Getting to knowGetting to know

the CBC…the CBC…

It’s about time!It’s about time!

Ma. Ysabel Lesaca-Medina, MDMa. Ysabel Lesaca-Medina, MD

Do you knowDo you know : :

How to evaluate anemia using How to evaluate anemia using MCV, RDW MCV, RDW and RETIC countand RETIC count

the significance of different the significance of different RBC shapesRBC shapes reported in the PBSreported in the PBS

How to deal with How to deal with leukocyte abnormalitiesleukocyte abnormalities seen on PBSseen on PBS

The causes of The causes of thrombocytosis and thrombocytosis and thrombocytopeniathrombocytopenia

Evaluating Anemia Evaluating Anemia -role of -role of MCV, MCH, MCHCMCV, MCH, MCHC

MCV MCV (mean corpuscular volume)(mean corpuscular volume)

Formula Formula (2-10 yrs old)(2-10 yrs old)

– Lower limitLower limit: 70 fL + age in years : 70 fL + age in years

– Upper limit:Upper limit: 84 fL + ( age in yrs x 0.6 ), 84 fL + ( age in yrs x 0.6 ), until upper limit of 96 is reacheduntil upper limit of 96 is reached

MEMORIZE !!MEMORIZE !!

Evaluating AnemiaEvaluating Anemia

MCH (Mean Corpuscular Hb)MCH (Mean Corpuscular Hb)

MCHC (Mean Corpuscular Hb conc)MCHC (Mean Corpuscular Hb conc)

- normo/hyper/hypo chromicnormo/hyper/hypo chromic- Used in Used in

- iron deficiency, thalassemia - iron deficiency, thalassemia - ↓↓- Spherocytosis - Spherocytosis -

MCH/MCHCMCH/MCHC

What’s the MCV range? What’s the MCV range? Give LL and ULGive LL and UL

7 year old7 year old

answeranswer

LL: 77 fL

UL: 88.2 fL

RETICULOCYTE COUNTRETICULOCYTE COUNT

-Expressed as % of circulating rbc’s

-Take up reticulin stain (supravital):

bec of inc RNA

-N = 0.5 % to 1.5 %

or = .005 to .015

RETICULOCYTE COUNTRETICULOCYTE COUNT

Provide crucial info on Provide crucial info on RATERATE of red cell of red cell productionproduction

2 broad classes of anemias2 broad classes of anemias1.1. 2 red cell 2 red cell loss or destructionloss or destruction – inc retic – inc retic

- e.g. hemolysis, blood loss- e.g. hemolysis, blood loss

2.2. Dec red cell Dec red cell productionproduction – dec retic – dec retice.g. aplastic, iron deficiencye.g. aplastic, iron deficiency

Reticulocyte indexReticulocyte index

Anemic patient --> Anemic patient --> increased reticincreased retic

so have to correct: so have to correct: retic observed x retic observed x px Hct / 0.45px Hct / 0.45

Example:Example:

Hb 50 Hb 50 Hct 0.15Hct 0.15

Retic countRetic count=.=.045= 4.5 %045= 4.5 %

Corrected retic =Corrected retic =

retic x (px Hct / 0.45)retic x (px Hct / 0.45)

4.5% x .15/.45 = 4.5% x .15/.45 = 1.5 %1.5 %( N = 0.5-1.5%)( N = 0.5-1.5%)

Absolute Retic CountAbsolute Retic Count

More accurateMore accurate

Compute :Compute :

RBC (in n x 10RBC (in n x 101212 ) )

x # retic/1000 rbcx # retic/1000 rbc

x 1000x 1000 Normal Normal

= 40,000 – 100,000/uL = 40,000 – 100,000/uL

Absolute Retic countAbsolute Retic count

EXAMPLEEXAMPLE

Hb 50 Hb 50 Hct 0.15Hct 0.15

RBC = 1.6 x 10RBC = 1.6 x 101212

Retic countRetic count

=.045 = 4.5 %=.045 = 4.5 %

Compute for absolute Compute for absolute retic countretic count

Formula: Formula:

