What do tear drop cells suggest?

Teardrop Cells in Peripheral Blood: Diagnostic Significance

Teardrop cells (dacryocytes) in peripheral blood smears primarily suggest myelofibrosis or myelodysplastic syndromes, but can also appear in autoimmune hemolytic anemia and microangiopathic conditions. 1

Primary Associations

Teardrop cells are red blood cells with a characteristic shape that tapers to a point at one end, resembling a teardrop. Their presence in peripheral blood has significant diagnostic implications:

Myeloid Disorders

• Myelofibrosis: Teardrop cells are classically associated with primary or secondary myelofibrosis 1
• Myelodysplastic Syndromes (MDS): Listed as a specific sign of red cell dysplasia in MDS according to ESMO guidelines 2
• Often accompanied by other findings in these conditions:
  • Leukoerythroblastic blood picture
  • Anisocytosis and poikilocytosis
  • Nucleated red blood cells
  • Immature myeloid cells in peripheral blood

Other Important Associations

• Autoimmune Hemolytic Anemia: Dacryocytes are found in 89% of AIHA cases 3
• Microangiopathic Hemolytic Anemia: Present in 91% of MAHA cases 3
• Infiltrative Bone Marrow Disorders: Malignant infiltration of bone marrow 1
• Splenic Involvement: Splenomegaly with extramedullary hematopoiesis can contribute to teardrop formation 4

Diagnostic Approach

When teardrop cells are identified in peripheral blood:

1. Complete Blood Count Analysis:

   • Evaluate for cytopenias or other abnormal cell counts
   • Assess percentage of teardrop cells present

2. Peripheral Blood Smear Examination:

   • Look for other red cell abnormalities: anisocytosis, poikilocytosis, dimorphic erythrocytes, polychromasia, hypochromasia, megalocytes, basophilic stippling 2
   • Evaluate granulocytes for dysplastic features
   • Assess platelets for abnormalities in size and morphology

3. Bone Marrow Examination:

   • Mandatory for proper evaluation when teardrop cells are present 1
   • Assess for:
     • Cellularity
     • Fibrosis (reticulin staining)
     • Dysplastic features
     • Blast percentage
     • Ring sideroblasts

4. Cytogenetic Analysis:

   • Essential for detecting clonal chromosome abnormalities 2
   • Standard karyotype has highest prognostic value in MDS 2

5. Molecular Testing:

   • Evaluate for mutations associated with myeloid disorders (DNMT3A, ASXL1, TET2, JAK2, TP53) 1
   • Helps distinguish between different myeloid disorders

Clinical Pearls and Pitfalls

• Don't overlook autoimmune causes: While myelofibrosis is the classic association, teardrop cells are common in autoimmune hemolytic anemia 3
• Spleen connection: Removal or resolution of splenomegaly can lead to disappearance of teardrop cells in some cases 4
• Transformation potential: Essential thrombocythemia can transform to myelofibrosis with subsequent appearance of teardrop cells 5
• Primary autoimmune myelofibrosis: Consider this distinct entity characterized by bone marrow fibrosis, autoantibodies, mild teardrop poikilocytosis, and excellent response to corticosteroids 6

Management Considerations

The finding of teardrop cells should prompt a systematic workup to identify the underlying cause:

• For suspected myelofibrosis or MDS: Complete hematologic evaluation including bone marrow biopsy, cytogenetics, and molecular testing
• For suspected autoimmune processes: Evaluate for autoantibodies, hemolysis markers, and consider corticosteroid therapy if primary autoimmune myelofibrosis is diagnosed
• For suspected microangiopathic processes: Evaluate for schistocytes, thrombocytopenia, and other signs of microangiopathy

The presence of teardrop cells should never be dismissed as insignificant, as they often indicate serious underlying hematologic conditions that require prompt and thorough evaluation.