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Priyadarshini Ramakrishnan: Schistocytes – The Most “Misleading Heroes” in a Peripheral Smear
Priyadarshini Ramakrishnan/LinkedIn
Jul 7, 2026, 20:56

Priyadarshini Ramakrishnan: Schistocytes – The Most “Misleading Heroes” in a Peripheral Smear

Priyadarshini Ramakrishnan, DHA-licensed Clinical Pathologist,  shared a post on LinkedIn:

“Schistocytes: The most ‘misleading heroes’ in a peripheral smear

One glance at fragmented RBCs, and the immediate thought is often:

‘TMA? DIC? Is this an emergency?’

But here’s one of the biggest interpretation traps in hematology:

Not every fragmented red cell is a true schistocyte

Fragmented cells may be seen due to:

  • Poor smear preparation
  • Old or improperly handled samples (in vitro damage)
  • Thick smears or feathered-edge artifacts
  • Increased RBC fragility in severe anemia

Without careful interpretation, a perfectly routine sample can be mistaken for a microangiopathic emergency.

So, when should schistocytes raise concern?

True schistocytes should be accompanied by evidence of hemolysis, not just morphology.

Expected laboratory correlation:

  • High LDH
  • Low Haptoglobin
  • High Indirect bilirubin
  • Low Hemoglobin (falling trend)
  • High Reticulocyte count
  • Plus or minus low Platelet count (especially in thrombotic microangiopathies)

If the smear reports schistocytes but LDH and platelets are normal, with no biochemical evidence of hemolysis, pause before labeling it as microangiopathic hemolysis. Review the smear, assess pre-analytical factors, and correlate clinically.

A good laboratory professional doesn’t just identify schistocytes—they interpret them in context

Because morphology raises suspicion, but clinical and laboratory correlation confirms the diagnosis.

Have you ever encountered a case where an artifact nearly led to an overcall”

Priyadarshini Ramakrishnan

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bilirubin Blood DIC haptoglobin Health Hematology Hemoglobin Hemostasis News Hemostasis Today Indirect bilirubin LDH Medicine Platelet Priyadarshini Ramakrishnan RBCs Reticulocyte Schistocytes TMA
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