Histology, Basophilic Stippling


Article Author:
John Sanchez


Article Editor:
David Lynch


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/28/2019 1:14:13 PM

Introduction

Basophilic stippling is one example of several clinically significant erythrocyte inclusions identified on peripheral blood smears. The presence of basophilic stippling is attributed to aggregates of ribosomes or fragments of ribosomal RNA precipitated throughout the cytoplasm of circulating erythrocytes. This finding is associated with acquired and heritable hematologic disorders affecting erythropoiesis and erythrocyte maturation.

Issues of Concern

Basophilic stippling is a frequent manifestation of hematologic disease in the peripheral blood, and it is also observable in bone marrow aspirates. It is implicated in cases of lead poisoning but can be an indicator of various heavy metal toxicities. Alternative causes of basophilic stippling such as hemoglobinopathies, nutritional deficiencies, and myelodysplasia warrant consideration as well in the context of appropriate clinical history.

Structure

Ribosomes and fragments of ribosomal RNA/ribonuclear proteins can form aggregates in circulating reticulocytes and erythrocytes as a consequence of disease. These aggregates precipitate in the cytoplasm similar to other erythrocyte inclusions like Pappenheimer bodies and Howell-Jolly bodies, but the composition of basophilic stippling is distinctive. Further discussion of the functional, histochemical, and pathologic implications of basophilic stippling follows in subsequent sections.

Function

Immature erythrocytes require the same organelles as other human cells to function and synthesize materials necessary to proceed with maturation. Ribosomes facilitate the translation of mRNA to produce proteins utilized in numerous cellular functions and remain present in reticulocytes alongside other essential organelles, such as mitochondria, following enucleation of erythroblasts. Terminal maturation of reticulocytes into erythrocytes involves the elimination of these remaining organelles. Clearance of ribosomes is thought to occur during later phases of maturation in which reticulocytes enter circulation from the bone marrow to complete their conversion into erythrocytes. Enzymatic degradation via Ulk1 protein kinase signaling appears to be attributable to ribosome clearance; however, a detailed mechanism is not clear at this time.[1]

Incomplete or failure of ribosomal degradation leads to precipitation of ribosomes or ribosomal remnants in circulating erythrocytes, which is visible as basophilic stippling on microscopy. Aberrant terminal maturation is involved in several hematologic disorders but is of particular interest in heavy metal toxicity and anemia – especially those associated with heritable enzymopathies. For example, pyrimidine nucleotidase is a key enzyme involved in the catabolism of ribosomal and messenger RNA during terminal maturation. Deficiency or inhibition of this enzyme causes anemia with marked basophilic stippling on peripheral smears.[1][2]

Tissue Preparation

Most specimens consist of whole blood collected via the appropriate protocol for hematologic studies, typically in a lavender top tube with potassium EDTA anticoagulant. A peripheral blood smear is then made from the specimen and prepared with Wright-Giemsa stain for light microscopy. Bone marrow aspirate with Wright-Giemsa staining may also demonstrate this histologic finding.

Histochemistry and Cytochemistry

No specific histochemical markers or staining methodologies yet exist for basophilic stippling. That said, basophilic stippling can be differentiated from other erythrocyte inclusions – namely Pappenheimer bodies – by its lack of special staining. Pappenheimer bodies have a similar appearance to basophilic stippling in peripheral blood with Wright-Giemsa staining; however, the former is composed of iron aggregates rather than ribosomal material. Prussian blue stain preferentially binds iron in tissues; therefore, Pappenheimer bodies rather than basophilic stippling will be visible on a specimen treated with Prussian blue.[3]

Microscopy Light

The appearance of basophilic stippling on light microscopy of peripheral blood and bone marrow aspirates is characteristic of its namesake. Affected erythrocytes demonstrate small, basophilic (purple-blue) punctate inclusions. Unlike other erythrocyte inclusions, basophilic stippling does not show polarity and is diffusely and evenly scattered throughout the cell. The inclusions may be coarse or fine in appearance, and these different morphologies can be associated with particular disease processes as discussed later.[4]

Microscopy Electron

Electron microscopy is not routine for the examination of peripheral blood smears. However, a study from 1965 comparing supravital staining (light microscopy) and electron microscopy of peripheral blood from rodents with induced lead/phenylhydrazine toxicity or post-phlebotomy anemia noted that the structure and general appearance of stippled material in reticulocytes was consistent with ribosomes.[5] Overall, the visualization of basophilic stippling in more mature erythrocytes was subject to limitations by preparation of peripheral blood for electron microscopy; therefore, researchers extrapolated findings in reticulocytes to other affected erythrocytes.[5]

