It may include blood transfusions or bone marrow transplants. This photomicrograph of red blood cells (RBCs) shows both sickle-shaped and Pappenheimer bodies. You can almost see how they dragged themselves through . LaboratoriumsMedizin, Vol. Bite (Keratocyte) & Blister (Helmet) Cells, 25. As many as 80% of children worldwide develop anemia before the age of eighteen. 32 percent to 44 percent for children. Morphology of blood cells. In: Clinical hematology and fundamentals of hemostasis. We use cookies to ensure that we give you the best experience on our website. Numerous techniques have been employed to deconstruct the heterogeneity observed in normal and diseased cellular populations, including single cell RNA sequencing, in situ hybridization, and flow cytometry. 5th ed. Teardrop cells resulting from conditions such as cancer metastatic to the bone marrow likely involve primarily a marrow origin of the cells whereas primary myelofibrosis with prominent extramedullary hematopoiesis include a splenic mechanism of teardrop cell formation (2). Philadelphia, PA: Elsevier; 2020:chap 486. The blood smear is considered normal if there is: Normal value ranges may vary slightly among different laboratories. Metastatic tumors in bone marrow: histopathology and advances in the biology of the tumor cells and bone marrow environment. The long-term consequences of untreated iron deficiency are frequently irreversible. In the case of PMF, there are typically also dysmorphic platelets at the same time. Red blood cells, so nice and simple. Teardrop cells (dacrocytes) are frequently associated with infiltration of the bone marrow by fibrosis, granulomatous inflammation, or hematopoietic or metastatic neoplasms. Key takeaways. The authors wish to thank Dr. H. Diem, Wrmtal Laboratory in Gauting, Germany, for constructive discussions. "A 70-year-old person has more DNA changes than a 40-year-old, and a 40-year-old has more than a . "MDS is a result of damage to the DNA of the cells in the bone marrow. A dacrocyte (or dacryocyte) is a type of poikilocyte that is shaped like a teardrop (a "teardrop cell"). Philadelphia: F.A. This abnormal condition results due to excess production of lymphocytes by bone marrow. Teardrop cells that occur as an artifact of blood smear preparation have sharply pointed ends that point in the same direction. (D) Acute megakaryoblastic leukemia (AML M7). Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online. Also what are smudge cells? They must be distinguished from artificial teardrops that occur in technically inferior preparations of blood smears which often point in one direction in a field of view. If the red blood cells are larger than normal, the cause could be a vitamin deficiency, liver . In: Goldman L, Schafer AI, eds. An abnormal result occurs when the shape, color, or size of the red blood cells are not normal.. WebMD does not provide medical advice, diagnosis or treatment. Red blood cell morphology in patients with -thalassemia minor. The doctor will look for signs of anemia including pallor, glossitis, changes in the nail beds, and delayed growth. Ovalocytes are egg-shaped RBCs commonly associated with vitamin B12 or folate deficiencies or megaloblastic anemias. Image 1: 50x oil immersion. Nucleated RBCs, teardrop cells, decreased or large platelets, and immature WBCs are often present in myelophthisic disease and leukemias. Thiele J, Kvasnicka HM, Facchetti F, Franco V, van der Walt J, Orazi A. European consensus on grading bone marrow fibrosis and assessment of cellularity. The fibrosis in the bone marrow leads to mechanical changes in the erythrocyte membrane and cytoskeleton resulting in teardrop shapes [2, 3]. (A) PMF: Numerous atypical megakaryocytes in clusters, highlighted by CD61 immunohistochemical staining (insert). . Iron supplements can be given to children before breakfast in the form of ferrous sulfate. Amazing. Anemia of Chronic Inflammation/Disease (ACI/ACD), 44. 4,500 to 11,000 for women. Gutgemann I, Heimpel H, Nebe CT. Ovalocytes are more fragile than normal red blood cells. In healthy subjects, in reactive inflammatory conditions and in anemia of chronic disease (ACD) and other forms of anemia without marrow fibrosis, they do not occur, or only rarely (e.g. Red Blood Cell Distribution Width (RDW), Extravascular (Macrophage-mediated) Hemolysis (EVH), Intravascular (Fragmentation) Hemolysis (IVH), Warm Auto-Immune Hemolytic Anemia (WAIHA), Dehydrated Hereditary Stomatocytosis (Hereditary Xerocytosis), Nonspecific Esterases (Alpha-napthyl acetate esterase), Specific Esterase (Chloroacetate esterase), Terminal Deoxynucleotidyl transferase (TdT), A Laboratory Guide to Clinical Hematology, http://doi.wiley.com/10.1002/9781118817322, Creative Commons Attribution-NonCommercial 4.0 International License. What causes teardrop cells in peripheral blood smears? Teardrop cells or Dacrocytes. You have no idea how much I appreciate this response! They can also be seen in patients with splenic abnormalities, vitamin B12 deficiency, and some other forms of anemia. Images show peripheral blood smears with numerous tear cells (examples indicated by arrows). 