Hematology analyzers: 3-part or 5-part,

that is the question

Automated hematology analyzers are frequently used in clinical laboratories to assess and
monitor health condition of patients. Although 3-part hematology analyzers provide sufficient
information for most clinical settings, trends show an increased interest in 5-part instruments.
While 5-part analyzers offer improved assessment of white blood cells, 3-part instruments offer
great cost benefits. Here, we describe clinical settings, where 3-part differentials and 5-part
differentials can provide different advantages.

Introduction
A complete blood count (CBC) is usually the first test No. of cells (no. of pulses) RBC
requested by a physician to evaluate a patient’s general health Lymphocytes
status. CBC is used to measure the oxygen-carrying red Platelet Granulocytes
blood cells (RBC), the platelets (PLT) that help clot the blood,
MID cells
and the white blood cells (WBC) of the immune system. As
part of the CBC, a WBC differential is conducted. Traditionally,
a laboratory technician uses a microscope to manually
count 100 WBC and differentiate them into neutrophils
(NEU), lymphocytes (LYM), monocytes (MONO), eosinophils Size of cells (fL) (amplitude of pulse)

(EOS), and basophils (BASO). Each cell type is reported as Fig 1. Test result from a 3-part hematology analyzer visualized in a histogram.
a percentage of total WBC, and a shift in the percentage
indicates a condition.
Automated hematology analyzers
In normal blood, about 60% of the cells are neutrophils.
In today’s general screenings, CBC tests are performed using
Neutrophils help fight bacteria (and fungi), and a high
automated hematology analyzers. In addition to reporting
count (> 85%) indicates a bacterial infection. Lymphocytes,
RBC, PLT, and WCB counts, an analyzer also measures the
accounting for about 30% of all WBC, help fight viruses.
oxygen-containing hemoglobin (HGB) and determines a range
A high lymphocyte count can therefore be an indication
of other parameters such as the mean cell volume (MCV),
of a viral infection. The last 10% comprises monocytes,
PLT width distribution, and hematocrit (HCT), that is, the red
eosinophils, and basophils. These cell types are typically
blood cell-to-plasma ratio. Hence, an automated analyzer can
associated with allergies or parasite infections. A high number
provide much more information than a manual count.
of monocytes (2%–8% normal), for example, can indicate a
chronic inflammatory disease or a bacterial infection, whereas A 3-part instrument commonly uses impedance to
high eosinophil counts (1%–4% normal) give an indication of differentiate WBC into granulocytes (mainly neutrophils, but
asthma, an allergic reaction, or a parasite infection. A high also eosinophils and basophils), lymphocytes, and MID cells
number of basophils (0.5%–1% normal) is typically associated (mainly monocytes, but also eosinophils) based on cell size
with inflammatory reactions, especially those causing allergic (Fig 1). Each cell passing through the aperture causes a drop
symptoms. High numbers of the WBCs can also be an in the electrical current (a pulse). The number of generated
indication of certain forms of cancers, such as leukemia or pulses correlates with the number of cells, whereas the size of
lymphoma. the pulse is related to the cell size (Fig 2).

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 Diluted
sample
Negative
Aperture pressure

Circuit
Voltage

Impulse Electrodes Consistent

current source

Time

Fig 2. The principle for measuring changes in the electrical impedance produced by a cell passing through an aperture.

In addition to impedance, a 5-part instrument employs the (A) Cell suspention

principle of flow cytometry to differentiate WBC into their
Sheath fluid
five major sub-populations—neutrophils, lymphocytes,
monocytes, eosinophils, and basophils—based on cell size
and complexity (granularity) (Fig 3). In flow cytometry, cells are
forced to flow in a single file through the aperture by a sheath
fluid, created by a fast-moving diluent that surrounds the slow-
moving sample (Fig 4A). A laser beam is passed through the
sample, and when a cell passes through the sensing zone, Scatter
the light is scattered and measured by a photoconductor detectors
Laser
that converts the light into an electrical impulse. The number
of generated impulses correlates with the number of cells,
whereas the light scatter is used to determine cell granularity,
shape, and size (Fig 4).

