Interpreting hemograms

in cats and dogs

ALAN REBAR, DVM, PhD, DACVP
School of Veterinary Medicine
Purdue University
West Lafayette, IN 47907

FRED METZGER, DVM, DABVP

(canine and feline practice)
Metzger Animal Hospital
1044 Benner Pike
State College, PA 16801

Editor’s note: This publication is an updated version of an issue Sample collection and management
of The Veterinary CE Advisor that appeared in 1995, which To ensure accurate hematologic interpretation, minimize
was titled “Clinical pathology for small animal practitioners: artifacts as much as possible. Poor blood collection tech-
Interpreting the hemogram.” niques, inadequate sample volumes, prolonged sample
storage, and delayed sample analysis all provide opportu-
The complete blood count (CBC), serum chemistry profile, nities for artifact formation.
and urinalysis are the cornerstones of clinical laboratory Proper blood collection techniques help prevent erro-
assessment. It is important to perform all the tests concur- neous results from sample clotting. To help ensure accuracy,
rently on presentation, particularly in sick patients. Inter- obtain hematologic samples from the largest blood vessel
preting one test or one group of tests without the others is possible, which will minimize cellular trauma and prevent
prone to diagnostic errors. activation of clotting mechanisms, and retest patients with
It is not our intention to provide veterinarians with clotted samples. Common venipuncture sites in dogs and
every interpretation for every test in this article. Our goal cats include the jugular and cephalic veins and the lateral
is to help small-animal practitioners develop a systematic saphenous vein as it crosses the tarsus. Anticoagulants used
approach that enables them to logically evaluate hemato- in hematology include ethylenediaminetetraacetic acid
logic data in any clinical situation. (EDTA), heparin, and citrate. EDTA is the anticoagulant of
choice for blood film preparation because it preserves cellu-
Indications for hematology lar detail better than other anticoagulants.
A CBC provides a broad overview of a patient’s general Inadequate sample volume is a common cause of inac-
health. For this reason, hematology is a critical compo- curate hematology results. Completely filling anticoagu-
nent of laboratory evaluation of patients. The periph- lated blood collection tubes avoids a falsely decreased
eral blood serves as the transport medium between the packed cell volume (PCV) and falsely decreased cell counts
bone marrow and the tissues; consequently, a CBC pro- and prevents red blood cell (RBC) shrinkage.
vides a snapshot of the hematopoietic system at a spe- Analyzing hematologic samples as soon as possible
cific point in time. prevents artifacts created by exposure to anticoagulants
A CBC should be performed in every sick patient, and from cell deterioration due to storage and shipment.
every patient with vague signs of disease, and every pa- Examine samples within three hours of collection or re-
tient undergoing a wellness or geriatric profile. A CBC is frigerate them at 39 F (4 C) to avoid artificially increased
also indicated as a recheck test in patients with previous PCV and mean cell volume and decreased mean cell he-
erythrocyte, leukocyte, or thrombocyte abnormalities and moglobin concentration.
in conjunction with treatment involving medications Erythrocyte crenation, neutrophil hypersegmentation,
that may affect erythrocyte, leukocyte, or thrombocyte and lymphocytic nuclear distortion may occur in aged
lines, such as chemotherapeutics. samples, as well as monocyte vacuolization, monocyte