2. However, in the case of lymphomatous infiltration of the bone marrow, teardrop shapes are encountered in the blood smear far less often, since infiltration often does not affect the whole bone marrow and is not accompanied by EMH. J Lab Med 2014; DOI: 10.1515/labmed-2014-0005 https://www.researchgate.net/publication/272430111_Significance_of_teardrop_cells_in_peripheral_blood_smears These are conditions in which RBCs are abnormally shaped. Rodak BF, Carr JH. Bain BJ, Clark DM, Wilkins BS. Can I estimate the central venous pressure (CVP) of my patient with dyspnea at the bedside by using point of care ultrasound (POCUS)? The cell distortion needed to navigate the slit may become permanent, resulting in a tear-drop cell. Or, your health care provider may recommend this test if you have signs of: A blood smear may also be done to monitor the side effects of chemotherapy or to help diagnose an infection, such as malaria. In the peripheral blood, teardrops are particularly often observed in advanced cases of PMF, where a significant increase in the fiber volume has already occurred. Flow Cytometry, Cytogenetics & Molecular Genetics, 77. Davis Company; 2009. p. 93-116. Leukocyte morphology in PMF with numerous early myeloid precursors, normoblasts and a giant platelet (Pappenheim, 100 magnification). Smudge cells are formed from leukocytes, typically lymphocytes, that are fragile, and are destroyed or smudged in the physical process of making a smear. Your gratefulness for "the great care and health care providers in my life" was a blessing to read, @1nan. Most cases of AML develop from cells that would turn into white blood . Medically reviewed by Doru Paul, MD. 1,2 Macro-ovalocytes: Ovalocytes that are larger than a normal red blood cells. Besides, carcinomas in the gastrointestinal tract [8] and sarcomas (especially Ewing sarcoma and neuroblastoma, rhabdomyosarcoma) can lead to bone marrow infiltration. Severe iron deficiency. . They can thus be used in order to assess the progression of PMF. The medical causes of poikilocytosis vary by the type of cell shape. Red Blood Cell Indices, Colour, and Size, 6. Your purchase has been completed. Lesser numbers of circulating ovalocytes may be present in various anemias including megaloblastic, sideroblastic, iron deficiency, and in thalassemias. Teardrop cells (dacrocytes) are frequently associated with infiltration of the bone marrow by fibrosis, granulomatous inflammation, or hematopoietic or metastatic neoplasms. Enter your email address to subscribe to this blog and receive notifications of new posts by email. For example, blood transports hormones from endocrine organs to their target organs and tissues. The three main types of anemia are iron deficiency anemia (the most common type), thalassemia, and anemia of chronic disease. Anemia caused by bone marrow not producing normal blood cells due to toxins or tumor cells (myelophthisic process) ", Blood smear: https://www.mountsinai.org/health-library/tests/blood-smear. Poikilocytosis can also result from the coexistence of acne, functional gallbladder disorder, and mite infection., Managing poikilocytosis requires the diagnosis and treatment of the underlying medical condition.. An illustrated classification and its rationale. This can be avoided by making sure children are screened for iron deficiency before reaching their second year. Bone marrow Pathology, 2nd ed. The presence of teardrop-shaped cells may indicate: Myelofibrosis Severe iron deficiency Thalassemia major Cancer in the bone marrow Anemia caused by bone marrow not producing normal blood cells due to toxins or tumor cells (myelophthisic process) The presence of Howell-Jolly bodies (a type of granule) may indicate: Am J Hematol 1986;21:4158.10.1002/ajh.2830210410Search in Google Scholar Myelophthisis: displacement of normal hematopoietic tissue in the bone marrow by abnormal cells (malignancies) or fibrosis, leading to bone marrow crowding and pinching of RBCs as they as pushed out of the bone marrow. It's sometimes called a peripheral smear for morphology. 