Inclusions in Erythrocytes

Howell-Jolly Bodies

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Figure 12.1A Howell-Jolly bodies (arrows).
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Figure 12.1B Howell-Jolly bodies (arrows) in a patient with sickle cell anemia.

COLOR: Dark blue to purple

SHAPE: Round to oval

SIZE: 0.5 to 1.5 μm

NUMBER PER CELL: Usually 1; may be multiple

COMPOSITION: DNA (deoxyribonucleic acid)

ASSOCIATED WITH: Splenectomy, hyposplenism, megaloblastic anemia, hemolytic anemia

Basophilic Stippling

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Figure 12.2A Basophilic stippling (arrows).
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Figure 12.2B Basophilic stippling (arrows).

COLOR: Dark blue to purple

SHAPE: Fine or coarse punctate granules

NUMBER PER CELL: Numerous with fairly even distribution

COMPOSITION: RNA (ribonucleic acid)

ASSOCIATED WITH: Lead intoxication, thalassemia, abnormal heme synthesis

Pappenheimer Bodies

Siderotic Granules

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Figure 12.3A Pappenheimer bodies (arrows) with Wright stain.
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Figure 12.3B Pappenheimer bodies (arrows) with Wright stain. (Courtesy George Girgis [CLS] Indiana University Health.)
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Figure 12.3C Siderotic granules with iron stain.

COLOR: Light blue

SHAPE: Fine irregular granules in clusters

NUMBER PER CELL: Usually one cluster; may be multiples; often at periphery of cell

COMPOSITION: Iron

ASSOCIATED WITH: Splenectomy, hemolytic anemia, sideroblastic anemia, megaloblastic anemia, hemoglobinopathies

Cabot Rings

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Figure 12.4A Cabot ring (arrow).
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Figure 12.4B Cabot ring: figure eight (arrow).

COLOR: Dark blue to purple

SHAPE: Loop, ring, or figure eight; may look like beads on a string

NUMBER PER CELL: 1 to 2

COMPOSITION: Thought to be remnants of mitotic spindle

ASSOCIATED WITH: Myelodysplastic syndrome, megaloblastic anemia

NOTE: This is a rare finding. May be confused with malaria (see Fig. 21.1A).

Inclusions with supravital stain

Stained with New Methylene Blue

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Figure 12.5A Reticulocytes.

CELL: Anuclear immature erythrocyte

COMPOSITION: Precipitated RNA

NUMBER: Two or more per cell

COLOR: Dark blue

ASSOCIATED WITH: Immature erythrocyte

NOTE: Supravital stains are taken up by living cells.

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Figure 12.5B Heinz bodies.

CELL: Mature erythrocyte

COMPOSITION: Denatured hemoglobin

NUMBER: Single or multiple, generally membrane bound

COLOR: Dark blue to purple

ASSOCIATED WITH: Unstable hemoglobin, some hemoglobinopathies, some erythrocyte enzyme deficiencies (e.g., glucose-6-phosphate dehydrogenase)

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Figure 12.5C Hemoglobin H. (From the American Society for Hematology slide bank.)

CELL: Mature erythrocyte

COMPOSITION: Hemoglobin β chain tetramers

NUMBER: Multiple evenly dispersed inclusions described as “golf balls” or “raspberries”

COLOR: Dark blue

Table 12.1

Staining Qualities of Erythrocyte Inclusion Bodies
InclusionCompositionWright- Giemsa stainNew Methylene Blue (or other supravital stain)Prussian Blue (iron)
Howell-Jolly body DNA + + 0
Basophilic stippling RNA + + 0
Pappenheimer body Iron + + +
Reticulocyte RNA 0 + 0
Cabot ring Remnant of mitotic spindle + + 0
Heinz body Unstable hemoglobin 0 + 0
Hemoglobin H β chain 0 + 0

+, Positive; 0, negative. DNA, Deoxyribonucleic acid; NA, not applicable; RNA, ribonucleic acid.