GOOD CBC PRINCIPLE,INTERPRETATION.pdf

7/27/2019 GOOD CBC PRINCIPLE,INTERPRETATION.pdf

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Introduction to CBC and BloodSmear Interpretation

Introduction to CBC and BloodIntroduction to CBC and BloodSmear InterpretationSmear Interpretation

Thanyaphong Na Nakorn, MD, PhD

Division of HematologyDepartment of MedicineChulalongkorn University

Thanyaphong Na Nakorn, MD, PhDThanyaphong Na Nakorn, MD, PhD

Division of HematologyDivision of HematologyDepartment of MedicineDepartment of Medicine

Chulalongkorn UniversityChulalongkorn University

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Complete blood countComplete blood countComplete blood count

z The most common test used in clinical medicinez Determine type and severity of blood cell

abnormalitiesz Nowadays, CBC is fully automated and highly

reproducible.z Correct interpretation of automated CBC can

reduce rate of unnecessary blood smearexamination

z Provide useful information for provisionaldiagnosis of RBC and WBC diseases

zz The most common test used in clinical medicineThe most common test used in clinical medicinezz Determine type and severity of blood cellDetermine type and severity of blood cell

abnormalitiesabnormalitieszz Nowadays, CBC is fully automated and highlyNowadays, CBC is fully automated and highly

reproducible.reproducible.zz Correct interpretation of automated CBC canCorrect interpretation of automated CBC can

reduce rate of unnecessary blood smearreduce rate of unnecessary blood smearexaminationexamination

zz Provide useful information for provisionalProvide useful information for provisionaldiagnosis of RBC and WBC diseasesdiagnosis of RBC and WBC diseases


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Component of automated CBCComponent of automated CBCComponent of automated CBC

z Blood count basic parameters: Hb, Hct,RBC, WBC, platlet.

z Red cell indices: MCV, MCH, MCHC, RDWz WBC differentialsz Cytogram or Scattergramz Reticulocyte count

zz Blood count basic parameters:Blood count basic parameters: HbHb,, HctHct,,RBC, WBC,RBC, WBC, platletplatlet..

zz Red cell indices: MCV, MCH, MCHC, RDWRed cell indices: MCV, MCH, MCHC, RDW

zz WBC differentialsWBC differentialszz CytogramCytogram oror ScattergramScattergram

zz ReticulocyteReticulocyte countcount

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Basic principles of automated bloodBasic principles of automated bloodcell analyzercell analyzer

zz Electrical impedance:Electrical impedance:

Coulter CounterCoulter Counter ,, CellCell--DynDyn

zz

Optical impedance and light scatter:Optical impedance and light scatter:TechniconTechnicon--H seriesH series

zz VCS (volume, conductivity, light scatter) technologyVCS (volume, conductivity, light scatter) technology

BeckmanBeckman--Coulter VCS, MAXM,Coulter VCS, MAXM, STKSSTKS

nidistrega.info
http://www.manidistrega.info/http://www.manidistrega.info/


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Cell count and size can be measured byelectrical impedance

Cell count and size can be measured byCell count and size can be measured byelectrical impedanceelectrical impedance

Coulter TechnologyCoulter TechnologyCoulter Technology

J.Paul RobinsonJ.Paul Robinson

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Direction of flowDirection of flow

The Bernoulli EffectThe Bernoulli Effect

Velocity GradientVelocity Gradient

Viscous drag along walls.Viscous drag along walls.

