![CORRECTION
CORRECTION I (for anemia) :
Reticulocyte count x [ Hb of the patient / Hb normal for the age ]
When to apply? : This correction is applied when there is low hematocrit
Why to apply? : The percentage of reticulocytes may be falsely elevated
because the whole blood contains fewer RBCs](https://image.slidesharecdn.com/clinicalhaematologyguide-230409125412-559c0bda/75/Clinical-Haematology-Basic-Guide-14-2048.jpg)
![MCV
Mean volume occupied by a red cell
MCV = { [ Haematocrit (%) x 10 ] / RBC count in million } fL
Normal range : 90 ± 8 fL](https://image.slidesharecdn.com/clinicalhaematologyguide-230409125412-559c0bda/75/Clinical-Haematology-Basic-Guide-19-2048.jpg)
![MCH
Mean mass of haemoglobin present in a red cell
MCH = { [ Haemoglobin (g/dL) x 10 ] / RBC count in million } pg
Normal Range : 30 ± 3 pg](https://image.slidesharecdn.com/clinicalhaematologyguide-230409125412-559c0bda/75/Clinical-Haematology-Basic-Guide-21-2048.jpg)
![MCHC
Mean mass of haemoglobin in 1dL of packed red cells
MCHC = { [ Haemoglobin (g/dL) / Haematocrit (of 100 mL) ] x 100 } %
OR
MCHC = { [ MCH/MCV ] x 100 } %
Normal Range: 33 ± 2 %](https://image.slidesharecdn.com/clinicalhaematologyguide-230409125412-559c0bda/75/Clinical-Haematology-Basic-Guide-22-2048.jpg)
![• Serum Iron: 50-150 μg/dL
• TIBC: 300-360 μg/dL
• Serum Ferritin:
Men: ~100 μg/L
Women: ~30 μg/L
• Transferrin saturation = [(SI/TIBC) x 100]: 25-50%
Iron Supply Studies](https://image.slidesharecdn.com/clinicalhaematologyguide-230409125412-559c0bda/75/Clinical-Haematology-Basic-Guide-43-2048.jpg)
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Clinical Haematology : Basic Guide
- 1. CLINICAL HAEMATOLOGY Basic Guide Presentedby Kushan Singh
- 2. Clinical Haematology It actsas a practical guide to the diagnosis and treatment of disorders of red blood cells, white blood cells, and haemostasis.
- 3. Common Haematological Tests 1.CBC & PBS 2. Marrow Examination 3. Red Blood Cell Mass 4. Iron Supply Studies 5. Serum Folate 6. Serum B-12 7. Complement system studies 8. Genetic studies
- 4. Complete Blood Count C.White Cells 1. Total Leukocyte Count 2. Differential Leukocyte Count D. Platelet Count E. PBS 1. Cell Size 2. Haemoglobin Content 3. Anisocytosis 4. Poikilocytosis 5. Polychromasisa A. Red Cells 1. Red Cell Count 2. Haemoglobin 3. Haematocrit 4. Reticulocyte Count B. Red Blood Cell Indices 1. MCV 2. MCH 3. MCHC 4. RDW
- 5. RED CELL COUNT Numberof red cells in a unit volume of blood Normal Range Male : 4.5 — 6.5 x 106/mm3 Female : 3.8 — 5.8 x 106/mm3
- 6. HAEMOGLOBIN AGE/SEX HEMOGLOBIN g/dl BIRTH17 CHILDHOOD 12 ADOLOSCENCE 13 ADULT MAN 16 ± 2 ADULT WOMAN (menstruating) 13 ± 2 ADULT WOMAN (postmenopausal) 14 ± 2 DURING PREGNANCY 12 ± 2 Mass of haemoglobin after lysis of red cells present in a unit volume of blood
- 7. HAEMATOCRIT AGE/SEX HEMATOCRIT BIRTH 52 CHILDHOOD36 ADOLOSCENCE 40 ADULT MAN 47 ± 6 ADULT WOMAN (menstruating) 40 ± 6 ADULT WOMAN (postmenopausal) 42 ± 6 DURING PREGNANCY 37 ± 6 Volume occupied by red cells in a unit volume of blood Rule of 3 : Haematocrit = Haemoglobin x 3
- 8. Red Blood CellMass Absolute volume occupied by red cells in blood Normal Range (mL/kg) Note: It is not a ratio and does not change with change in plasma volume Red Blood Cell Volume Plasma Volume Total Blood Volume Men 30 ± 5 35 ± 5 65 ± 8 Women 25 ± 5 35 ± 5 60 ± 7
- 9. Erythrocytosis ABSOLUTE ERYTHROCYTOSIS Red BloodCell Mass is increased RELATIVE ERYTHROCYTOSIS Haematocrit is increased but Red Blood Cell Mass is not raised
- 10.
