Chapter 20: Hemolytic Anemia Resulting from a Chemical or Physical Agent

A. Blood film prepared from a patient exposed to arsenic hydride (AsH). Note the very pale red cells resulting from partial hemoglobin loss secondary to membrane damage. An extreme example, represented by the virtual ghost thinly rimmed with scant residual hemoglobin, can be found in the upper left-hand corner. Other cells are spherocytic or stomatocytic. B. Blood film from person with lead poisoning. Note the tear drop–shaped red cell with basophilic stippling. The stippling may be fine or course but may be minimized or absent in blood anticoagulated with Na₂EDTA. C. Wilson disease. In this image from a patient with Wilson disease, there are numerous visible sequelae of oxidative damage caused by excess copper. The striking dense microspherocytes indicate damage to the membrane. Damage to hemoglobin is demonstrated by the Heinz bodies projecting from red cells (asterisks show two examples). The horizontal arrow points to one of several microspherocytes. The vertical arrow points to a macrocyte (reticulocyte). An occasional cell shows damage to both membrane and hemoglobin. The presence of echinocytes (oblique arrows show two examples) suggests that the liver is also affected. D. Blood film prepared at admission from a patient who had suffered severe burn injury involving a large percentage of the body surface. Note the presence of normal erythrocytes (apparently from vessels not exposed to heat damage) along with populations of normocytic and microcytic spherocytes. In addition, there are numerous red cell fragments, some smaller than platelets, from heat-related red cell fragmentation. (A, B, and D: Reproduced with permission from Lichtman MA, Shafer MS, Felgar RE, et al: Lichtman’s Atlas of Hematology 2016. New York, NY: McGraw Hill; 2017. www.accessmedicine.com.; C: Reproduced with permission from Barbara J. Bain, Imperial College, London, UK.)