Lower pressureLower pressure

Particles move to low pressure areaParticles move to low pressure area

Laminar Coaxial FlowLaminar Coaxial FlowSheath fluidSheath fluid

Hydrodynamic FocusingHydrodynamic Focusing

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Technicon TechnologyTechniconTechnicon TechnologyTechnology

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VCS TechnologyVCS TechnologyVCS Technology

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Impedance, laser light scatterImpedance, laser light scatterCellCell DynDyn 4000 (Abbott)4000 (Abbott)

CytochemistryCytochemistry, flow technology, flow technology((reticulocytereticulocyte analysis)analysis)

AdviaAdvia 120 (Bayer)120 (Bayer)

CytochemistryCytochemistry, flow technology, flow technology

((reticulocytereticulocyte analysis)analysis)

TechniconTechnicon HH--3 (Bayer)3 (Bayer)

Impedance, light absorption (halogenImpedance, light absorption (halogenlight source)light source)

CobasCobas Argos 5Argos 5--diff (Roche)diff (Roche)

Direct current (resistance to cellDirect current (resistance to cellvolume); radiovolume); radio--frequency (cell density,frequency (cell density,size)size)

SysmexSysmex SESE--90009000

Impedance, flowImpedance, flow cytometrycytometry,,conductivity, laser light scatterconductivity, laser light scatter((reticulocytereticulocyte analysis)analysis)

Coulter GENCoulter GEN--SS

Impedance, conductivity, laserImpedance, conductivity, lasertechnologytechnology

Coulter STKSCoulter STKSMethodology featuresMethodology featuresInstrumentInstrument

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Red cell parametersRed cell parametersRed cell parameters

z Direct Measurement Erythrocyte Concentration (RBC) x 106/ml Mean Corpuscular Volume (MCV) Femtolitre (fl) Hemoglobin (Hb) Gram/decilitre (g/dl)

z Indirect Measurement Hematocrit (Hct) = RBC x MCV/10 % Mean Corpuscular Hemoglobin (MCH) = HB x 10 / RBC (pg) Mean Corpuscular Hemoglobin Concentration (MCHC)

= Hb/Hct x 100 (g/dl) Red Cell Distribution Width (RDW) %

zz Direct MeasurementDirect Measurement Erythrocyte Concentration (Erythrocyte Concentration (RBCRBC)) x 10x 1066/ml/ml Mean Corpuscular Volume (Mean Corpuscular Volume (MCVMCV)) FemtolitreFemtolitre (fl)(fl) Hemoglobin (Hemoglobin (HbHb)) Gram/Gram/decilitredecilitre (g/dl)(g/dl)

zz Indirect MeasurementIndirect Measurement HematocritHematocrit ((HctHct) = RBC x MCV/10) = RBC x MCV/10 %% Mean Corpuscular Hemoglobin (Mean Corpuscular Hemoglobin (MCHMCH) = HB x 10 / RBC (pg)) = HB x 10 / RBC (pg) Mean Corpuscular Hemoglobin Concentration (Mean Corpuscular Hemoglobin Concentration (MCHCMCHC))

== Hb/HctHb/Hct x 100x 100 (g/dl)(g/dl) Red Cell Distribution Width (Red Cell Distribution Width (RDWRDW)) %%

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RBC size and MCVRBC size and MCVRBC size and MCV

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RRed Celled Cell DDistributionistribution WWidthidthRBC x 106/ml

75 80 85 90

20th

percentile 80th percentile

RDW

RDW =80th percentile - 20th percentile

80th percentile + 20th percentileX constant


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WBC: three-part differentialsWBC: threeWBC: three--part differentialspart differentials

CellCell--DynDyn 1700CS1700CS

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WBC: Five-part differentialsWBC: FiveWBC: Five--part differentialspart differentials

Neutrophil

Lymphocyte

Monocyte Eosinophil

Basophil

NeutrophilNeutrophil

LymphocyteLymphocyte

MonocyteMonocyte EosinophilEosinophil

BasophilBasophil

Coulter VCSCoulter VCS

lymphocyte

Monocyte

Baso

NEo


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WBC: Six-part differentialsWBC: SixWBC: Six--part differentialspart differentials

Neutrophil

Lymphocyte

Monocyte

Eosinophil

Basophil

Large Unstained Cell

(LUC)

NeutrophilNeutrophil

LymphocyteLymphocyte

MonocyteMonocyte

EosinophilEosinophil

BasophilBasophil

Large Unstained CellLarge Unstained Cell

(LUC)(LUC)

