Typical blood smear findings in selected hemolytic anemias

Hemolytic anemia	Typical blood smear findings
Acquired
Autoimmune hemolytic anemia	Spherocytes (some), microspherocytes
Clostridial (or other fulminant bacterial) sepsis	RBC ghosts
Cold agglutinin disease	RBC clumps
Drug-induced hemolysis	Nonspecific findings
Hemolytic transfusion reaction	Nonspecific findings or some spherocytes
Microangiopathic hemolytic anemia (MAHA; eg, as in TTP, HUS, or DIC)	Schistocytes (may be less abundant in DIC)
RBC parasite (eg, malaria, Babesia)	Intracellular parasitic ring forms (especially on thick smear)
Inherited
Alpha thalassemia	Microcytic and hypochromic cells (can be profound in severe disease), target cells, microspherocytes, basophilic stippling
Beta thalassemia	Microcytic and hypochromic cells (can be profound in severe disease), target cells, teardrop cells, RBC fragments, basophilic stippling
G6PD deficiency	Bite cells, nonspecific findings
Hemoglobin C disease	Hemoglobin crystals
Hereditary elliptocytosis
Classic hereditary elliptocytosis Hereditary pyropoikilocytosis Southeast Asian ovalocytosis	Elliptocytes/ovalocytes Spherocytes, elliptocytes, microcytes Stomatocytic elliptocytes
Hereditary spherocytosis	Spherocytes (abundant)
Hereditary stomatocytosis	Stomatocytes (cells with a mouth-shaped area of central pallor), may be as high as 40 to 60%
Hereditary xerocytosis	Xerocytes (hyperchromic misshapen cells with hemoglobin puddled at the periphery), target cells
Pyruvate kinase deficiency	Nonspecific findings, echinocytes
Sickle cell disease	Sickle cells, Howell-Jolly bodies

Typical findings are listed for each of the conditions; some patients may have other findings depending on their clinical status (eg, concomitant deficiency of vitamin B12, folate, copper, or iron; concomitant myelodysplasia; concomitant renal or hepatic insufficiency). Nonspecific findings include polychromatophilia, due to reticulocytosis (present in all individuals with hemolytic anemia who have a bone marrow response). Other general findings in hemolytic anemia include increased reticulocyte count (unless the bone marrow is unable to respond), as well as serum markers of hemolysis (eg, increased LDH, increased indirect bilirubin, low haptoglobin). Refer to UpToDate for details of the evaluation and clinical features.

RBC: red blood cell; MAHA: microangiopathic hemolytic anemia; TTP: thrombotic thrombocytopenic purpura; HUS: hemolytic uremic syndrome; DIC: disseminated intravascular coagulation; G6PD: glucose-6-phosphate dehydrogenase; LDH: lactate dehydrogenase.

Graphic 116947 Version 2.0

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Typical blood smear findings in selected hemolytic anemias