RBC (in n x 10RBC (in n x 101212 ) )

x # retic/1000 rbcx # retic/1000 rbc

x 1000x 1000

= 1.6 x 45 x 1000= 1.6 x 45 x 1000

= = 72 ,00072 ,000

Normal = 40,000 – 100,000/uLNormal = 40,000 – 100,000/uL

QuizQuiz

Compute for absolute Compute for absolute retic count :retic count :Hb 90Hb 90

RBC 3 x 10RBC 3 x 1012 12 /L /L

Retic .015Retic .015

AnswerAnswer

45,000 retics / uL45,000 retics / uL

Anemia based on MCV and reticAnemia based on MCV and retic

Increased MCVIncreased MCV– High reticHigh retic– Low reticLow retic

Decreased MCVDecreased MCV– High reticHigh retic– Low reticLow retic

Normal MCVNormal MCV– High reticHigh retic– Low reticLow retic

Increased MCVIncreased MCV

Increased ReticIncreased Retic– Acute blood lossAcute blood loss– HemolysisHemolysis

> Increased MCV> Increased MCV

- cased by inc # retics- cased by inc # retics

retics have a large retics have a large cellular volumecellular volume

Anemia based on MCV and reticAnemia based on MCV and retic

Increased MCVIncreased MCV– High reticHigh retic– Low reticLow retic

Decreased MCVDecreased MCV– High reticHigh retic– Low reticLow retic

Normal MCVNormal MCV– High reticHigh retic– Low reticLow retic

Inc MCV, low reticInc MCV, low retic

1.1. Bone Marrow FailureBone Marrow Failure• Retic count greatly dec for degree of anemiaRetic count greatly dec for degree of anemia

----------------------------------------------------------------------------------------------------------------------------------

E.g. Known case of Aplastic anemiaE.g. Known case of Aplastic anemia

RBC 1.73 Hb 52 Hct 0.15 Retic = 1 % or 0.010RBC 1.73 Hb 52 Hct 0.15 Retic = 1 % or 0.010

> Compute for corrected retic count % absolute retic> Compute for corrected retic count % absolute retic

AnswerAnswer

Corrected retic:Corrected retic:

0.33 %0.33 %

( 0.5 – 1.5 %)( 0.5 – 1.5 %)

You got it!You got it!

Absolute Retic Count:

17,300 /uL

(40,000-100,000)

Bone Marrow Failure Bone Marrow Failure

MCV inc bec of production of stress rbc’s MCV inc bec of production of stress rbc’s

Examples of bone marrow failureExamples of bone marrow failureo Aplastic AnemiaAplastic Anemiao Fanconi’s AnemiaFanconi’s Anemiao Diamond-Blackfan anemiaDiamond-Blackfan anemia

(Congenital hypoplastic anemia)(Congenital hypoplastic anemia)

o Transient Erythroblastopenia of Childhood Transient Erythroblastopenia of Childhood (TEC)(TEC)

TEC vs DBATEC vs DBA

Diamond Blackfan Anemia

- Congenital- 90% cases < 6 mos- Some recover by 7 years old- ADA increased

Transient Transient erythroblastopenia erythroblastopenia of childhoodof childhood– AcquiredAcquired– 90% cases in > 1 y.o.90% cases in > 1 y.o.– Recovery within 2 mosRecovery within 2 mos– In recovery phase, inc In recovery phase, inc

MCV bec inc reticsMCV bec inc retics– ADA normalADA normal

Inc MCV, Dec ReticInc MCV, Dec Retic2. 2. Megaloblastic Megaloblastic

disordersdisorders Folate and Vit B 12 Folate and Vit B 12

deficiencydeficiency Other things seen :Other things seen :

Hypersegmentation of Hypersegmentation of PMN’sPMN’s

Giant segmenters, Giant segmenters, stabs stabs

MacroovalocytosisMacroovalocytosis Megaloblastic changes Megaloblastic changes

in BMin BM

hypersegmentationhypersegmentation

Inc MCV, Dec ReticInc MCV, Dec Retic

3. 3. AlcoholAlcohol direct toxic effect on BMdirect toxic effect on BM Induces folate deficiencyInduces folate deficiency

