Hb C trait plus alpha thal trait plus iron deficiency

There is a lot going on here. This patient has HbC, alpha thal trait, and is iron deficient. 

Alpha thalassaemia trait is morphologically heterogenous - it can present as just a microcytosis with rather unexciting morphology, or it can be quite hypochromic, microcytis with irregaulr shapes - although the really abnormal morphology is restricted to HbH. No points lost for not getting alpha thal here. 

Getting the easy ones out of the way - the platelets and white cells are normal. Lymphocytes and neutrophils are present in normal numbers and morphology.

The iron deficiency you should be suspicious of because of the anisochromasia. This shouldn't be a feature of either haemoglobinopathies or thalassaemias, although it can be a difficult morphological concept.

What else do we have? We have target cells - they could be iron deficiency, or anything else. We have pencil cells - probably iron related. We have some red cell anisopoikilocytosis and reticulocytosis, nothing currently you can hang your hat on. 

So then we see some cells where there are very straight, deliniated abnormalities. These could be missed under the 'abnormal haemoglobinisation' heading, but they are too straight and too dark in terms of staining to be just normal red cells. These are likely C crystals forming inside the red cells. You can't have C crystals without Hb C, and there aren't enough of them for HbCC disease. There also aren't any features of Beta thal, so CBThal is out. That leaves us with Hb AC - plus iron deficiency. The alpha thal is really difficult morphologically - you would really need to see the MCV and realise it's too small for just the iron alone.