Supplement to Veterinary Medicine 1

pseudopod formation, and platelet aggregation. To pre- all three zones of the film. In the monolayer—the zone be-
vent these morphological artifacts from occurring, pre- tween the thick layer where the blood drop originated and
pare blood films within one hour of collection. In addi- the much thinner feathered edge—the cells are individual-
tion, keep formalin and formalin-containing containers ized and do not overlap. This monolayer is the only area
away from all blood and cytologic smears to prevent in- where evaluation of cell morphology should take place.
adequate staining. First, examine the blood film at low magnification
(103 or 203) and scan the entire slide to determine over-
Blood film preparation and examination all film thickness, cell distribution, and differentiation of
Examining blood films provides vital information for the three layers. Examine the feathered edge for the pres-
practitioners. Proper preparation and staining and sys- ence of microfilariae, phagocytosed organisms, atypical
tematic examination are necessary to interpret blood cells, and platelet aggregation. Then, still using low mag-
films accurately. nification, evaluate the monolayer. Estimate the total
Producing high-quality blood films begins with clean, white blood cell (WBC) count (see below) and predict the
new slides; used slides frequently contain scratches and expected WBC differential count. Finally, use oil immer-
other physical imperfections. Slides must be free of finger- sion (1003) to examine erythrocyte, leukocyte, and
prints, dust, alcohol, detergents, and debris. Using a micro- platelet morphology. Evaluate RBCs for evidence of aniso-
hematocrit tube, place a small drop (2 to 3 mm in diame- cytosis, poikilocytosis, polychromasia, hemoglobin con-
ter) of well-mixed EDTA blood approximately 1 to 1.5 cm centration, and RBC parasites. Important erythrocyte
from the end of the sample slide. Next, draw a spreader morphologic abnormalities include spherocytes, schisto-
slide back into the blood drop at approximately a 30-de- cytes, acanthocytes, and burr cells, among others. Exam-
gree angle until the spreader slide’s edge touches the sam- ine leukocytes for important information—neutrophils
ple drop and capillary action disperses the sample along for toxic change and the presence or absence of a left shift
the edge. Then use a smooth and steady motion to push (elevated band neutrophils), lymphocytes for reactivity,
the spreader slide away from the blood drop, creating a and monocytes for phagocytosed organisms.
uniform film that covers nearly the entire length of the
slide. Note that changing the angle of the spreader slide Determination of cell counts
will change the length and thickness of the blood film. Several technologies have been applied to determine ery-
Allow the blood film to air-dry thoroughly before staining, throcyte, leukocyte, and thrombocyte counts in veterinary
and do not heat it. A high-quality blood film should have medicine. Traditional in-clinic hematologic evaluation
three distinct zones: the thick layer, the monolayer, and methods include estimations from blood films, manual
the feathered edge. counting, electronic resistance (impedance) counters, and
Most veterinary practices use Diff-Quik (Dade Behring) quantitative buffy coat analysis. Most reference laborato-
stain, which is a modified Wright’s stain. Diff-Quik stain ries use impedance technology or laser flow cytometry.
uses three separate solutions: an alcohol fixative (light blue Making accurate cell count estimations directly from
in color), an eosinophilic staining solution (orange), and blood films requires experience. One method of estimating
methylene blue stain (dark blue). To help ensure reliable total leukocyte counts involves counting several 203 objec-
results, use two separate Coplin stain jar sets—one for tive fields—10 to 20 WBCs per 203 field is considered nor-
staining hematologic and cytologic samples and one for mal in dogs and cats. Another method is to count several
staining contaminated samples, such as ear and fecal cyto- 1003 oil immersion fields, then multiply the average num-
logic specimens. Replace Diff-Quik stains routinely for op- ber of WBCs per 1003 oil immersion field by 2,000 to ob-
timal results. To properly stain the sample, dip the air- tain a final estimated total WBC count. Determining total
dried slide five to 10 times in each solution while blotting erythrocyte numbers from blood films is not recommended
one edge briefly in between each solution. Rinse the slide because variations in film thickness make counts imprecise.
with distilled water after the final staining step with the Manual cell counting requires a counting chamber
methylene blue, and allow the stained blood film to air- (hemacytometer) and close visual inspection. Although
dry before examination. this method is inexpensive, it is labor-intensive and re-
A high-quality microscope is essential for hematology quires operator training and experience for successful
and cytology. We recommend a binocular microscope with analysis. Studies report a margin of error of 20% to 25%
103, 203, 503 or 603, and 1003 oil immersion objec- compared with automated methods.1
tives. The microscope manufacturer will include cleaning Electronic (impedance) counters use the Coulter princi-
instructions and maintenance information. ple developed in 1945. In this system, a suspension of
Systematic blood film evaluation includes assessment of blood cells in a metered volume of electrolyte medium

2 December 2001
 TABLE 1
General patterns of leukocyte response
Total WBC Segmented Band
count neutrophils neutrophils Lymphocytes Monocytes Eosinophils
Inflammation
Acute Increased Increased Increased Decreased or Variable Variable
no change
Chronic Increased or Increased or Increased or Increased or Increased Variable
no change no change no change no change
Overwhelming Decreased Decreased or Increased Decreased or Variable Variable
no change no change
Excitement Increased Increased in dogs; No change No change in No change No change
leukocytosis increased or no dogs; increased
change in cats in cats
Stress leukogram Increased Increased No change Decreased Increased or Decreased
no change