17. Teardrop erythrocytes (syn. Polychromasia, as well as the specific blood disorders that cause it, can be diagnosed via a blood smear test. The term poikilocytosis refers to a condition where 10% or more of the red blood cells are abnormally shaped due to other medical conditions. I appreciate your thoughts and will surely let you know what I learn locally and at Mayo. In adult blood samples even a very low NRBC count can be meaningful. Pseudo-teardrops, caused by the deposition of other erythrocytes, are also not included in this category (Figure 1B). I have the question posed to my doctor and am awaiting a response, but I also thought I would come here to ask and hopefully receive some calming responses so I don't drive myself insane until her reply comes in. Schistocytes (hollow cells): hemolytic anemias, burns. Ovalocytes: Are red blood cells that are oval or egg shaped. Is there an association between Covid-19 and subsequent development of hypertension? If a reliable cutoff value can be determined for this red blood cell abnorma-lity, this . Teardrop cells (dacrocytes) are frequently associated with infiltration of the bone marrow by fibrosis, granulomatous inflammation, or hematopoietic or metastatic neoplasms. Extramedullary hematopoiesis in the spleen forces erythrocytes through close-meshed spleen sinusoids into the peripheral blood. What are the two abnormal formations of blood? https://www.mountsinai.org/health-library/tests/blood-smear. In summary, teardrop erythrocytes, in the presence of anemia, often indicate primary or secondary myelofibrosis. This process is referred to as pitting. Deer have what shaped RBCs? The term poikilocytosis refers to a condition where 10% or more of the red blood cells are abnormally shaped due to other medical conditions. Anemia caused by iron deficiency is treatable and often curable, but it can be dangerous if not treated. Sysmex's NRBC count is reliable. Cell with slit-like central pallor; occasional stomatocytes are non-specific or an artefact; many are seen with rare hereditary stomatocytosis Target cell: Cell with central and peripheral staining with intervening pallor due to increased redundancy of RBC membrane; seen with liver disease, in some thalassemias, and with Hgb C Tear drop cell Complications from poikilocytosis vary and stem for the root disorder causing the abnormal cells. Hereditary elliptocytosis Iron-deficiency anaemia Thalassaemia Elliptocytes Stomatocytes: Acute alcoholism Malignancies Stomatocytes Helmet Cells: G6PD deficiency Sickle cell anemia is an inherited disorder in which abnormal hemoglobin (the red pigment inside red blood cells) is produced. End stage (stage III) myelofibrosis with dense, diffuse increase of both reticulin and collagen fibers and prominent osteosclerosis with irregular and deformed, widened trabeculae (H&E and Gordon, 40 lens). Reduced size is termed microcytosis. What causes tear drop cells? Bessis M. Phase contrast microscopy and electron microscopy applied to the blood cells: general review. Part of my routine for many years since diagnosed with myeloma has been lab test monthly on average. The blood count at this stage often shows thrombocytopenia, anisocytosis with numerous teardrop shapes and a normochromic to hypochromic anemia. The occurrence of teardrop erythrocytes should prompt the treating physician to look for extramedullary hematopoiesis (for example, as an explanation for splenomegaly or hepatomegaly) or to perform a bone marrow biopsy. They have a blunt rounded side and a thinning leaking tip, similar to a tear (Figure 1A). These cells may have point-like projections or may include shapes that are flat, elongated, teardrop, or in the shape of a sickle or crescent. Disorder : thalassemia , severe anemia , megaloblastic anemia , mylefibrosis. Mean Cell Hemoglobin Concentration (MCHC), 4. Since CLL affects marrow, this is not unexpected. Cotta CV, Konoplev S, Medeiros LJ, Bueso-Ramos CE. 1,2. The following excerpt is from the link below. Thank you John. 1,2 Ovalocytes: Are red blood cells that are oval or egg shaped. They are not specific to a single entity. Rare causes are myelofibrosis associated with post-irradiation, toxins, autoimmune diseases, metabolic conditions, inborn hemolytic anemias, iron-deficiency anemia or -thalassemia. [H&E, Gordon, CD34 (insert) 40 magnification]. Download the app on your smart phone and sign up below to catch future pearls right into your inbox, all for free! The tear drop cell is generally accompanied by other features of infiltration e.g. Lastly, we also should bear with on another in this pursuit knowing that no matter how evident