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- 2. Complete blood count interpretation ByDr / Mohammed Basiony 2
- 3. BLOOD COMPONENTS CELLS 45% PLASMA55% WBCs PlateletsRBCs 3
- 4. 4 How Are BloodCells Formed?
- 5. 5 Reticulocyte Count Reticulocytesare “young” red blood cells that were recently released from the bone marrow. Normally, reticulocytes comprise 0.5 - 2% of all red blood cells. Increased reticulocytes (reticulocytosis) is a normal response to blood loss or anemia. Since reticulocytes are larger, the MCV (and RDW) may be elevated. The combination of anemia with a low or normal reticulocyte count indicates that the bone marrow is unable to respond normally, either due to lack of essential ingredients (iron deficiency, vitamin B12 or folate deficiency), bone marrow disease, or chronic disease.
- 6. White Blood Cells 6 There are several types of White Blood Cells They are all involved in immunity but in somewhat different ways Never 60 Let 30 Monkey 6 Eat 3 Banana 1
- 7. 7 Platelets Really moreof a fragment of a cell They are broken off from a very large cell in the bone marrow called a megakaryocyte Primary function is to aid in blood clotting Lifetime in the blood is 7- 10 days after which they are destroyed in the spleen Their clotting function is permanently inhibited by aspirin
- 8. The Three BasicMeasures Measurement Normal Range A. RBC count 5 million 4 to 6 B. Hemoglobin 15 g% 12 to 17 C. Hematocrit 45 38 to 50 A x 3 = B x 3 = C 8
- 9. Special Considerations in DeterminingAnemia Acute Bleeding Drop in Hgb or Hct may not be shown until 36 to 48 hours after acute bleeding. Pregnancy In third trimester, RBC and plasma volume are expanded by 25 and 50%, respectively. Labs will show reductions in Hgb, Hct, and RBC count, often to anemic levels, but according to RBC mass, they are actually polycythemic This affect HB - RBC count - HT ------but no effect on MCV Volume Depletion Patient’s who are severely volume depleted may not show anemia until after rehydrated 9
- 10. 10 Descriptive Terms Usedon Peripheral Smears Anisocytosis: marked variation in RBC sizes (visual counterpart of increased RDW) Poikilocytosis: marked variation in the shape of RBCs Hypochromia : RBCs are paler than normal because they contain less hemoglobin (visual counterpart of decreased MCH) Macrocytosis: increased number of large RBCs (visual counterpart of increased MCV) Microcytosis: increased number of small RBCs (visual counterpart of decreased MCV)
- 11. How to read 1st look for HB 3 possibilities: A - normal its ok. B - high polycythemia. C - low anemia 11
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- 13. HB HB • 11 Female •12 male HB • 13 child • 14 infant 13
- 14. Red Cell Indices Aremeasurements that indicate the size and hemoglobin content of red cells: M.C.V (Mean Corpuscular Volume) M.C.H (Mean Corpuscular Hemoglobin) M.C.H.C (Mean Corpuscular Hemoglobin Concentration) 14
- 15. M.C.V (Mean CorpuscularVolume): Referred to the average volume of red cells , normally = 77 - 99 fl It can be calculated from an independently-measured red blood cell count and hematocrit: MCV (femtoliters) = 10 x HCT(percent) ÷ RBC (millions/µL) MICROCYTOSIS & MACROCYTOSIS : By definition, microcytosis is taken to mean the presence of RBCs with a MCV less than normal, while macrocytosis means the presence of RBCs with an MCV greater than normal. 15
- 16. M.C.H (Mean CorpuscularHemoglobin): or "mean cell hemoglobin" (MCH), is a measure of the mass of hemoglobin contained by a red blood cell. It is diminished in microcytic anemias, and increased in macrocytic anemias. It is calculated by dividing the total mass of hemoglobin by the RBC count :- MCH=Hb/RBC A normal value in humans is 27 to 32 picograms/cell 16
- 17. M.C.H.C (Mean Corpuscular HemoglobinConcentration): is a measure of the concentration of hemoglobin in a given volume of packed red blood cell . It is diminished )"hypochromic") in microcytic anemias, and normal "(normochromic )"saimena citycorcam ni ro tnuoma nibolgomeh eht hguoht ,ezis llec regral ot eud( lamron sniamer noitartnecnoc eht ,hgih si HCM.) It is calculated by dividing the hemoglobin by the hematocrit : M.C.H.C = Hb / Hct A normal value is 30 to 36 g/dl . 17