flows through a small orifice where a constant electrical cur- next, and platelet data last. This order is useful because
rent is applied. In theory, each cell emits an electrical signal changes in WBCs often predict alterations in other he-
unique to its classification, which the device registers and mogram findings.
records. Disadvantages of impedance technology include a
great deal of analyzer maintenance and cleaning, grouping Evaluating the WBCs (leukogram)
of granulocytes together, and an inability to provide valu- Leukogram data include total and differential WBC
able reticulocyte information. In addition, platelet clump- counts and a description of WBC morphology from the
ing frequently results in an artifactually increased total peripheral blood film. Differential cell counts should al-
WBC count and decreased platelet counts because imped- ways be expressed and interpreted in absolute numbers,
ance counters often register clumped platelets as leukocytes. not percentages. All leukocyte compartments—including
Quantitative buffy coat technology incorporates cellu- neutrophils and their precursors, eosinophils, basophils,
lar density and nuclear and cytoplasmic staining character- monocytes, and lymphocytes—must be counted.
istics to discriminate cellular types. Advantages of this WBC data are used to answer the following questions:
technique include ease of use, low maintenance, system 1. Is there evidence of inflammation?
abnormality alerts, a reticulocyte percentage report, and a 2. Is there evidence of a glucocorticoid (stress) or epi-
visual buffy coat graph to aid in interpretation. Disadvan- nephrine (excitement) response?
tages include the inability to recognize feline eosinophils 3. Is there a demand for phagocytosis or evidence of tis-
and the grouping of lymphocytes and monocytes together. sue necrosis?
Furthermore, the operator must understand the buffy coat 4. If inflammation is present, can it be further classified
graph to maximize the system’s usefulness. as acute, chronic, or overwhelming?
Laser flow cytometry uses optical laser scattering to dis- 5. Is there evidence of systemic toxemia?
tinguish cellular elements. Advantages of this technology Table 1 lists the general patterns of leukocyte response
include a full five-part WBC differential (neutrophils, under a variety of circumstances.
eosinophils, basophils, lymphocytes, and monocytes) plus
expanded RBC information (reticulocyte percentage and 1. Is there evidence of inflammation? Neutrophilic left
absolute reticulocyte count) and platelet data (platelet vol- shifts (Figure 1), persistent eosinophilia, and monocytosis
ume and count). The disadvantage is the higher cost asso- (Figure 2) are the best indicators of inflammation. Left
ciated with this more sophisticated technology. shifts (increased numbers of immature, or band, neu-
trophils in circulation) indicate increased turnover and tis-
Hemogram interpretation sue use of neutrophils. Persistent peripheral eosinophilia
A CBC is composed of WBC, RBC, and platelet data as well indicates a systemic allergic or hypersensitivity reaction.
as total protein concentration. In general, we prefer to Monocytosis is seen in peripheral blood when there is a
evaluate WBC data first, RBC and protein data collectively demand for phagocytosis.

Supplement to Veterinary Medicine 3

 Figure 1 Figure 2
1. Blood film from a dog with
inflammation (Wright’s stain;
1003). Leukocytosis, neutro-
philia, and a left shift were
evident on the CBC.
2. Blood film from a dog
with an inflammatory leuko-
gram with monocytosis (Wright’s
stain; 1003). Three monocytes
and a neutrophil are visible. Figure 3 Figure 4
3. Blood film from a dog with
hemangiosarcoma (Wright’s
stain; 1003). An RBC fragment
(schistocyte) is seen in the center.
4. This cat had an inflammatory
leukogram with a left shift
(Wright’s stain; 1003). The band
cell at the left is toxic, with
basophilic granular cytoplasm.

Inflammatory leukograms without any of the above exceed the renal threshold), marked hyperglycemia in
changes are possible, but they are harder to recognize. For cats, and elevations in serum alanine transaminase (ALT)
example, a mild leukocytosis with mature neutrophilia and serum alkaline phosphatase (ALP) activities in dogs. In
may indicate inflammation, but it may also represent a particular, stress lymphopenias can be important in inter-
physiological response to an epinephrine surge (excite- preting hepatic disorders. As a guideline, a greater than
ment leukocytosis) or a response to endogenous or exoge- fourfold rise in serum ALP activity in a dog results either
nous glucocorticoids. When the results of a leukogram are from cholestasis or high concentrations of circulating glu-
ambiguous, they can sometimes be clarified by repeating cocorticoids. If lymphopenia is present, neither cause can
the CBC after several hours or days or testing for other be eliminated; if lymphopenia is absent, cholestatic liver
markers of inflammation, such as erythrocyte sedimenta- disease is likely.
tion rates, fibrinogen concentrations, or reactive C-pro- It’s important to distinguish the stress response accom-
tein concentrations. A period of four hours is generally re- panied by an increased concentration of circulating gluco-
quired to see important changes in the leukogram. corticoids from the excitement response associated with
increased concentrations of epinephrine. The stress re-
2. Is there evidence of a glucocorticoid (stress) or epi- sponse is the result of changes both in circulating and
nephrine (excitement) response? High concentrations of bone marrow pools of leukocytes; it takes several hours to
circulating glucocorticoids cause a mild mature neu- develop and persists for about 24 hours.
trophilia, lymphopenia and eosinopenia, and mild mono- In contrast, with the excitement response, in-
cytosis. Of these changes, lymphopenia is the most consis- creased blood flow mobilizes marginating leukocytes
tent and reliable indicator of stress. We regard lymphocyte from vessel walls and brings them back into circula-
counts of 1,000 to 1,500/µl as marginal lymphopenia, tion. This type of response dissipates in minutes. In
whereas lymphocyte counts below 1,000/µl are absolute dogs, excitement leukocytosis is primarily a mild ma-
lymphopenias. Stress typically results in lymphopenias in ture neutrophilia; in cats, it is a lymphocytosis, a neu-
the range of 750 to 1,500 lymphocytes/µl. When lympho- trophilia, or both.
cyte counts drop below 600/µl, we consider other causes
of lymphopenia, such as chylous effusions, lymphangiec- 3. Is there a demand for phagocytosis or evidence of
tasia, and malignant lymphoma. tissue necrosis? Monocytosis indicates a demand for
The presence or absence of a glucocorticoid response in phagocytosis or tissue necrosis. Monocytosis is almost
the leukogram carries important implications for the inter- always present in chronic inflammatory conditions, but
pretation of other laboratory data. High concentrations of it can also occur with acute inflammation. Whenever
circulating glucocorticoids can be associated with mild to you observe a severe monocytosis (> 4,000/µl), prepare a
moderate hyperglycemia in dogs (elevations that do not buffy coat smear to identify any particles or causative