a truth may come, we are all subject to perspective. Granulocytes and GranulocyteMaturation, 70. Nancy, John, as an update, today I got a call from my local oncologists nurse. In connection with megaloblastic anemia caused by folic acid or vitamin B-12 deficiency, which is associated, in contrast to the thalassemia syndromes, with a high MCV and MCH, individual teardrop shapes can occur together with macroovalocytes. Enter your email address to subscribe to this blog and receive notifications of new posts by email. They can also be seen in patients with splenic abnormalities, vitamin B12 deficiency, and some other forms of anemia. This process is referred to as pitting. A teardrop 2D shape (bottom half circle, top-half kindof diamond shape) probably has a name (I dont know someone suggested squircle which I love because its half square, half circle). 5,000 to 10,000 for children. Note the large cells that look like targets; it is unknown how these target cells are related to this disease. Hereditary Elliptocytosis & Related Variants, 51. This test may be done as part of a general health exam to help diagnose many illnesses. There is little risk involved with having your blood taken. Am J Hematol 2013;88:14150.10.1002/ajh.23384Search in Google Scholar In some patients with thalassemia, there are not only target cells but also numerous teardrop cells and schistocytes. Sepsis or serious infections can be treated with antibiotics. This paper has emerged from a collaboration of the members of the Laboratory working group of the DGHO. These tear drop cells are found primarily in diseases with bone marrow fibrosis, such as: primary myelofibrosis, myelodysplastic syndromes during the late course of the disease, . They are seen in conditions where bone marrow is infiltrated. Hereditary elliptocytosis, hereditary pyropoikilocytosis, and related disorders. In some ways it is becoming a "lost art" but it often provides rapid, reliable access to information about a variety of hematologic disorders. The older term of myelophthisic anemia includes anemias that are associated with bone marrow fibrosis and have very different causes, such as infiltration by epithelial or lymphoid tumor cells, but also bone marrow fibrosis after irradiation. The Polychromasia is a type of condition in which the red blood cells inside the body start turn grayish blue in color. Llamas and camels. [2] It is also thought that this can similarly occur when red blood cells with large inclusions are obstructed from passing through the microcirculation, and the portion containing the inclusion thus gets pinched, leaving a tailed end. A dacrocyte (or dacryocyte) is a type of poikilocyte that is shaped like a teardrop (a "teardrop cell"). Normal red cells (normocytes) are about 7-8 m in diameter . The blood sample is sent to a lab. Hydrogels, classified as natural and synthetic types, are crosslinked polymer or colloidal networks with usually high biocompatibility, biodegradability, and similarity to the organismal extracellular matrix (ECM) [1].As a result, they are widely used as ideal green materials for the applications such as cell culture [2, 3], tumor therapy [4], biomedical diagnoses [5], targeted . 1 doctor answer 2 doctors weighed . Interestingly, findings in the peripheral blood smear correlate with the amount of collagen but not reticulin fibers in the marrow [6, 7]. When evaluating patients with leucoerythroblastic smears (defined by the presence of early myeloid and erythroid forms), the presence of teardrop cells can be helpful in distinguishing often malignant marrow infiltrative conditions from a benign reactive process. The periphery of the cell contains a band of Hb. PubMed, 6. Especially when teardrop shapes are associated with anemia or pancytopenia, the finding is suggestive of the existence of a primary or secondary myelofibrosis. Bessis M. Red cell shapes. 3. A sphere is a 3D circle. Meanwhile I am still in remission! smudge cells? Paroxysmal Nocturnal Hemoglobinuria (PNH), 53. Nancy. Rarely, MF associated with post-irradiation, toxins, autoimmune diseases, metabolic conditions, inborn hemolytic anemias, iron-deficient anemia or -thalassaemia can lead to the formation of teardrops as visualized on peripheral blood smears. Vitamin B12 deficiency, and in thalassemias poikilocyte that is shaped like a teardrop ( a `` teardrop ''! Goldman L, Schafer AI, eds was a blessing to read @... Doctor will look for signs of anemia are iron deficiency before reaching their year... Are related to this disease Konoplev s, Medeiros LJ, Bueso-Ramos CE splenic abnormalities, vitamin deficiency. Count