- 18. RDW Red cell distributionwidth It is correlates with the degree of anisocytosis Normal range from 10-15% <21 in thalathemia. >21 in IDA elevated RDW is the first hematological manifestation of iron deficiency anemia, and hence a very sensitive screening test for that particular disorder 18
- 19. Is the patientAnemic or not ? Anemic means single or total decrease in : - Hb - Hct - RBCs count in millions But…? What Type of Anemia..? This depends on the RBCs indices 19
- 20. Red Cell Indices Accordingto MCV & MCH Normal 77-99 Normocytic Normochromic Anemia Decreased >77 Microcytic Hypochromic AnemiaIncreased <99 Macrocytic Anemia 20
- 21. Normocytic Normochromic Anemia Itmay be due to : - Acute Blood Loss - Aplastic Anemia - Hemolytic Anemia ( Except Thalasemia) - A.O.C.D (Anemia Of Chronic Diseases) Normal A.O.C.D e.g.: TB, SLE, Malignancy, Rh. Arthritis Note: - Evidence of the cause - Anemia May be Micro- cytic Hypochromic Low or Absent B.M.F “Aplastic Anemia” BM biopsy or BM aspiration show : Acellular or Hypo- cellular BM High - Acute Blood Loss ( search for evidence of the cause) - Hemolytic Anemia Which of Which ….? Do Reticulocytic Count 21
- 22. Hemolytic Anemia - lowHb &/or Hct & /or RBCs count - Normal RBCs indices - Reticulocytosis Do Indirect Serum Billirubin Unconjugated Hyper-billirubinemia “ jaundice” Other Evidences of Hemolysis e.g.:- - Hemoglobinuria - Hemoglobinemia (increased free Hb) - Decreased Haptoglobin. What is the Further Step………..? Coombs Test 22
- 23. Coombs Test Positive Immune Hemolytic Anemia: -Iso immune - Auto immune Negative Non-immune Hemolytic Anemia: May be due to : - Membrane Defect e.g. Spherocytosis (lab show increased O.F.) & P.N.H - Enzyme Defect e.g. G6PD (lab : Enz. assay) - Hb Defect (Hemoglobinopathy) e.g. Sickle Cell Anemia (lab: Hb Electrophoresis). - Others : Malaria (lab: Bl. Film) 23
- 24. NN anemia NN anemia lookfor WBC& plat markedly decrased pancytopenia Look for retic count If decreased aplastic anemia If increased hypersplenism 24
- 25. Red Cell Indices Accordingto MCV & MCH Decreased Microcytic Hypochromic AnemiaIncreased Macrocytic Anemia 25
- 26. Microcytic Hypochromic Anemia -The Commonest Cause is: Iron Deficiency Anemia -Other Causes: - Thalasemias - Sedroplastic Anemia - Lead Poisoning - A.O.C.D - Serum Iron - Serum Ferritin - T.I.B.C (Total Iron Binding Capacity) - Transferrin Saturation Which of Which ….? Do Iron Studies: 26
- 27. According to IronStudies A.C.O.DSideroplastic Anemia ThalassemiaIron Deficiency Anemia Serum Fe N orNormalSerum Ferritin NormalT.I.B.C Transferrin Saturation 27
- 28. Iron Deficiency Anemia Notes: -Search For The Cause: e.g.: Chronic Blood Loss Ankylostoma Cancer Colon Nutritional causes - Severe Aniso-cytosis and Poikilo-cytosis: Increased R.D.W(N ≤ 13%( Iron Studies Serum Fe Serum Ferritin T.I.B.C Transferrin Saturation 28
- 29. Thalassemia Notes: - Hb Electrophoresiswill show: Persistence of hb f major type hb a2 minor type -Rdw <21 -HPLC = high performance chromatography A more accurate substitute for HB electropheresis Iron Studies Serum Fe Serum Ferritin T.I.B.C Transferrin Saturation 29
- 30. Sideroplastic Anemia Notes: Sedroplastic Anemiais due to: - B6 Deficiency - Drugs e.g.: INH - Inherited Blood film show: RBCs contain Iron Granules Treated by: B6 supply Iron Studies Serum Fe NormalSerum Ferritin NormalT.I.B.C Transferrin Saturation 30
- 31. Red Cell Indices Accordingto MCV & MCH Increased Macrocytic Anemia 31
- 32. Macrocytic Anemia -In Which : - low Hb &/or Hct & /or RBCs count - Increased RBCs indices -TYPES : A. Megaloblastic Macrocytic – B12 and Folate↓ B. Non Megaloblastic Macrocytic Anaemias 1. Liver disease/alcohol 2. Hypothyroidism 3. Myelodystrophy, BM infiltration 4. Accelerated Erythropoesis –as in ↑destruction 5. Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants) 32