4 December 2001
agents that have been phagocytosed by circulating anemia of inflammatory disease. This is a mild to moder-
monocytes (e.g. opsonized RBCs in immune-mediated ate nonregenerative anemia, resulting in a PCV as low as
hemolytic anemia, Ehrlichia canis organisms, or Histo- 30% in dogs and 25% in cats. This anemia can develop
plasma capsulatum organisms). fairly rapidly (within seven to 10 days), particularly in cats
in which the life span of circulating RBCs is relatively short
4. If inflammation is present, can it be further classi- (about 80 days). Chronic inflammatory conditions are
fied as acute, chronic, or overwhelming? In many cases, often associated with stimulation of the immune system,
the inflammation cannot be further classified based on the hypergammaglobulinemia, and resultant elevated total
inflammatory leukogram. However, in some cases, the dif- protein concentrations. Whenever inflammation is severe,
ferential cell count is typical of acute, chronic, or over- give special attention to platelet counts. Low platelet num-
whelming inflammation (Table 1). bers (<100,000/µl) in conjunction with an inflammatory
The classic acute inflammatory leukogram in dogs and leukogram suggest the possibility of disseminated intravas-
cats is characterized by neutrophilic leukocytosis with a cular coagulopathy (DIC). In dogs, the presence of RBC
left shift (increased numbers of immature neutrophils in fragments (schistocytes) in the peripheral blood can fur-
circulation), which is also called a regenerative left shift. ther signal DIC (Figure 3). Immune-mediated thrombocy-
The WBC count is elevated because bone marrow produc- topenia can cause a similar pattern but is usually associ-
tion and release of granulocytes into the blood is greater ated with an even lower platelet count (<35,000/µl).
than the migration of granulocytes from the peripheral
blood into the tissues. A left shift is apparent because as 5. Is there evidence of systemic toxemia? Circulating
neutrophils are being rapidly mobilized from the bone toxins (i.e. systemic toxemia) can arrest the development
marrow, immature neutrophils (band cells) are drawn from of neutrophil precursors in the bone marrow, which can
the bone marrow maturation pool into circulation. Gener- affect either cytoplasmic or nuclear development. The ab-
ally, lymphopenia is also present as a reflection of superim- normal neutrophils produced in this way are recognized
posed stress (glucocorticoid response). The presence of on the peripheral blood film as toxic neutrophils. Cyto-
monocytosis is variable. plasmic features of toxemia include foamy basophilia (Fig-
In chronic inflammatory conditions, the myeloid mar- ure 4) and the presence of small basophilic precipitates
row has expanded enough for production to keep pace known as Döhle’s bodies.
with tissue demand, and the left shift dissipates. If the in- Döhle’s bodies are a sign of mild toxemia in cats
flammation is severe and localized, as in the case of a large (often seen in low numbers in normal cats), but indicate
abscess or pyometra, then the WBC count may be quite serious toxemia in dogs. Nuclear changes of toxemia in-
high, reaching 50,000/µl or more. In most other instances clude bizarre nuclear shapes and cellular giantism. Sys-
of chronic inflammation, the total WBC count is closer to temic toxemia is usually associated with bacterial endo-
normal. Animals with chronic inflammatory leukograms toxins. Infectious diseases commonly associated with se-
usually have normal lymphocyte counts. Monocyte counts vere toxemia include feline pyothorax, pyometra, and se-
are almost always elevated because of tissue necrosis and vere canine prostatitis. Toxemia can also accompany
demand for phagocytosis. So a classic chronic inflamma- noninfectious conditions such as tissue necrosis, heavy
tory leukogram is characterized by a normal to slightly ele- metal toxicosis, or cytotoxic drug therapy.
vated leukocyte count (rarely dramatically elevated), a nor-
mal to slightly elevated neutrophil count, a normal or ele- Evaluating the RBCs (erythrogram)
vated lymphocyte count, and an elevated monocyte count. RBC data include the PCV, RBC count, hemoglobin con-
Overwhelming inflammatory responses usually occur centration, mean cell volume, and mean cell hemoglobin
with acute conditions in which bone marrow production concentration. As stated earlier, we include total protein
is unable to match tissue use. The bone marrow storage concentration as part of the RBC evaluation. The RBC data
pool of neutrophils is quickly depleted and immature are used to determine whether the RBC mass is normal, re-
neutrophils are drawn into circulation, resulting in duced, or increased.
leukopenia, normal or decreased neutrophil counts, and a RBC mass is evaluated by assessing the PCV, hemoglo-
degenerative left shift. Monocytosis may be present be- bin concentration, and RBC count. For in-clinic laborato-
cause of tissue destruction. Superimposed stress lym- ries, one reason for determining all three is to achieve
phopenia is also common. some measure of internal quality control. Any deviation
Recognizing and classifying inflammatory reactions is from the reference range should occur in all three tests to
important to the interpretation of other hemogram para- the same degree. If the results of the three tests do not cor-
meters. The most common anemia in dogs and cats is the relate, consider the possibility of laboratory error.