Clinical Significance

Many hematologic disorders involve disrupted erythropoiesis and erythrocyte maturation, which introduces the potential for basophilic stippling on peripheral smears. Coarse basophilic stippling is always clinically significant. Fine basophilic stippling may be seen artifactually, as well as in a variety of clinical instances mentioned below.  Classically, coarse basophilic stippling is associated with heavy metal toxicity with a predominant emphasis on lead poisoning. Lead toxicity is attributed to coarse-appearing basophilic stippling due to inhibition of pyrimidine-5'-nucleotidase, thereby preventing degradation of ribosomal RNA in circulating erythrocytes.[4] Basophilic stippling is considered a pathognomonic finding in lead poisoning in conjunction with hypochromic microcytic anemia (although normocytic anemia can be appreciated as well) and deposition of lead in the gingiva and joints.[6] 

Supporting clinical history classically entails environmental or occupational exposure to lead. Basophilic stippling can occur in cases of lead intoxication secondary to foreign bodies such as bullet fragments and retained shrapnel in active-duty military personnel.[7][8] Patients demonstrating anemia with basophilic stippling and toxic blood lead concentrations have also been connected to the use of adulterated illicit drugs (ex. opium) and contaminated herbal remedies/supplements imported from Asian countries.[4][9][6][10] Toxic levels of other heavy metals such as zinc may produce basophilic stippling as well but are considerably rare compared to lead.[11]

Patients with anemia secondary to hemoglobinopathies such as thalassemia and sickle cell disease can exhibit basophilic stippling that may be finer in appearance than observed in lead toxicity.[4][12] The presence of basophilic stippling in the context of hemoglobinopathies is likely related to increased erythrocyte hemolysis and release of immature cells into the bloodstream to compensate for relatively rapid erythrocyte turnover.[12] Moreover, pyrimidine-5'-nucleotidase (P5'N) deficiency is a rare autosomal recessive enzymopathy characterized by hemolytic anemia with significant basophilic stippling on peripheral smear. P5'N deficiency may have links to a mutation in the NT53C gene, but additional studies are needed to characterize the full scope of genetic factors related to this condition.[2]

Megaloblastic anemia due to vitamin B12/folate deficiency or chronic alcohol use disorder can present with basophilic stippling as well.[4] Furthermore, myelodysplastic syndrome (MDS) acquired from variable gene mutations over time induces faulty erythropoiesis and hematopoietic stem cell differentiation. Numerous morphological defects are present on peripheral smears from patients with MDS, and basophilic stippling is a common finding.[13]


  • Image 11250 Not availableImage 11250 Not available
    Image courtesy Dr Chaigasame
Attributed To: Image courtesy Dr Chaigasame

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Histology, Basophilic Stippling - Questions

Take a quiz of the questions on this article.

Take Quiz
A 34-year-old female presents to her primary care provider with four weeks of fatigue, vague recurrent abdominal pain, and intermittent arthralgias. She does not have any significant past medical or surgical history. She does not take any prescription medications but endorses using traditional herbal supplements imported from India that she has been ordering online for the past year. She denies tobacco, alcohol, and drug use. Vital signs are within normal limits. Physical exam is significant for diffuse, mild abdominal tenderness to palpation without rebound or guarding but is otherwise unremarkable. Laboratory studies are ordered. CBC with manual differential is significant for microcytic hypochromic anemia and basophilic stippling on the peripheral smear. Which of the following additional laboratory abnormalities best correlates with the patient's hematologic findings?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A male newborn develops persistent neonatal jaundice. He was born at term via an uncomplicated spontaneous vaginal delivery to a healthy 30-year-old woman G1P1 with an unremarkable prenatal course. Vitals are within normal limits. The physical exam is significant for diffuse, mild jaundice but no organomegaly or masses appreciated on abdominal exam. Complete blood count (CBC) demonstrates anemia, and examination of the peripheral smear shows schistocytes, increased reticulocytes, and marked basophilic stippling. Additional laboratory studies are pending. What is the most likely cause of the newborn's condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 25-year-old male with a history of beta-thalassemia minor presents for an annual physical exam. Routine labs are ordered, and his CBC reveals mild anemia consistent with his existing diagnosis. Occasional erythrocytes containing scattered intracytoplasmic basophilic inclusions are observed on his peripheral smear. Which phase of erythrocyte development is associated with this finding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old female presenting with fatigue, dyspnea, easy bruising, and frequent recurrent infections for the past 5 months is referred to hematology for further evaluation after obtaining her complete blood count (CBC). The CBC is remarkable for pancytopenia and macrocytosis. The microscopic examination of the peripheral smear shows dysplastic neutrophils, large ovalocytes, and occasional basophilic erythrocyte inclusion bodies scattered throughout the cytoplasm. The inclusion bodies are composed of what cellular material?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 2-year-old male is brought by his mother for a routine well visit. She reports that the patient has had mild abdominal discomfort and constipation for the past 3 months. During this time, the patient has also displayed loss of appetite, irritability, and difficulty concentrating which his mother attributes to ongoing constipation. The patient eats a diet rich in fruits, vegetables, and whole grains since both parents are vegetarians. The family lives in a house built in 1945 with the kitchen undergoing renovation. His immunizations are up to date. Vital signs are within normal limits. The patient is quiet but appears uncomfortable and restless. The physical exam is significant for conjunctival pallor, decreased bowel sounds, and mild abdominal tenderness to deep palpation without guarding or organomegaly. The cardiopulmonary exam is unremarkable. CBC demonstrates microcytic hypochromic anemia. Examination of the peripheral smear shows basophilic erythrocyte inclusion bodies. The inclusion bodies consist of material active in what cellular process during erythrocyte development?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Histology, Basophilic Stippling - References