- 11. Polycythaemia vera WHO DiagnosticCriteria (2007) Major criteria 1. Hb > 18.5 g/dL in men; Hb > 16.5 g/dL in women Or Increased red cell mass ( > 36 mL/kg in men; > 32 mL/kg in women ) 2. JAK2 V617F mutation present Minor criteria • Prominent leukocytosis, thrombocytosis, or bone marrow hypercellularity involving all cell lines • EPO levels: <4 mU/ml (or normal reference range) • BFU-E hypersensitivity to EPO
- 12. Approach to DDsof patients with ↑Hb
- 13. RETICULOCYTE COUNT (orRPI) Ratio of reticulocytes to red cells in the blood expressed as percentage • To check Marrow response • Haematologist counts 1000 red cells • The number of reticulocytes observed are expressed in percentage RPI is falsely elevated in anaemia Therefore, corrections are applied
- 14. CORRECTION CORRECTION I (foranemia) : Reticulocyte count x [ Hb of the patient / Hb normal for the age ] When to apply? : This correction is applied when there is low hematocrit Why to apply? : The percentage of reticulocytes may be falsely elevated because the whole blood contains fewer RBCs
- 15. CORRECTION II (forlonger life of prematurely released reticulocytes in the blood) : Haemoglobin Correction / Maturation Time Correction When to apply? : When polychromatophilic macrocytes are present in PBS Why to apply? : The normal ~1 day of maturation time of reticulocytes increases, therefore, the immature red cells are remaining in peripheral blood for >1 day, giving falsely elevated number of reticulocytes CORRECTION
- 16. CORRECTION Shift Factor orMaturation Time Correction Factor Marrow normoblasts Peripheral blood and reticulocytes (days) reticulocytes (days) 3.5 1.0 3.0 1.5 2.5 2.0 2.5 2.5 45 35 25 15 Haematocrit (%)
- 17. Normal Marrow Responseto Anaemia HAEMOGLOBIN(g/dL) PRODUCTION INDEX RETICULOCYTE COUNT/μL 15 1 50000 11 2 — 2.5 100000 — 150000 8 3 — 4 300000 — 400000 This table is used to check the marrow response But, as reticulocyte count is not generally available as absolute number of reticulocytes, therefore in anaemia % values cannot be trusted without correction
- 18. Interpreting RPI Broadly, correctedRPI can hint us in two directions: 1. RPI < 2% : • Hypoproliferative • Red Cell Maturation Defect 2. RPI > 3% : • Decreased Red Cell Survival
- 19. MCV Mean volume occupiedby a red cell MCV = { [ Haematocrit (%) x 10 ] / RBC count in million } fL Normal range : 90 ± 8 fL