Inc MCV, dec reticInc MCV, dec retic

4.4. Anti-metabolitesAnti-metabolitesa.a. Methotrexate (folic acid anti-metabolite)Methotrexate (folic acid anti-metabolite)

b.b. Co-trimoxazoleCo-trimoxazole

5.5. HypothyroidismHypothyroidisma. Causes red cell hypoplasiaa. Causes red cell hypoplasia

b.b. Usually normocytic/normochromicUsually normocytic/normochromic

c.c. Macrocytosis may developMacrocytosis may develop

Next …Next …DECREASED MCVDECREASED MCV

Decreased MCVDecreased MCV

Caused by Caused by insufficient insufficient Hb synthesisHb synthesis

Mostly caused by:Mostly caused by:– Iron deficiencyIron deficiency– Inability to use ironInability to use iron

Chronic diseaseChronic disease

ThalassemiaThalassemia

Lead poisoningLead poisoning

Sideroblastic anemiaSideroblastic anemia

Decreased MCVDecreased MCV

Increased reticIncreased retic

– Thalassemia Thalassemia majormajor

Normal /decreased Normal /decreased reticretic

Thalassemia majorThalassemia major

PresentsPresents : 6 to 24 months old : 6 to 24 months old

SymptomsSymptoms– Profound anemiaProfound anemia– HepatosplenomegalyHepatosplenomegaly– JaundiceJaundice– Growth retardationGrowth retardation

Decreased MCVDecreased MCV

Increased reticIncreased retic

– Thalassemia majorThalassemia major

Normal /decreased Normal /decreased reticretic– Iron deficiencyIron deficiency– Thalassemia TraitThalassemia Trait– Anemia of chronic Anemia of chronic

diseasedisease– Lead poisoningLead poisoning– Sideroblastic anemiaSideroblastic anemia

hardest differentials !

1. Iron deficiency1. Iron deficiency

Common cause in 1-3 years of ageCommon cause in 1-3 years of age

As iron stores become depleted:As iron stores become depleted:

– ↑↑RRDW DW

↓↓serum serum FFe e

↓ ↓ MMCV CV ↓ Hb↓ Hb

Remember!Remember!

First manifestationFirst manifestation : : RDWRDW

1. Iron deficiency1. Iron deficiency

Reasonable Reasonable approach: Oral iron approach: Oral iron replacementreplacement

(+) response: (+) response:

Hb by 15-20 in 1 monthHb by 15-20 in 1 month

PRESUMPTIVE DX MADE !

2. Thalassemia trait2. Thalassemia trait

Microcytosis +/- mild anemiaMicrocytosis +/- mild anemia– 1 of 2 B-globin genes are intact 1 of 2 B-globin genes are intact – or 2 of 4 alpha-globin genes are intactor 2 of 4 alpha-globin genes are intact

Often confused with iron deficiencyOften confused with iron deficiency

Thal trait vs Iron deficiencyThal trait vs Iron deficiency

Thal traitThal trait Iron deficiencyIron deficiency

Mentzer indexMentzer index(MCV/RBC count)(MCV/RBC count)

< 12< 12 Smaller cells,Smaller cells,

More rbc numberMore rbc number

>13>13Bigger cells, less rbc Bigger cells, less rbc numbernumber

Poikilocytosis;Poikilocytosis;

Basophilic stipplingBasophilic stipplingMore More

RDWRDW NormalNormal increasedincreased

RED CELL DISTRIBUTION WIDTHRED CELL DISTRIBUTION WIDTH

Quantitative measure of anisocytosisQuantitative measure of anisocytosis

The greater the # of sizes of rbc’s, the The greater the # of sizes of rbc’s, the higher the RDWhigher the RDW

Normal = 11.5-14.5Normal = 11.5-14.5

No subnormal values have been reportedNo subnormal values have been reported

RDWRDW

HIGH ( HIGH ( HIGH-F HIGH-F ))

– IIron deficiencyron deficiency– Hb Hb HH disease disease– FFragmentationragmentation– GG-6PD-6PD– Chronic disease Chronic disease

3. Anemia of Chronic Disease3. Anemia of Chronic Disease

Mild to moderate anemia (Hb 100 – 110)Mild to moderate anemia (Hb 100 – 110)