TechniconTechnicon*H2*H2

PeroxidasePeroxidase channelchannel

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WBC: Six-part differentialsWBC: SixWBC: Six--part differentialspart differentials

TechniconTechnicon*H2*H2

Basophil/lobularityBasophil/lobularity channelchannel

Additional parameters inTechnicon-H analyzer

1. Mean peroxidase activityindex (MPXI)

2. Lobularity Index (LI)

Additional parameters inAdditional parameters inTechniconTechnicon--H analyzerH analyzer

1.1. MeanMean peroxidaseperoxidase activityactivityindex (MPXI)index (MPXI)

2.2. LobularityLobularity Index (LI)Index (LI)


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Platelet parametersPlatelet parametersPlatelet parameters

z Platelet count

z Mean Platelet Volume (MPV)

z Platelet Distribution Width (PDW)

z Plateletcrit (Pct)

zz Platelet countPlatelet count

zz Mean Platelet Volume (MPV)Mean Platelet Volume (MPV)

zz Platelet Distribution Width (PDW)Platelet Distribution Width (PDW)

zz PlateletcritPlateletcrit (Pct)(Pct)

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Reticulocyte countReticulocyteReticulocyte countcount

z Reticulocyte = non-nucleated RBCwith polyribosomal RNA as stainedby supravital stain (new methyleneblue or brilliant cresyl blue)

z Polychromasia underestimatesreticulocytes

z Three methods of reticulocyteenumeration Manual count on slide per 1,000

RBC Automated CBC with

reticulocyte counter (CoulterVCS, Cell-Dyne 4000, Technicon-H3)

Flow cytometry with fluorescentdyes

zz ReticulocyteReticulocyte = non= non--nucleated RBCnucleated RBCwithwith polyribosomalpolyribosomal RNA as stainedRNA as stainedbyby supravitalsupravital stain (newstain (new methylenemethyleneblue or brilliantblue or brilliant cresylcresyl blue)blue)

zz PolychromasiaPolychromasia underestimatesunderestimates

reticulocytesreticulocyteszz Three methods ofThree methods of reticulocytereticulocyte

enumerationenumeration Manual count on slide per 1,000Manual count on slide per 1,000

RBCRBC Automated CBC withAutomated CBC with

reticulocytereticulocyte counter (Coultercounter (CoulterVCS, CellVCS, Cell--Dyne 4000, TechniconDyne 4000, Technicon--H3)H3)

FlowFlow cytometrycytometry with fluorescentwith fluorescentdyesdyes


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Report from CoulterReport from CoulterReport from Coulter

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Report from Technicon-HReport fromReport from TechniconTechnicon--HH


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Clinical Utility of automated CBCClinical Utility of automated CBCClinical Utility of automated CBC

z Differential diagnosis of RBC disordersMicrocytic RBC

z Use WBC differential cytogram to guideWBC morphology and phenotypes

zz Differential diagnosis of RBC disordersDifferential diagnosis of RBC disorders MicrocyticMicrocytic RBCRBC

zz Use WBC differentialUse WBC differential cytogramcytogram to guideto guideWBC morphology and phenotypesWBC morphology and phenotypes


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WBCWBC 5.005.00 x10x1033//LLRBCRBC 3.563.56 x10x1066//LLHbHb 6.06.0 g/dLg/dL

HCTHCT 21.021.0 %%

MCVMCV 59.059.0 fLfL

MCHMCH 17.017.0 pgpg

MCHCMCHC 28.828.8 g/dLg/dL

RDWRDW 19.419.4 %%

HDWHDW 4.024.02 g/dLg/dL

PLTPLT 427427 x10x1033//LL

What is your diagnosis?What is your diagnosis?What is your diagnosis?