- 20. CLASSIFICATION OF ANEMIA ONTHE BASIS OF MCV MICROCYTIC (MCV<82fL) NORMOCYTIC (82-98fL) MACROCYTIC (MCV>98fL) 1. SIDEROBLASTIC ANEMIA 2. IRON DEFICIENCY ANEMIA (<80fL) 3. ANEMIA OF CHRONIC INFLAMMATION (>75fL) 4. THALESSEMIA (<70fL) 5. HAEMOGLOBINOPATHIES (70-80fL) 1. NON MEGALOBLASTIC • APLASTIC ANEMIA • CHRONIC LIVER DISEASE • ALCOHOLOISM 2. MEGALOBLASTIC • FOLATE DEFICIENCY • VIT B12 DEFICIENCY • MYELODYSPLASIA 1. HEMOLYTIC ANEMIA 2. APLASTIC ANEMIA 3. ANEMIA OF RENAL DISEASE 4. ANEMIA OF CHRONIC INFLAMMATION (<85fL) 5. HYPOMETABOLIC STATES
- 21. MCH Mean mass ofhaemoglobin present in a red cell MCH = { [ Haemoglobin (g/dL) x 10 ] / RBC count in million } pg Normal Range : 30 ± 3 pg
- 22. MCHC Mean mass ofhaemoglobin in 1dL of packed red cells MCHC = { [ Haemoglobin (g/dL) / Haematocrit (of 100 mL) ] x 100 } % OR MCHC = { [ MCH/MCV ] x 100 } % Normal Range: 33 ± 2 %
- 23. MCH & MCHCInterpretation Normal values imply Normochromic picture: 1. Negative Iron balance 2. Iron deficient erythropoiesis 3. Marrow Damage • Infiltration/Fibrosis • Aplasia 4. Decreased Stimulation • Inflammation • Renal disease • Metabolic Defect
- 24. Decreased values implyHypochromic picture: 1. Iron Deficiency Anaemia 2. Thalassemia 3. Hb E Disease/trait 4. Sideroblastic Anaemia MCH & MCHC Interpretation
- 25. RDW RDW = {( Standard Deviation of MCV/ MCV ) x 100 } % Normal range: 11—14 %
- 26. RDW & MCV LippiG, Plebani M. Recent developments and innovations in red blood cell diagnostics. J Lab Precis Med 2018. Normal RDW: 1. Thalassemia 2. Sickle Cell Trait 3. Anaemia in Chronic Disease 4. Aplastic Anaemia 5. Chronic Leukaemia 6. Acute Haemorrhage
- 27. TOTAL LEUKOCYTE COUNT Numberof leukocytes in a unit volume of blood Normal Range: 4 — 11 x 10³ / mm³
- 28. DIFFERENTIAL LEUKOCYTE COUNT Neutrophils40 — 70 % 2.0 — 7.5 x 10³/mm³ Lymphocyte 20 — 40 % 1.5 — 4.0 x 10³/mm³ Monocyte 2 — 10 % 0.2 — 0.8 x 10³/mm³ Eosinophil 1 — 6 % 0.04 — 0.4 x 10³/mm³ Basophil 0 — 2 % 0.01 — 0.1 x 10³/mm³
- 29. Neutrophilia Adults: >7000/μL Infants &children: >8,500/μL Newborn: >25,000/μL • Most important cause: Acute Infection • Causes: 1. ↑ production: drug induced (glucocorticoids), infections, inflammation, myeloprofirerative diseases (PV, CML) 2. ↑ marrow release: glucocorticoids, acute infection (endotoxin) 3. ↓ margination: drugs (epi., NSAIDs, glucocorticoids), Adr. rush (stress, excitement, vigorous exercise), LAD
- 30. Neutropaenia <1000/μL: sharp ↑in susceptibility to infections <500/μL: impaired control of endogenous microbial flora (e.g., gut, mouth) <200/μL: local inflammatory response absent
- 31.
