This week’s Morphology Monday case presented with a complex picture involving anaemia, thrombocytosis, and raised white cell count. The striking red cell morphology prompted a wide range of differentials.

The patient has a history of renal impairment, iron deficiency anaemia, and chronic liver disease. These comorbidities are important to keep in mind as they can significantly influence red cell morphology.

Laboratory results:

• Hb: 106 g/L (low)
• RBC: 4.17 ×10¹²/L (low)
• Hct: 0.349 L/L (low)
• MCV: 83.7 fL (low–normal)
• MCH: 25.4 pg (low)
• MCHC: 303 g/L (normal)
• RDW: 19.7% (raised)
• Platelets: 740 ×10⁹/L (high)
• WBC: 25.4 ×10⁹/L (raised)

Blood film features:

• Marked poikilocytosis with a wide range of abnormal red cell shapes
• Echinocytes (burr cells) – often associated with renal impairment
• Schistocytes/helmet cells – suggestive of fragmentation
• Acanthocytes – frequently seen in liver disease
• Elliptocytes and pencil cells – supporting iron deficiency anaemia
• Occasional sickle-like cells and irregularly contracted forms

This mix of features highlights the interplay of the patient’s renal impairment, iron deficiency, and liver dysfunction, all of which contribute to a strikingly abnormal film.

The case underlines how multiple comorbidities can converge to produce complex red cell morphology. Burr cells suggest renal dysfunction, acanthocytes point towards liver disease, and the elliptocytes/pencil cells support iron deficiency anaemia. The thrombocytosis and neutrophilia may reflect an inflammatory response or underlying marrow stress.

This case reminds us that not all films point to a single cause, sometimes the full clinical picture, combined with laboratory data, is essential to understand the multiple factors driving red cell changes.