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Differential diagnosis of anemiausing MCV and RDW

Differential diagnosis of anemiaDifferential diagnosis of anemiausing MCV and RDWusing MCV and RDW

B12 deficiencyB12 deficiencyFolateFolate deficiencydeficiency

AIHAAIHADrugs: HU, ARV,Drugs: HU, ARV,

AZA, etc.AZA, etc.

Early or combinedEarly or combinednutritionalnutritionaldeficiencydeficiency

MyelodysplasiaMyelodysplasiaMyelophthisisMyelophthisisSickle cell anemia orSickle cell anemia or

HomozygousHomozygous HbCSHbCS

Iron deficiency anemiaIron deficiency anemiaThalassemiaThalassemia intermediaintermedia

SideroblasticSideroblastic anemiaanemiaSevere ACDSevere ACD

RBC fragmentationRBC fragmentationRDW >15RDW >15

AplasticAplastic anemiaanemia

MDSMDSMyelomaMyeloma

Liver diseaseLiver diseaseHyperthyroidismHyperthyroidism

ACDACD

HeterozygousHeterozygous HbSHbS,,HbCSHbCS,, HbEHbE, etc., etc.

HereditaryHereditaryspherocytosisspherocytosisAcute hemorrhageAcute hemorrhage

ThalassemiaThalassemia traittrait

HeterozygousHeterozygous HbEHbE,, HbCHbC,,etc.etc.

Anemia of chronicAnemia of chronicdisease (ACD)disease (ACD)

RDW


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SatellitismSatellitism, clumping, clumpingWBC fragmentation, severeWBC fragmentation, severemicrocytosismicrocytosis,, cryoglobulinscryoglobulins

PlateletsPlatelets

ClottingClottingNucleated red cells, platelet clumps,Nucleated red cells, platelet clumps,unlysedunlysed red cells,red cells, cryoglobulinscryoglobulins

WBCsWBCsPost transfusionPost transfusionRDWRDW

WBC >50 000/mmWBC >50 000/mm33HyperlipidemiaHyperlipidemia, cold agglutinins, cold agglutininsMCHCMCHC

CryoglobulinsCryoglobulinsCold agglutinins, hyperglycemia,Cold agglutinins, hyperglycemia,WBC >50 000/mmWBC >50 000/mm33

MCVMCV

ClottingClottinghyperlipidemiahyperlipidemia,, hyperbilirubinemiahyperbilirubinemiaHbHb

ClottingClottingWBC >50 000/mmWBC >50 000/mm33RBCsRBCs

Spuriously increasedSpuriously increased Spuriously decreasedSpuriously decreasedParameterParameter

Factors known to cause spurious laboratoryFactors known to cause spurious laboratory

results in hematology analyzers.results in hematology analyzers.

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Basic Principles for Blood SmearInterpretation

Basic Principles for Blood SmearBasic Principles for Blood SmearInterpretationInterpretation

z Assess quality of smears Specimen preparation & staining

z Estimate cell numbers RBC: evenly dispersed with minimalintercellular space

WBC: 10-20/LPF Platelets: 7-20/OF

z Determine predominant cell populationsz Carefully examine cellular morphology

zz Assess quality of smearsAssess quality of smears Specimen preparation & stainingSpecimen preparation & staining

zz Estimate cell numbersEstimate cell numbers

RBC: evenly dispersed with minimalRBC: evenly dispersed with minimalintercellular spaceintercellular space

WBC:WBC: 1010--20/LPF20/LPF Platelets: 7Platelets: 7--20/OF20/OF

zz Determine predominant cell populationsDetermine predominant cell populationszz Carefully examine cellular morphologyCarefully examine cellular morphology


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RBC disordersRBC disordersRBC disordersz Hypochromic microcytic anemia