- 32. Eosinopaenia Causes: • Acute bacterialinfection • Glucocorticoid treatment There is no known adverse effect of Eosinopaenia
- 33. PLATELET COUNT Number ofplatelets in a unit volume of blood Normal Range : 1.5 — 4.5 x 10⁵ / mm³
- 34. Malignancy Clinical Presentation WhiteCells (cells/μL) Anaemia (Hb in g/dL) Platelets (cells/μL) Marrow Response/ Cellularity AML Fatigue, Anorexia, Wt. Loss, Fever, Bruising, Bone Pain, Splenomegaly & Hepatomegaly Median ~15,000 25-40%: <5,000 20%: >100,000 Not severe; Normocytic, Normochromic; d/t ↑ destruction Bizarre shaped ~75%: <100,000 ~25%: <25,000 RPI ↓ CML Anaemia sx, LUQ pain, Splenomegaly (20-70%), Hepatomegaly & Lymphadenopathy (5- 10% each) 10,000-500,000; Left shift; ↑Basophils & Eosinophils; Blasts ≤5% In 1/3rd patients Thrombocytosis (>450,000): More common; Thrombocytopenia (<100,000): Rare & Worse prognosis M : E = 15-20 : 1 ALL Early: Anaemia sx, infection & bleed Late: LN enlargement, hepatosplenomegaly, Meningeosis leukemica Only 16%: >100,000; Neutropaenia; In 8%: 0 Leukemic blasts in PB 47%: Hb >9 33%: Hb 7-9 20%: Hb <7 Thrombocytopenia; 1/5th pts: <20,000 Leukemic blasts are predominant CLL Lymphadenopathy, Splenomegaly, Hepatomegaly ↑TLC w/ Lymphocyte predominance; Flow Cytometry: Clonal B cell count ≥5000 AIHA in 10% pts <100,000 in Stage C of Binet Staging System Abnormal white cells
- 35. Peripheral Blood Smear Cellsize Normocytic, Microcytic, Macrocytic Hb Content Normochromic, Hypochromic Anisocytosis Difference in size of cells Poikilocytosis Difference in shape of cells Polychromasia Purple-grey staining reticulocytes with Wright’s stain
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- 37.
- 38.
- 39. Microcytic, Hypochromic w/Anisopoikilocytosis SMALL LYMPHOCYTE TEAR DROP CELL CIGAR SHAPED CELL CENTRAL PALLOR >40% DDs: Iron deficiency anaemia, Anaemia of chronic disease
- 40. Burr cells red cellsw/ numerous, small regularly spaced spiny projections BURR CELL OR ECHINOCYTE INDICATE: Uraemia DDs: CKD, Liver Disease, Haemolytic Anaemia
- 41.
- 42. Reticulocytes in NMBStain RETICULOCYTE
- 43. • Serum Iron:50-150 μg/dL • TIBC: 300-360 μg/dL • Serum Ferritin: Men: ~100 μg/L Women: ~30 μg/L • Transferrin saturation = [(SI/TIBC) x 100]: 25-50% Iron Supply Studies
- 44. Stages of Iron deficiency Serumferritin: 1st to be affected Serum ferritin < 15 μg/L: No marrow iron stores
- 45. Dx of MicrocyticAnaemia
- 46. Dx of HypoproliferativeAnaemias Burr cells in PBS
- 47. Serum Folate Normal Range 2— 15 μg/L Low levels: Dietary deficiency, Malabsorption, Excess utilization or losses (pregnancy, prematurity, homocysteinuria, CHF) High levels: Cobalamin deficiency (b/o block in conversion of MTHF to THF)
- 48. Serum B-12 Normal Range:160 — 1000 ng/L Borderline: 100 — 200 ng/L Deficiency of either Folate or Cobalamin can cause Megaloblastic Anaemia
- 49.
- 50. Case-1 • 55y/F • H/oDM 7-8y, dysnea 3mo , burning micturition 3mo, B/L pedal oedema 3mo, melena 3mo • GPE: pallor, b/l pitting pedal oedema, bounding pulse, tachycardia • Endoscopy: Upper GI bleed PARAMETERS RESULT NORMAL RANGE INTERPRETATION HEMOGLOBIN (g/dl) 6 12 — 16 ↓ HEMATOCRIT (%) 18.9 36 — 48 ↓ RBC COUNT (in million/μL) 2.39 3.8 — 5.8 ↓ MCV (fL) 79 90 — 98 ↓ MCH (pg) 25.3 27 — 33 ↓ MCHC (g/dL) 32.1 31 — 35 N RDW-CV (%) 22.1 11-14 ↑
- 51. According to CBC, Microcytic,Hypochromic , w/ ↑RDW DDs: Iron deficiency, Inflammation, Sideroblastic Anaemia Thalassemia can be ruled out: because RDW is raised Dx of Microcytic Anaemia requires Iron studies Case-1…contd.