- 33. Anemia - Macrocytic(MCV > 100) Macrocytic anemias may be asymptomatic until the Hb is as low as 6 grams MCV 100-110 fl must look for other causes of macrocytosis MCV > 110 fl almost always folate or B12 deficiency 33
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- 35. Leukocytosis increaseWBCs.>11000 Leukopenia decrease WBCs.<4000 Granulocytosis neutrophilia <8000/cmm Granulocytopenia neutropenia<2000/cmm Agranulocytosis neutropenia<500/cmm ( pseudoleukopenia?) 35
- 36. What to Doif WBC Abnormal Take a Good History Physical Examination Look at Old CBC’s!!!! 36
- 37. History and clinical examination Important features of history and clinical examination: fever, lymphadenopathy hepatomegaly, splenomegaly frequency and severity of infections, mouth ulcers, recent viral illness exposure to drugs and toxins fatigue/weight loss pallor, jaundice bleeding/bruising 37
- 38. Total WBC maybe misleading The absolute count of each of the cell types is more useful than the total. The total count may be misleading, eg: low neutrophils with an elevated lymphocyte count may produce a total white count that falls within the reference range. 38
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- 40. WBC IF decreased itis leukocytopenia look for lymphocyte عاليه لقيتها لو قليله او طبيعيه المفروض relative lymphocytosis → Thyphoid 40
- 41. WBC Neutrophils →↑bacterial infection Lymphocyte→↑Viral infection Monocyte →↑fungal , bacterial Esinophil →↑allergy , parasite Basophil →↑↑↑↑↑autoimmune disease 41
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- 43. Neutrophils Neutropenia Mild ANC1000-1500 Moderate 500-1000 Severe >500 Neutrophilia Absolute Neutrophil Count > 8000 Leukemoid Reaction Elevation in WBC Typically 30000-50000 LAP score can differentiate from leukemia 43
- 44. Neutrophilia – Conditions associatedwith : 1-Bacterial infections (most common cause) 2-Tissue destruction e.g. tissue infarctions, burns. 3- leukemoid reaction 4-Leukemia 44
- 45. Neutrophillia Other causes anystressor/heavy exercise drugs pregnancy Red flags person particularly unwell severity rate of change of neutrophilia presence of left shift 45
- 46. Neutropenia Most commoncauses viral infection Chronic bacterial infection Chemotherapy - radiotherapy Drugs…… Red flags person particularly unwell severity rate of change of neutropenia lymphadenopathy, hepatosplenomegaly46
- 47. Drugs associated with neutropenia Anticonvulsants ---- phenytoin Antithyropid ------- carbimazole Phenothiazines ------ carbamazepine Anti-inflammatory ------- phenylbutazone antibacterial ------ co trimoxazole Cytotoxic Others ----- gold, penicillamine, imipramine 47
- 48. • T cells:cellular immunity • B cells: humoral (antibody) • Natural Killer Cells 48
- 49. lymphocyte ↑lymphocyte → viralinfection(EBV-CMV) chronic bact.infection(tb) Post splenectomy ↓ lymphocyte → RadioTherapy , chemotherapy + 2S (Sepsis,Steroid therapy) Hiv lupus 49
- 50. esinophil Highest Levelsin am Contain histamin enzyme so increased in conditiond with increased histamin release from mast cells as Allergic conditions 1-asthma 2-allergic dermatitis 3-allergic rhinitis 4-parasitic infections except ?? Rarer causes: Hodgkins disease myeloproliferative disorders Churg-Strauss syndrome ↓↓↓↓↓↓with increased circulating steroids (ex or en ) - typhoid 50
- 51. monocyte Monocyte inblood = macrophage in tissue Increased in the 3 most common conditions 1-typhoid 2-brucella 3-tb + 4- Chronic inflammatory diseases 5- Viral infections common with measles & mumps Decreased with steroid therapy 51
- 52. Basophils Contain twosubstances in vesicles Histamin ___ vasodilatation Heparin_____prevent coagulation Increased in immune diseases and tumors (most uncommon) 52
- 53. Basophils Increased in 2a2c 1- after splenectomy 2-allergic conditions 3- collagen vascular diseases 4-cancer blood( CML ) + hypothyroidism Decreased in CASH 1- cancer 2-acute infection 3- severe injury 4-hyperthyroidism 53
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