Supplement to Veterinary Medicine 5

 Figure 5

Classification of anemia
Decreased PCV
Consider state of hydration

Reticulocyte count—dogs and cats

Regenerative Nonregenerative
> 80,000 reticulocytes/µl in dogs < 80,000 reticulocytes/µl in dogs
> 60,000 reticulocytes/µl in cats < 60,000 reticulocytes/µl in cats

Bone marrow evaluation

Blood loss anemia Hemolytic anemia
External hemorrhage Immune-mediated hemolytic anemia with spherocytosis
Internal hemorrhage Heinz body hemolytic anemia from ingesting onions,
Parasites (fleas, hookworms) acetaminophen, or other toxins
Takes one to three days to see PCV decrease

Bone marrow hypoplasia Bone marrow hyperplasia

Anemia of inflammation with ineffective erythropoiesis
Anemia of chronic renal disease
Myelophthisis — bone marrow disease
Toxicosis — chemotherapy
Nuclear maturation defect Cytoplasmic maturation defect
FeLV infection Lead toxicosis
Drug toxicosis Iron deficiency including chronic
blood loss

Classifying polycythemia. If RBC mass is increased, then animals recently moved to high altitudes or that suffer
the animal is polycythemic. This then raises the question: from pulmonary or cardiovascular disease. Inappropriate
Is the polycythemia relative or absolute? Relative poly- secondary polycythemia, characterized by excessive ery-
cythemia, the most common polycythemia recognized in thropoietin production, often accompanies renal carci-
veterinary medicine, is the result of hemoconcentration. noma, renal cysts, hydronephrosis, and, occasionally,
Relative polycythemia is generally established based on the nonrenal tumors.
clinical history and signs consistent with dehydration, as Excessive exogenous administration of erythropoietin
well as an elevated total protein concentration. Poly- can also cause polycythemia in dogs and cats. Further-
cythemia in the absence of these findings is absolute. Ab- more, mild polycythemia can result from hyperthyroidism
solute polycythemia can be either primary or secondary. and hyperadrenocorticism.
Primary absolute polycythemia, also called polycythemia
vera, is a myeloproliferative disease. It is a multipotential Classifying anemias. If RBC mass is reduced, then the
stem cell defect characterized by overproduction of all cell animal is anemic (Figure 5). The degree of anemia should
lines. The clinical signs—including lethargy, hyperemia, be further considered in conjunction with plasma protein
dyspnea, cardiac murmur, and splenomegaly—are attrib- concentrations. If protein concentrations are elevated,
uted to hyperviscosity syndrome related primarily to in- then the animal may be dehydrated and the anemia may
creased RBC mass. A markedly increased RBC mass (e.g. be more severe than the RBC mass measures indicate.
PCV = 75%) in the presence of normal arterial oxygen con- Once anemia is recognized, the next issue of concern is
centrations and normal or low serum erythropoietin con- bone marrow responsiveness: Is the anemia regenerative or
centrations generally confirms the diagnosis. nonregenerative? If the RBC marrow responds with an in-
Secondary absolute polycythemia is both appropriate crease in production of the appropriate magnitude, the
and compensatory for hypoxemia or inappropriate and anemia is regenerative (responsive). On the other hand,
caused by increased concentrations of circulating ery- the anemia is nonregenerative (nonresponsive) when the
thropoietin. Compensatory polycythemia is present in increase in RBC production is not sufficient.