Slight inc RDW; dec Fe, inc FerritinSlight inc RDW; dec Fe, inc Ferritin

Px has chronic Px has chronic INFLAMMATIONINFLAMMATION

Disturbs iron recycling Disturbs iron recycling iron left trapped iron left trapped in RESin RES– Cytokines IL-1, IL-6 Cytokines IL-1, IL-6 inc ferritin syn inc ferritin syn

empty ferritin shells provide excess iron empty ferritin shells provide excess iron storage capacity storage capacity iron sequestered in RES iron sequestered in RES

Decreased MCVDecreased MCV

4. 4. Lead poisoningLead poisoning

Inhibits enzymes Inhibits enzymes involved in heme involved in heme synthesissynthesis

Reduction of Reduction of intracellular iron intracellular iron

5. 5. Sideroblastic Sideroblastic AnemiaAnemia

Rare in childhoodRare in childhood

Failure to incorporate Failure to incorporate iron into hemeiron into heme

Causes:Causes:– Inherited (XL)Inherited (XL)– MDSMDS– Drugs ( INH, ethanol)Drugs ( INH, ethanol)

NEXT. ..NEXT. ..

NORMAL MCVNORMAL MCV

MCV NORMALMCV NORMAL

MCV NORMAL

INC RETIC DEC RETIC N OR DEC RETIC

1. HEMOLYSIS2. BLOOD LOSS

MCV NORMALMCV NORMAL

MCV NORMAL

INC RETIC DEC RETIC N OR DEC RETIC

1. BALANCED2. PRCA/TEC3. APLASTIC4. HYPOTHYROIDISM5. REPLACEMENT OF MARROW

MCV NORMALMCV NORMAL

Normal or decreased retic

Renal diseaseHyperparathyroidism

Liver diseaseChronic Inflammation

Renal DiseaseRenal Disease

Cause:Cause:– erythropoeitin erythropoeitin

insufficiencyinsufficiency– Serum inhibitors of Serum inhibitors of

erythropoeisis erythropoeisis accumulate in uremic accumulate in uremic patients patients shortened shortened rbc lifespanrbc lifespan

– AcanthocytosisAcanthocytosis

When BUN > 150 mg/dL

HyperparathyroidismHyperparathyroidism

Fibrosis in marrow Fibrosis in marrow cavitycavity

Decreased erythropoeisis

Liver diseaseLiver disease

Anemia is due toAnemia is due to– HypersplenismHypersplenism– Vitamin-nutritional Vitamin-nutritional

deficiencies (lipid deficiencies (lipid soluble)soluble)

– Blood lossBlood loss

PLATELETSPLATELETS

Cytoplasmic fragments ; no nucleusCytoplasmic fragments ; no nucleusLife span = 7-10 daysLife span = 7-10 days1/3 in spleen, 2/3 in circulation1/3 in spleen, 2/3 in circulationSize= 1 – 4 umSize= 1 – 4 um– Large Large

YoungYoung2 peripheral destruction2 peripheral destruction

– Small or normalSmall or normalProduction defectProduction defect

THROMBOCYTOSISTHROMBOCYTOSIS

Platelet count > 600,000Platelet count > 600,000

Rarely causes complications !Rarely causes complications !– Therefore, antiplatelet tx is rarely indicatedTherefore, antiplatelet tx is rarely indicated– Kawasaki is an exceptionKawasaki is an exception

THROMBOCYTOSISTHROMBOCYTOSIS

Hemolytic anemiaHemolytic anemia

HemorrhageHemorrhage

InfectionInfection

Iron def anemiaIron def anemia

Vit E deficiencyVit E deficiency

Vascular Collagen Vascular Collagen disordersdisorders

Post-splenectomyPost-splenectomy

Post-opPost-op

Inflammatory Bowel DisInflammatory Bowel Dis

TraumaTrauma

TumorsTumors

Syndrome, kawasakiSyndrome, kawasaki

Syndrome, nephroticSyndrome, nephrotic

Syndrome, myeloprolifSyndrome, myeloprolif

HIV is the PITS !

