogle Scholar
  • 5 Palmer L, Briggs C, McFadden S. et al. ICSH recommendations for the standardization of nomenclature and grading of peripheral blood cell morphological features. Int J Lab Hematol 2015; 37 (03) 287-303
    CrossrefPubMedGoogle Scholar
  • 6 Greer JP, Arber DA, Appelbaum FR. et al. Thrombotic Thrombocytopenic Purpura, Hemolytic-Uremic Syndrome, and Related Disorders. Wintrobe's Clinical Hematology. 14th ed.. Europe: Wolters Kluwer Health Pharma Solutions; 2018: 3434-3495
    Google Scholar
  • 7 Lansigan F, Isufi I, Tagoe CE. Microangiopathic haemolytic anaemia resembling thrombotic thrombocytopenic purpura in systemic lupus erythematosus: the role of ADAMTS13. Rheumatology (Oxford) 2011; 50 (05) 824-829
    CrossrefPubMedGoogle Scholar
  • 8 Noutsos T, Laidman AY, Survela L. et al. An evaluation of existing manual blood film schistocyte quantitation guidelines and a new proposed method. Pathology 2021; 53 (06) 746-752
    CrossrefPubMedGoogle Scholar
  • 9 Bahr TM, Judkins AJ, Christensen RD. et al. Neonates with suspected microangiopathic disorders: performance of standard manual schistocyte enumeration vs. the automated fragmented red cell count. J Perinatol 2019; 39 (11) 1555-1561
    CrossrefPubMedGoogle Scholar
  • 10 Biswal S, Giri R, Senapati U. Schistocytosis in megaloblastic anemia masquerading peripheral blood picture as maha (microangiopathic hemolytic anemia) and decrease mean corpuscular volume. Indian J Pathol Oncol. 2020; 7 (03) 357-361
    CrossrefGoogle Scholar
  • 11 Semeraro N, Ammollo CT, Semeraro F, Colucci M. Sepsis-associated disseminated intravascular coagulation and thromboembolic disease. Mediterr J Hematol Infect Dis 2010; 2 (03) e2010024
    CrossrefPubMedGoogle Scholar
  • 12 Shastry I, Belurkar S. The spectrum of red blood cell parameters in chronic kidney disease: a study of 300 cases. J Appl Hematol. 2019; 10: 61-66
    CrossrefGoogle Scholar
  • 13 Raffa GA, Byrnes DM, Byrnes JJ. The diagnosis is in the smear: a case and review of spur cell anemia in cirrhosis. Case Rep Hematol 2021; 2021: 8883335
    PubMedGoogle Scholar
  • 14 Saigo K, Jiang M, Tanaka C, Fujimoto K, Kobayashi A, Nozu K. et al. Usefulness of automatic detection of fragmented red cells using a hematology analyzer for diagnosis of thrombotic microangiopathy. Clin Lab Haematol 2002; Dec;24 (06) 347-51
    CrossrefPubMedGoogle Scholar
  • 15 Banno S, Ito Y, Tanaka C, Hori T, Fujimoto K, Suzuki T. et al. Quantification of red blood cell fragmentation by the automated hematology analyzer XE-2100 in patients with living donor liver transplantation. Clin Lab Haematol 2005; Oct;27 (05) 292-296
    CrossrefPubMedGoogle Scholar