- 52. Case-1…contd. PARAMETERS RESULT NORMALRANGE INTERPRETATION Serum Iron (μg/dL) 15 50 — 150 ↓ TIBC (μg/dL) 148 300 — 360 ↓ Serum Ferritin (μg/L) 311 50 — 200 ↑ As ferritin stores are raised; serum iron is reduced and so is TIBC. It indicates inflammation. Upper GI bleed justify severe anaemia d/t blood loss. Dx: Anaemia of Inflammation superimposed on Anaemia of Blood Loss
- 53. Case-2 • 70y/M • H/orecurrent epistaxis, fatigue. Past h/o PTB, ATT intake 20y back • GPE: pallor; USG Abdomen: Prostatomegaly, Splenomegaly PARAMETERS RESULT NORMAL RANGE INTERPRETATION HEMOGLOBIN (g/dl) 4.6 14 — 18 ↓ HEMATOCRIT (%) 14.8 41 — 53 ↓ RBC COUNT (10⁶/μL) 1.73 4.5 — 6.5 ↓ MCV (fL) 85 90 — 98 ↓ MCH (pg) 26.5 27 — 33 ↓ MCHC (g/dL) 31.0 31 — 35 N RDW-CV (%) 21.1 11 — 14 ↑ TLC (10³/μL) 5.8 4 — 11 N Platelet Count (10³/μL) 200 → 100 after 2 days 150 — 450 ↓
- 54. RPI Uncorrected: 2.75% PBS:Mild shift to left with leucoerythroblastic blood picture RPI Correction Hb Correction: 2.75 x (4.6/16) = 0.79% Maturation Time Correction: Hb Correction/2.5 = 0.32% RPI↓ Case-2…contd.
- 55. Case-2…contd. PARAMETERS RESULT NORMALRANGE INTERPRETATION Serum Iron (μg/dL) 61 50 — 150 N TIBC (μg/dL) 180 300 — 360 ↓ Serum Ferritin (μg/L) 1163 50 — 200 ↑ Conclusion: Hypoproliferative state, w/ thrombocytopenia, and splenomegaly, and recurrent epistaxis which may be due to thrombocytopenia Dx: AML (very rare) Further investigations: BM aspirate
- 56. Case-3 • 70y/M • H/osilicosis, oliguria 5-7 days, steroid intake • GPE: pallor; Crt: 10.3, Urea: 319 PARAMETERS RESULT NORMAL RANGE INTERPRETATION HEMOGLOBIN (g/dl) 8.6 14 — 18 ↓ HEMATOCRIT (%) 29.2 41 — 53 ↓ RBC COUNT (10⁶/μL) 2.64 4.5 — 6.5 ↓ MCV (fL) 111 90 — 98 ↑ MCH (pg) 32.6 27 — 33 N MCHC (g/dL) 29.5 31 — 35 N RDW-CV (%) 18 11 — 14 ↑ Platelet Count (10³/μL) 128 150 — 450 ↓
- 57. Macrocytic, Normochromic B-12: 153ng/L Folate: 12.6 μg/L B-12 at borderline Case-3…contd. PARAMETERS RESULT NORMAL RANGE INTERPRETATION Serum Iron (μg/dL) 24 50 — 150 ↓ TIBC (μg/dL) 139 300 — 360 ↓ Serum Ferritin (μg/L) 1854 50 — 200 ↑ Dx: B-12 deficiency w/ Anaemia of Renal Disease
- 58. THANKYOU BIBLIOGRAPHY 1. Harrison's Principlesof Internal Medicine, 21e Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D, & Jameson J(Eds.),Eds. Joseph Loscalzo, et al. 2. RS Hillman et al: Hematology in Clinical Practice, 5th ed. New York, McGraw-Hill, 2010. 3. Lippi G, Plebani M. Recent developments and innovations in red blood cell diagnostics. J Lab Precis Med 2018.