(B)
DIFF NEU BASO HS

MS
Complexity of cells

Complexity of cells

EOS Laser beam

LS
LYM, NEU, MONO, EOS

Ghost
MONO LS
BASO
LYM MS

Size of cells Size of cells HS

Fig 3. Test results from a 5-part hematology analyzer are visualized in a Fig 4. (A) Laser-based flow cytometry for 5-part differential of white blood
4-part differential scattergram and a separate scattergram for BASO. cells. (B) Three-angle laser-scatter method, where the low angle signal
Ghost = nucleated RBC, lyse-resistant RBC, and platelet clumps. (about 1° to 5°) represents the cell volume information, the middle angle
signal (about 7° to 20°) represents the cell nucleus information, and the
high angle signal (about 90°) represents the cell nucleus and cytoplasm
information.

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3-part versus 5-part analyzers for a 5-part differential. Yet, government reimbursements
commonly do not consider whether WBCs are differentiated
Although each WCB sub-type provides information that
into 3- or 5-parts. Hence, 5-part instruments are typically
helps diagnose blood-related conditions, a 3-part instrument
used by oncology or allergy clinics that can justify the need
will provide sufficient information for the typical physician
for eosinophil and basophil counts.
office laboratory (POL). With a simple CBC, the neutrophil
and lymphocyte counts will answer the question of a viral Depending on local policies, samples that are flagged as
infection or a bacterial infection that can be treated with abnormal commonly require microscopical examination to
antibiotics (Fig 5). confirm the results obtained with the analyzer, regardless
of instrument type. For this, blood smears are typically sent
For specialty laboratories, however, a 5-part instrument can
to a hematology laboratory for a manual count. According
provide a more detailed and targeted assessment of the
to many hematology laboratories experienced in blood
blood status. To distinguish eosinophils and basophils from
smear examinations, the number of samples that requires
neutrophils, for example, a 5-part differentiation is mandatory
manual examination can be greatly reduced with the more
(Fig 6).
detailed information on the blood status provided by a 5-part
However, the cost for a typical 5-part instrument can be differential. If about 30% of the total number of samples
two to three times higher (20,000 to 50,000 USD) than for generates a suspicious flag with a 3-part instrument, and thus
a 3-part instrument (less than 10,000 USD). In addition, a will require manual examination, the more detailed information
5-part differential often requires more reagents than a 3-part provided by a 5-part instrument can reduce this number to
differential, also increasing the cost per test from below about 20%, ultimately decreasing laboratory time and cost for
1 USD/test for a 3-part differential to 1.5 to 3 USD/test shipping of samples (Fig 7).

(A) WBC (B) WBC (C) WBC

No. of cells

No. of cells

No. of cells

Size Size Size

Fig 5. Histograms from (A) a normal sample, (B) a sample from patient with a virus infection, and (C) a sample from patient with a bacterial infection.

(A) WBC (B) DIFF (C) BASO

No. of cells

Complexity

Complexity

Size Size Size

Fig 6. (A) Abnormal 3-part histogram, where lymphocytes cannot be differentiated from MID cells, and MID cells not from granulocytes.
(B, C) Scattergrams from a 5-part instrument, showing a 4-part differential with a clearly separated eosinophil population, and the basophile
population displayed in a separate diagram.

(A) WBC (B) DIFF

No. of cells

Complexity

Size Size

Fig 7. (A) A 3-part histogram, showing a lymphocyte peak that gives suspicion of finding smaller than normal lymphocytes, possibly
caused by nucleated RBC that could not be distinguished from lymphocytes. (B) A 4-part differential that shows no flags and well
separated cell populations, giving no suspicion of immature cells, resulting in an approved sample.

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For general screenings, however, and when reimbursement
is the same irrespective of 3-part and 5-part differential, a
3-part instrument can contribute to an improved laboratory
economy by offering the caregiver a greater profit opportunity.
In addition, a 3-part instrument based on robust impedance
technology might require less maintenance than a 5-part
instrument, which also includes a more sensitive laser-based
measurement technology.

Conclusion
For most cases, the same decisions can be made with a
3-part hematology analyzer as with a 5-part analyzer. Typically,
a 3-part instrument is also quicker and cheaper. If abnormal
values are obtained, microscopy is still required, irrespective of
instrument type. Although 3-part differentials provide excellent
precision for general screenings, accuracy is improved with
5-part differentials for abnormal samples, reducing the number
of manual blood smears.
Regardless of the choice of a 3-part or a 5-part instrument, of
utmost importance is the ability of the analyzer to detect and
flag for abnormal samples.

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