THROMBOCYTOPENIATHROMBOCYTOPENIA

Immune Platelet DestructionImmune Platelet Destruction

InfectionsInfections

Platelet clumpingPlatelet clumping- falsely low - falsely low

- 2 inadequate coagulation- 2 inadequate coagulation

RBC abnormalitiesRBC abnormalities

AnisocytosisAnisocytosis– MicrocytesMicrocytes– MacrocytesMacrocytes– NormocytesNormocytes

PoikilocytosisPoikilocytosis– Different shapesDifferent shapes

Spherocytes Spherocytes

– Hereditary spherocytosisHereditary spherocytosis– ABO incompatibilityABO incompatibility– Hemolytic anemiaHemolytic anemia– HypersplenismHypersplenism– MalariaMalaria– HemoglobinopathiesHemoglobinopathies– Post-transfusion !Post-transfusion !– Liver diseaseLiver disease

AcanthocytesAcanthocytes

– AbetalipoproteinemiaAbetalipoproteinemia– Hemolytic anemiasHemolytic anemias– ThalassemiaThalassemia– Liver diseaseLiver disease– Severe burnsSevere burns– Post splenectomyPost splenectomy– Renal diseaseRenal disease– Enzyme deficienciesEnzyme deficiencies

SchistocytesSchistocytes

- Hemolytic anemia- Hemolytic anemia– HypersplenismHypersplenism– Megaloblastic Megaloblastic

anemiaanemia– ThalassemiaThalassemia– Acute LeukemiaAcute Leukemia– Post severe burnsPost severe burns

OvalocyteOvalocyte

Normochrom ovalocyteNormochrom ovalocyte– OvalocytosisOvalocytosis– ThalassemiaThalassemia

Hypochrom ovalocyteHypochrom ovalocyte– Iron deficiencyIron deficiency

Macrocytic ovalocyteMacrocytic ovalocyte– Megaloblastic anemiaMegaloblastic anemia

ElliptocytesElliptocytes

– ElliptocytosisElliptocytosis– Megaloblastic Megaloblastic

anemiaanemia– MyelofibrosisMyelofibrosis– ThalassemiaThalassemia

TARGET CELLSTARGET CELLS

– Liver diseaseLiver disease

– ThalassemiaThalassemia

– Iron deficiencyIron deficiency

– Post-Post-splenectomysplenectomy

Abn RBC shapesAbn RBC shapes

Blister cellBlister cell– Microangiopathic Microangiopathic

hemolytic anemiahemolytic anemia

Tailed RBCTailed RBC– Megaloblastic anemiasMegaloblastic anemias– Iron deficiencyIron deficiency

Tear dropTear drop– HypersplenismHypersplenism– ThalassemiaThalassemia– Hemolytic AnemiaHemolytic Anemia