References

Moras M,Lefevre SD,Ostuni MA, From Erythroblasts to Mature Red Blood Cells: Organelle Clearance in Mammals. Frontiers in physiology. 2017;     [PubMed]
Santos Ad,Dantas LE,Traina F,Albuquerque DM,Chaim EA,Saad ST, Pyrimidine-5'-nucleotidase Campinas, a new mutation (p.R56G) in the NT5C3 gene associated with pyrimidine-5'-nucleotidase type I deficiency and influence of Gilbert's Syndrome on clinical expression. Blood cells, molecules     [PubMed]
Meguro R,Asano Y,Odagiri S,Li C,Iwatsuki H,Shoumura K, Nonheme-iron histochemistry for light and electron microscopy: a historical, theoretical and technical review. Archives of histology and cytology. 2007 Apr;     [PubMed]
Chan NCN,Chan KP, Coarse basophilic stippling in lead poisoning. Blood. 2017 Jun 15;     [PubMed]
JENSEN WN,MORENO GD,BESSIS MC, AN ELECTRON MICROSCOPIC DESCRIPTION OF BASOPHILIC STIPPLING IN RED CELLS. Blood. 1965 Jun;     [PubMed]
Tsai MT,Huang SY,Cheng SY, Lead Poisoning Can Be Easily Misdiagnosed as Acute Porphyria and Nonspecific Abdominal Pain. Case reports in emergency medicine. 2017;     [PubMed]
Grasso IA,Blattner MR,Short T,Downs JW, Severe Systemic Lead Toxicity Resulting From Extra-Articular Retained Shrapnel Presenting as Jaundice and Hepatitis: A Case Report and Review of the Literature. Military medicine. 2017 Mar;     [PubMed]
Weiss D,Lee D,Feldman R,Smith KE, Severe lead toxicity attributed to bullet fragments retained in soft tissue. BMJ case reports. 2017 Mar 8;     [PubMed]
Fakoor M,Akhgari M,Shafaroodi H, Lead Poisoning in Opium-Addicted Subjects, Its Correlation with Pyrimidine 5'-Nucleotidase Activity and Liver Function Tests. International journal of preventive medicine. 2019;     [PubMed]
Zhao Y,Lv J, Basophilic Stippling and Chronic Lead Poisoning Turkish journal of haematology : official journal of Turkish Society of Haematology. 2018 Nov 13;     [PubMed]
Vander Meeren S,Van Damme A,Jochmans K, Prominent basophilic stippling and hemochromatosis in glucose-6-phosphate dehydrogenase deficiency. International journal of hematology. 2015 Feb;     [PubMed]
Thom CS,Dickson CF,Gell DA,Weiss MJ, Hemoglobin variants: biochemical properties and clinical correlates. Cold Spring Harbor perspectives in medicine. 2013 Mar 1;     [PubMed]
Zahid MF,Khan N,Pei J,Testa JR,Dulaimi E, Genomic imbalances in peripheral blood confirm the diagnosis of myelodysplastic syndrome in a patient presenting with non-immune hemolytic anemia. Leukemia research reports. 2016;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for PA-Hospital Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in PA-Hospital Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of PA-Hospital Medicine. When it is time for the PA-Hospital Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study PA-Hospital Medicine.