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Myelodysplastic syndrome (MDS) is characterized by morphological dysplastic changes in one or more of the major hematopoietic cell lines. It can presents with varying degrees of single or multiple cytopenias including neutropenia, anemia and thrombocytopenia.This image shows the peripheral blood smear of a patient diagnosed with MDS. Granulocytic hypogranulation and hyposegmentation, pelger huet-like anomaly, immature myeloid cells, nucleated erythrocytes and macrocytosis can be seen. These are the characteristic features for establishing a diagnosis of myelodysplasia.