6 December 2001
 Evidence of RBC regeneration can be evaluated on a pe- in cases of DIC or hemangiosarcoma). In dogs, Heinz bod-
ripheral blood film. In dogs and cats, regeneration is indi- ies in the peripheral blood confirm a diagnosis of Heinz
cated by the presence of polychromatophils (using Wright’s body hemolytic anemia. In cats, large numbers of Heinz
or Diff-Quik stain) or reticulocytes (using new methylene bodies are associated with such conditions as diabetes
blue stain). These immature RBCs stain bluish because they mellitus or hyperthyroidism in the absence of hemolysis
contain RNA (Figure 6). Because polychromatophils and (Figure 9). To confirm Heinz body hemolytic anemia in
reticulocytes are larger than mature RBCs, another feature cats, Heinz bodies, anemia, and evidence of regeneration
of regeneration is anisocytosis (variation in RBC size). Nu- must be present.
cleated RBCs may also be present in small numbers, but Nonregenerative anemias lack polychromasia on the
there should always be fewer of them than polychro- peripheral blood films. This type of anemia can be sepa-
matophils. A large number of nucleated RBCs in the ab- rated into two classes: nonregenerative anemias with mar-
sence of polychromasia usually indicates bone marrow stro- row hypoplasia, and nonregenerative anemias with RBC
mal damage; this finding is called an inappropriate nucle- marrow hyperplasia but ineffective erythropoiesis.
ated RBC response (Figure 7). This process will be addressed Nonregenerative anemias with RBC marrow hypoplasia
in more detail in the discussion of lead poisoning anemia. are the most common anemias in dogs and cats. These are
If the issue of regeneration is still in doubt after you usually normocytic, normochromic anemias, based on
evaluate stained blood films, do a reticulocyte count. As a RBC indices (mean cell volume and mean cell hemoglobin
guideline, a reticulocyte count above 60,000/µl in cats concentration) and RBC morphology. Included in this cat-
and 80,000/µl in dogs indicates a regenerative anemia. In egory are the anemias of inflammatory or neoplastic dis-
many cases, the reticulocyte counts in dogs with regenera- ease, the anemia of renal disease, the anemia of hypothy-
tive anemias are much higher than 80,000/µl. Cats show roidism, myelophthisic anemias (such as those that occur
a somewhat lower overall regenerative capacity than do with myelofibrosis), and anemias resulting from exposure
dogs. Cats have two types of reticulocytes called aggregate to a variety of bone marrow toxins. Pure RBC aplasia is
and punctate. Aggregate reticulocytes indicate active RBC also in this category. Cytologic evaluation of bone marrow
regeneration, while punctate reticulocytes indicate past is very useful in differentiating these various causes, but a
regeneration. When performing a reticulocyte count in a detailed discussion of bone marrow collection and evalua-
cat, it is important to count only aggregate reticulocytes. tion is beyond the scope of this article.
In both dogs and cats, peak reticulocyte counts occur four Nonregenerative anemias with ineffective erythro-
to eight days after the onset of anemia. poiesis can result from nuclear or cytoplasmic maturation
Regenerative anemias can be further classified as either defects in RBC precursors (cytonuclear dissociation). Inef-
blood loss or hemolytic anemias. Remember that it might fective erythropoiesis implies that even though the RBC
take one to three days for the PCV to decrease from blood marrow is active, increased numbers of normal RBCs are
loss because the severity of anemia may be masked by not being released into circulation. The peripheral blood
splenic contraction and restoration of blood volume by evaluation suggests the diagnosis, and the combination of
fluid passing from the extravascular space. A patient history peripheral blood findings and bone marrow findings con-
of trauma or parasitic infection may suggest blood loss. Fur- firm the diagnosis.
thermore, the total protein concentration may be decreased Nuclear maturation defect anemias result when the for-
in such cases. Another useful differentiating factor is that mation of nuclear DNA or RNA is blocked. This can occur
hemolytic anemias are generally much more regenerative from a deficiency of certain nutrients (e.g. vitamin B12 or
than are blood loss anemias. Iron is preserved with he- folic acid) or through active interference (e.g. methotrexate
molytic anemias and lost with blood loss. toxicosis). The most common nuclear maturation defect
Whenever hemolysis is suspected, examine RBC mor- anemia in small-animal medicine is caused by feline
phology closely. Infectious causes of hemolysis, such as leukemia virus (FeLV) infection. FeLV infection is thought
Haemobartonella canis, Haemobartonella felis, Babesia canis, to directly interfere with DNA synthesis. The anemia of
and Babesia gibsoni, may be visible on blood films from af- FeLV infection can have either normocytic, normochromic
fected animals. In addition, certain RBC morphological RBC indices or macrocytic, normochromic indices.
abnormalities, such as spherocytes (Figure 8), schistocytes In nuclear maturation defect anemias, the diagnostic
(Figure 3), and Heinz bodies (more easily recognized with finding is the presence of megaloblastic RBC precursors in
new methylene blue staining) (Figure 6), can be markers peripheral blood, bone marrow, or both. Megaloblasts (Fig-
for certain types of hemolysis. Spherocytosis is present ures 10 & 11) are giant RBC precursors in which the nuclei
with immune-mediated hemolytic anemias. Schistocytes are more immature than the cytoplasm. For example, nor-
in large numbers suggest microangiopathic hemolysis (e.g. mal metarubricytes have small pyknotic (aged, condensed)

