•Vacuolated erythroid precursors can be seen in copper deficiency, Pearson syndrome, and myelodysplastic syndromes.  In this image, a vacuolated erythroid precursor is adjacent to another dysplastic erythroid precursor with megaloblastic features (nuclear-cytoplasmic asynchrony) and nuclear irregularities.  The patient had acute myeloid leukemia with myelodysplasia-related changes.