Iron deficiency anemia Thalassemia and hemoglobinopathy

z Macrocytic anemia Megaloblastic anemia Non-megaloblastic macrocytic anemia

z Hemolytic anemia Immune hemolytic anemia: AIHA, DHTR

Microangiopathic hemolytic anemia (MAHA) Red cell enzymopathies: G-6-PD deficiency RBC membrane defects: spherocytosis,

ovalocytosis, elliptocytosis, stomatocytosisz RBC inclusion bodies and parasites

zz HypochromicHypochromic microcyticmicrocytic anemiaanemia Iron deficiency anemiaIron deficiency anemia ThalassemiaThalassemia andand hemoglobinopathyhemoglobinopathy

zz MacrocyticMacrocytic anemiaanemia MegaloblasticMegaloblastic anemiaanemia NonNon--megaloblasticmegaloblastic macrocyticmacrocytic anemiaanemia

zz Hemolytic anemiaHemolytic anemia Immune hemolytic anemia: AIHA, DHTRImmune hemolytic anemia: AIHA, DHTR

MicroangiopathicMicroangiopathic hemolytic anemia (MAHA)hemolytic anemia (MAHA) Red cellRed cell enzymopathiesenzymopathies: G: G--66--PD deficiencyPD deficiency RBC membrane defects:RBC membrane defects: spherocytosisspherocytosis,,

ovalocytosisovalocytosis,, elliptocytosiselliptocytosis,, stomatocytosisstomatocytosiszz RBC inclusion bodies and parasitesRBC inclusion bodies and parasites

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Area of blood film examinationArea of blood film examinationArea of blood film examination


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RBC Size and MCVRBC Size and MCVRBC Size and MCV

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WBC disordersWBC disordersWBC disordersz Leukopenia

with absolute neutropenia: bone marrow failure,agranulocytosis

with atypical lymphocytes: viral infection, chroniclymphoproliferative disorders

with immature myeloid cells: acute leukemia, MDSor myelopthisis

z Leukocytosis Reactive leukocytosis: leukemoid reaction Acute leukemia: AML vs. ALL Chronic myeloproliferative disorders Chronic lymphoproliferative disorders

z Leukoerythroblastosis

zz LeukopeniaLeukopenia

with absolutewith absolute neutropenianeutropenia: bone marrow failure,: bone marrow failure,agranulocytosisagranulocytosis

with atypical lymphocytes: viral infection, chronicwith atypical lymphocytes: viral infection, chroniclymphoproliferativelymphoproliferative disordersdisorders

with immature myeloid cells: acute leukemia, MDSwith immature myeloid cells: acute leukemia, MDSoror myelopthisismyelopthisis

zz LeukocytosisLeukocytosis

ReactiveReactive leukocytosisleukocytosis:: leukemoidleukemoid reactionreaction

Acute leukemia: AML vs. ALLAcute leukemia: AML vs. ALL

ChronicChronic myeloproliferativemyeloproliferative disordersdisorders

ChronicChronic lymphoproliferativelymphoproliferative disordersdisorders

zz LeukoerythroblastosisLeukoerythroblastosis

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Platelet disordersPlatelet disordersPlatelet disorders

z Quantitative disorders Isolated thrombocytopenia: Immune vs. non-immune Thrombocytopenia associated with other hematologic

abnormalities Thrombocytosis

z Qualitative disorders Giant platelets (megathrombocytes)

Platelet inclusion or granule abnormality Bizarre in shape and size Megakaryocytes or megakaryoblasts

zz Quantitative disordersQuantitative disorders

Isolated thrombocytopenia: Immune vs. nonIsolated thrombocytopenia: Immune vs. non--immuneimmune

Thrombocytopenia associated with otherThrombocytopenia associated with other hematologichematologicabnormalitiesabnormalities

ThrombocytosisThrombocytosis

zz Qualitative disordersQualitative disorders

Giant platelets (Giant platelets (megathrombocytesmegathrombocytes))

Platelet inclusion or granule abnormalityPlatelet inclusion or granule abnormality Bizarre in shape and sizeBizarre in shape and size

MegakaryocytesMegakaryocytes oror megakaryoblastsmegakaryoblasts

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Documents

GOOD CBC PRINCIPLE,INTERPRETATION.pdf