Supplement to Veterinary Medicine 7

 Figure 6 Figure 7 Figure 8

Figure 9 Figure 10 Figure 11

Figure 12 Figure 13
6. Heinz body hemolytic anemia in a dog
(Wright’s stain; 1003). The Heinz bodies are blunt
noselike projections from the RBC surface. A large
polychromatophil is visible on the upper left side.
7. Low magnification of a blood film from a dog
with lead poisoning (Wright’s stain; 203). Three
nucleated RBCs are seen in the absence of
polychromasia (an inappropriate nucleated RBC
response). 8. Blood film from a dog with
immune-mediated hemolytic anemia (Wright’s
stain; 1003). Spherocytes (small RBCs that stain intensely and lack cytoplasm, and the relatively immature nucleus. 12. Blood film from a
central pallor) are scattered throughout. 9. Blood film from a cat with dog with iron deficiency anemia (Wright’s stain; 203). Many of the
hyperthyroidism (Wright’s stain; 1003). Numerous RBCs containing Heinz RBCs are small (microcytic) and have enlarged areas of central pallor
bodies are present, but there is no anemia and no polychromasia. (hypochromasia). 13. This blood film from a cat with FeLV infection shows
10 & 11. Megaloblasts from a cat with FeLV infection (Wright’s stain; 1003). an inappropriate nucleated RBC response (Wright’s stain; 1003). The large
Note the large size of these two nucleated RBCs, the well-hemoglobinated cell at left center is a blast cell.

nuclei and well-hemoglobinated cytoplasm. In contrast, cells), and elliptocytes may also occur with iron
megaloblastic metarubricytes have well-hemoglobinated deficiency anemia.
cytoplasm, but their large nuclei are vesiculated and im- The anemia of lead poisoning in dogs is generally
mature. Megaloblasts are larger than normal blood cells at mild, with RBCs of normal size and a normal amount of
the same stage of cytoplasmic development; they do not hemoglobin (normocytic, normochromic). A striking
divide as often because they are unable to synthesize nu- finding in peripheral blood films is a marked inappropri-
cleic acids. Nucleic acid synthesis is a prerequisite of nor- ate nucleated RBC response (Figure 7). In some cases, ba-
mal mitosis. sophilic stippling of RBCs may be apparent. Other causes
The principal cytoplasmic maturation defect anemias of inappropriate nucleated RBC responses include hyper-
are the anemia of iron deficiency and the anemia of lead adrenocorticism, endotoxemia, splenic disorders, frac-
poisoning. In both cases, the cytoplasmic maturation tures, and extramedullary hematopoiesis. All of these are
defect results from inadequate hemoglobin synthesis. associated with mild responses (five to 10 nucleated
Iron deficiency anemia is a consequence of chronic RBCs/100 WBCs). Suspect lead poisoning whenever more
or severe blood loss. It is usually characterized by the than 10 nucleated RBCs/100 WBCs and minimal poly-
presence of small RBCs with excessive areas of central chromasia are seen in dogs. In cats, inappropriate nucle-
pallor (microcytosis and hypochromasia) (Figure 12). ated RBC responses are most commonly associated with
Poikilocytes such as schistocytes, codocytes (target FeLV infections (Figure 13).