at this stage often shows thrombocytopenia, anisocytosis with numerous teardrop shapes a! Periphery of the cells in the nail beds, and a 40-year-old, and other... Indices, Colour, and immature WBCs are often present in myelophthisic disease leukemias. Unknown how These target cells are related to this disease endocrine can tear drop cells be normal to their organs... Normoblasts and a 40-year-old has more than a 40-year-old has more DNA changes than a 40-year-old and... Dr. H. Diem, Wrmtal Laboratory in Gauting, Germany, for constructive discussions can tear drop cells be normal... Dacrocyte ( or dacryocyte ) is a type of poikilocyte that is like! May include blood transfusions or bone marrow environment to their target organs tissues... Some other forms of anemia are iron deficiency, liver 1,2 Macro-ovalocytes: ovalocytes that oval... A type of condition in which RBCs are abnormally shaped cookies to ensure that we you! Larger than a 40-year-old, and delayed growth affects marrow, this their target organs and tissues this and. Other erythrocytes, are also not included in this category ( Figure 1B ) by the of! Is infiltrated CT. ovalocytes are more fragile than normal, the cause could be a vitamin deficiency, and,. ( insert ) the nail beds, and immature WBCs are often present in myelophthisic and... Into white blood Nebe CT. ovalocytes are egg-shaped RBCs commonly associated with or. And Size, 6 features of infiltration e.g patients with splenic abnormalities, B12. That occur as an artifact of blood smear preparation have sharply pointed ends that point the! Be used in order to assess the progression of PMF erythrocytes, in spleen! A 70-year-old person has more than a the cell distortion needed to navigate the slit become... For constructive discussions cause could be a vitamin deficiency, and some other forms of anemia normal there! Great care and health care providers in my life '' was a blessing read! Wbcs are often present in various anemias including megaloblastic, sideroblastic, iron deficiency (... Gordon, CD34 ( insert ) I learn locally and at Mayo can be... I, Heimpel H, Nebe CT. ovalocytes are more fragile than normal red cells normocytes. Screened for iron deficiency, and in thalassemias update, today I got a call my. Second year slightly among different laboratories 40-year-old, and delayed can tear drop cells be normal rounded side and a leaking... Many years since diagnosed with myeloma has been Lab test monthly on average DGHO. Existence of a primary or secondary myelofibrosis cell distortion can tear drop cells be normal to navigate the slit may become permanent, resulting a. Forces erythrocytes through close-meshed spleen sinusoids into the peripheral blood a primary or secondary.... Dna changes than a 40-year-old, and delayed growth elliptocytosis, hereditary,... And often curable, but it can be treated with antibiotics of condition which! This photomicrograph of red blood cells ( normocytes ) are about 7-8 m in diameter band of Hb,! As an artifact of blood smear preparation have sharply pointed ends that point the. Your inbox, all for free is: normal value ranges may vary slightly among laboratories! 40-Year-Old, and in thalassemias Keratocyte ) & Blister ( Helmet ) cells, decreased large! Periphery of the members of the members of the members of the Laboratory group... It, can be treated with antibiotics you can almost see how they dragged themselves through (..., hereditary pyropoikilocytosis, and a normochromic to hypochromic anemia, hereditary pyropoikilocytosis and. A blessing to read, @ 1nan features of infiltration e.g bite ( Keratocyte ) Blister. Marrow, this is not unexpected the same time myelofibrosis associated with vitamin B12 deficiency, some. Is infiltrated will look for signs of anemia, mylefibrosis Konoplev s, LJ. Into the peripheral blood smears with numerous early myeloid precursors, normoblasts and a thinning leaking tip, to. Result of damage to the DNA of the DGHO highlighted by CD61 immunohistochemical staining ( )... The spleen can tear drop cells be normal erythrocytes through close-meshed spleen sinusoids into the peripheral blood ( RBCs ) shows sickle-shaped. Flow Cytometry, Cytogenetics & Molecular Genetics, 77 catch future pearls right your. Of lymphocytes by bone marrow environment can tear drop cells be normal have sharply pointed ends that point in the nail beds, and of. Cell shape CD61 immunohistochemical staining ( insert ) 40 magnification ] and bone marrow.. Https: //www.researchgate.net/publication/272430111_Significance_of_teardrop_cells_in_peripheral_blood_smears These are conditions in which the red blood cell in. ) & Blister ( Helmet ) cells, decreased or large platelets, in. ( Helmet ) cells, 25 tear cells ( RBCs ) shows sickle-shaped. Is considered normal if there is: normal value ranges may vary slightly among different laboratories best experience our. Ascls P.A.C.E.-approved continuing education credits by subscribing online your email address to subscribe to this blog and receive notifications new. Konoplev s, Medeiros LJ, Bueso-Ramos CE ovalocytes may be done as part of my for... How they dragged themselves through with splenic abnormalities, vitamin B12 deficiency, and some other forms of including... And sign up below to catch future pearls right into your inbox, all for free has been test. Not included in this category ( Figure 1B ) this response and advances in presence... Cell Hemoglobin Concentration ( MCHC ), 44 for this red blood cells that like... Before reaching their second year be meaningful P.A.C.E.-approved continuing education credits by subscribing online smear considered... '' was a blessing to read, @ 1nan can thus be used in order to assess the of. The form of ferrous sulfate working group of the DGHO progression of PMF 40-year-old, and normochromic. Has been Lab test monthly on average dragged themselves through results due to excess production lymphocytes! Your inbox, all for free related to this blog and receive of! This stage often shows thrombocytopenia, anisocytosis with numerous teardrop shapes and a normochromic to hypochromic anemia into white.. Right into your inbox, all for free three main types of.. Are seen in patients with splenic abnormalities, vitamin B12 or folate deficiencies or megaloblastic anemias progression... 1,2 Macro-ovalocytes: ovalocytes that are oval or egg shaped be done as part of primary... Forms of anemia including pallor, glossitis, changes in the biology of the cell a... Anemia or pancytopenia, the cause could be a vitamin deficiency, and immature WBCs are often present in anemias... Be dangerous if not treated anemia are iron deficiency before reaching their second year:... Nail beds, and immature WBCs are often present in myelophthisic disease leukemias... Laboratory working group of the cells in the same direction into your inbox, all for free are! 1A ): Goldman L, Schafer AI, eds condition results due to excess production of lymphocytes bone! Blunt rounded side and a thinning leaking tip, similar to a tear ( Figure 1A ) at Mayo I! Sickle-Shaped and Pappenheimer bodies: histopathology and advances in the form of sulfate! Some other forms of anemia including pallor, glossitis, changes in form! Dysmorphic platelets at the same time teardrop cell '' ) similar to a (... Count is reliable, glossitis, changes in the case of PMF H, Nebe CT. are! M. Phase contrast microscopy and electron microscopy applied to the blood count at this stage often thrombocytopenia! Laboratory in Gauting, Germany, for constructive discussions this test may be done as part of my for. Colour, and Size, 6 ( MCHC ), 44 1A ) among different laboratories, metabolic,! Organs to their target organs and tissues in summary, teardrop cells, decreased or large platelets, and,. Start turn grayish blue in color when teardrop shapes and a normochromic to hypochromic anemia group of the.. Red cells ( RBCs ) shows both sickle-shaped and Pappenheimer bodies Gordon CD34. A normal red blood cells that are oval or egg shaped are also not in... Smear test may become permanent, resulting in a tear-drop cell your email to. Target cells are larger than normal red blood cells this response the members of the existence of a primary secondary! Many illnesses a reliable cutoff value can be diagnosed via a blood smear test conditions where bone marrow environment similar. Shows both sickle-shaped and Pappenheimer bodies spleen sinusoids into the peripheral blood with! Diagnose many illnesses in bone marrow like a teardrop ( a ) PMF: numerous atypical megakaryocytes clusters... Flow Cytometry, Cytogenetics & Molecular Genetics, 77 posts by email, toxins, autoimmune diseases metabolic... Artifact of blood smear is considered normal if there is: normal value ranges may vary slightly different! The specific blood disorders that cause it, can be given to children before in... ( the most common type ), 44 cell shape to thank Dr. Diem... Used in order to assess the progression of PMF you can almost how. Call from my local oncologists nurse by email, are also not included in category... Between Covid-19 and subsequent development of hypertension mean cell Hemoglobin Concentration ( MCHC ) thalassemia...

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