8 December 2001
 Evaluating the platelets mal to increased number of bone marrow megakaryocytes.
An assessment of platelet numbers is an important part In dogs with an inflammatory leukogram or schistocytes
of every CBC. As with RBCs, the principal issue is whether on the blood film, DIC is a strong possibility, so perform a
platelet numbers are normal, increased (thrombocytosis), coagulation profile. After ruling out other causes of periph-
or reduced (thrombocytopenia). eral platelet use (e.g. ehrlichiosis, Rocky Mountain spotted
Thrombocytosis is rare. When the number of platelets fever), you can attempt antiplatelet antibody tests. Kansas
in dogs or cats approaches 1 million/µl, consider platelet State University currently offers platelet-bound antibody
leukemia (primary thrombocythemia, megakaryocytic testing. Based on the diagnostic findings, you can then in-
myelosis). More commonly, thrombocytosis is less marked, stitute appropriate therapy.
and reactive responses are probably more likely. For exam-
ple, stimulation of RBC production in any regenerative Conclusion
anemia also stimulates platelet production. Laboratory medicine continues to evolve as research and
Thrombocytopenia is more common than thrombocy- technology create new tests and improve current diagnos-
tosis and can be of great clinical significance. Platelet tics. We hope this review of current concepts in hematol-
counts below 50,000/µl can lead to overt bleeding. Platelet ogy will assist veterinarians and veterinary technicians in
clumping can give a falsely low platelet count, particularly their constant efforts to improve patient care through lab-
in cats. Platelet clumping frequently interferes with results oratory diagnostics. ■
from impedance counters because aggregated platelets may
be included in the RBC count. If you obtain a low platelet REFERENCE
1. Willard, M. et al.: The complete blood count. Textbook of Small Animal
count in a cat by using impedance counter technology, use Clinical Diagnosis by Laboratory Methods, 3rd Ed. W.B. Saunders, Philadel-
another method, such as blood film examination or laser phia, Pa., 1999; p 17.
flow cytometry, to avoid an unnecessary workup.
SUGGESTED READINGS
Thrombocytopenia can result from: 1. Boon, G.D.; Rebar, A.H.: The clinical approach to disorders of hemostasis.
• decreased platelet production (e.g. with estrogen Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat, 3rd
Ed. (S.J. Ettinger, ed.). W.B. Saunders, Philadelphia, Pa., 1989; pp 105-108.
toxicosis or infection with FeLV or feline immunodefi- 2. Duncan, J. et al.: Erythrocytes, leukocytes, hemostasis. Veterinary Labora-
ciency virus) tory Medicine, 3rd Ed. Iowa State University Press, Ames, 1994; pp 3-61, 75-
93.
• increased peripheral use of platelets (e.g. in DIC, acute 3. Day, M.J. et al.: Manual of canine and feline hematology and transfusion
ehrlichiosis, or Rocky Mountain spotted fever) medicine, British Small Animal Veterinary Association, London, U.K., 2000; p
254.
• peripheral destruction of platelets (e.g. in immune- 4. Cotter, S.M.: Hematology. Teton New Media, Jackson Hole, Wyo., 2001; p 147.
mediated thrombocytopenia) 5. Lewis, H.B.; Rebar, A.H.: Bone Marrow Evaluation in Veterinary Practice.
Ralston Purina, St. Louis, Mo., 1979.
• sequestration of platelets in the spleen (e.g. in hyper- 6. Rebar, A.H.: Anemia. Clinical Signs and Diagnosis in Small Animal Practice
splenism). Hypersplenism is rare, poorly documented in (R.B. Ford, ed.). Churchill Livingstone, New York, N.Y., 1988; pp 389-413.
7. Rebar, A.H.: Interpreting the feline hemogram. Handbook of Feline Medi-
animals, and generally can be ruled out in the absence of cine. Pergamon Press, Oxford, U.K., 1993; pp 112-119.
splenomegaly. 8. Feldman, B.F. et al.: Hemostasis. Schalm’s Veterinary Hematology, 5th
Ed. Lippincott, Williams, & Wilkins, Baltimore, Md., 2000; p 1344.
The next step in classifying the causes of thrombocy- 9. Reagan, W.J. et al.: Veterinary Hematology Atlas of Common Domestic
topenia is bone marrow evaluation. Hypoproliferative Species. Iowa State University Press, Ames, 1998; p 75.
10. Willard, M. et al.: The complete blood count. Small Animal Clinical Diagno-
thrombocytopenia is characterized by a decreased number sis by Laboratory Methods, 3rd Ed. W.B. Saunders, Philadelphia, Pa., 1999;
of megakaryocytes in the bone marrow. Some hypoprolif- pp 11-23.
11. Cowell, R. et al.: Blood film examination. Diagnostic Cytology and Hema-
erative thrombocytopenias may be immune-mediated and tology of the Dog and Cat, 2nd Ed. Mosby, St. Louis, Mo., 1999; pp 254-259.
steroid- or immunosuppressive-responsive. Both utilization 12. Harvey, J.: Atlas of Veterinary Hematology: Blood and Bone Marrow of
Domestic Animals. W.B. Saunders, Philadelphia, Pa., 2001.
thrombocytopenia (DIC) and destruction thrombocytope- 13. Rebar A.H., et al.: Idexx Manual of Hematology. Teton New Media, Jack-
nia (immune-mediated disease) are characterized by a nor- son Hole, Wyo., 2001.

Supplement to Veterinary Medicine 9