BURR CELLSBURR CELLS

– Hemolytic Hemolytic anemiasanemias

– Iron deficiencyIron deficiency

– Megaloblastic Megaloblastic anemiaanemia

– ThalassemiaThalassemia

– HypersplenismHypersplenism

STOMATOCYTESSTOMATOCYTES

– Hereditary Hereditary stomatocytosisstomatocytosis

– ArtefactArtefact

– Acute leukemia, Acute leukemia, treatedtreated

– Alcoholics with Alcoholics with liver diseaseliver disease

The following scale is used by many laboratories in the delta region of the U. S.morphology                        normal       1+             2+           3+           4+characteristics                     limitsMacrocytes (>9 μ dia.)            0 - 5       5 - 10     10 - 20     20 - 50       >50Microcytes (<6 μ dia.)             0 - 5       5 - 10     10 - 20      0 - 50       >50Hypochromia                         0 - 2       3 - 10     10 - 50      50 - 75      >75Poikilocytosis                        0  - 2       3 - 10     10 - 20      20 - 50      >50Anisocytosis                           0 - 2       3 - 10      10 - 20     20 - 50       >50Acanthocyte                          none       1 - 5         5 - 10     10 - 20        >20Burr Cell                                0 - 2        3 - 10      10 - 20     20 - 50      >50Target cell (codocyte)            0 - 2        3 - 10      10 - 20     20 - 50      >50Tear drop cell (dacryocyte)     0 - 2        2 - 5        5 - 10      10 - 50      >50Sickle Cell (depranocyte)        none   (If present in any number, report as positive.)Elliptocyte/Ovalocyte             0 - 2        2 - 10      10 - 20     20 - 50      >50Helmet cell / Bite cell             none        1 - 5        5 - 10      10 - 20      >20Schistocytes                           none        1 - 5        5 - 10       10 - 20     >20Spherocytes                            0 - 2        2 - 10     10 - 20      20 - 50      >50Stomatocytes                          0 - 2        2 - 10     10 - 20       20 - 50     >50Basophilic stippling                  0 - 1        1 - 5        5 - 10       10 - 20     >20Polychromatophilia, adult         0 - 1       2 - 5        5 - 10       10 - 20     >20Polychromatophilia, infant        1 - 6       7 - 15     15 - 20       20 - 50     >50Howell-Jolly (HoJo) body           none     1 -  2        3 - 5          5 - 10     >10Pappenheimer body (siderocyte) none     1 - 2        3 - 5          5 - 10      >10

RBC abnormalitiesRBC abnormalities

Severe hemolysisSevere hemolysis– Nucleated rbc’sNucleated rbc’s– Schistocytes: helmet cells, triangle cells, bite Schistocytes: helmet cells, triangle cells, bite

cellscells– Spherocytes (immune mediated)Spherocytes (immune mediated)– acanthocytesacanthocytes

RBC InclusionsRBC Inclusions

Howell-Jolly bodiesHowell-Jolly bodies– Nuclear remnants not Nuclear remnants not

extruded from mature extruded from mature erythrocyteserythrocytes

– Indicate splenic Indicate splenic hypofunctionhypofunction

– Seen in Seen in Post-splenectomyPost-splenectomy

LeukemiaLeukemia

Hemolytic Hemolytic

thalassemiathalassemia

RBC InclusionsRBC Inclusions

Basophilic stipplingBasophilic stippling– Caused by aggregated Caused by aggregated

ribosomes in rbcribosomes in rbc– Seen in Seen in

ThalassemiaThalassemia

Lead intoxication Lead intoxication /heavy metal/heavy metal

WBC abnormalitiesWBC abnormalities

Toxic changesToxic changes– Toxic granulesToxic granules– Dohle bodiesDohle bodies

Dark blue cytoplasmic Dark blue cytoplasmic inclusionsinclusions

Seen in neutrophilsSeen in neutrophils

Seen in : infection, Seen in : infection, burns, MDS, pregnancyburns, MDS, pregnancy

– VacuolationsVacuolations

Toxic granulesToxic granules

DOHLE BODIESDOHLE BODIES

remnants of free remnants of free ribosomes of RERribosomes of RER

Single or multiple, Single or multiple, blue, grayish-blue, blue, grayish-blue, or greenish or greenish inclusions.inclusions.

VacuolizationVacuolization

QUIZ SHOWQUIZ SHOW

10 year old with Hb 80, WBC 9 plt 350. 10 year old with Hb 80, WBC 9 plt 350. On co-tri for repeated UTI. MCV 102 On co-tri for repeated UTI. MCV 102 MCH 340 Retic ct 0.002MCH 340 Retic ct 0.002

What is most likely diagnosis ?What is most likely diagnosis ?a.a. Fe deficiencyFe deficiency

b.b. Megaloblastic anemiaMegaloblastic anemia

c.c. Diamond Blackfan AnemiaDiamond Blackfan Anemia

d.d. Hemolytic anemiaHemolytic anemia

AnswerAnswer

BB

MEGALOBLASTICMEGALOBLASTIC

ANEMIAANEMIA

(Prob 2 folate def)(Prob 2 folate def)

The ff is a cause of thrombocytosisThe ff is a cause of thrombocytosis

A. Immune thrombocytopenic purpuraA. Immune thrombocytopenic purpura

B. PregnancyB. Pregnancy

C. Iron deficiency anemiaC. Iron deficiency anemia

D. Renal failureD. Renal failure

ANSWERANSWER

CC

Iron deficiency Iron deficiency anemiaanemia

Compute absolute retic countCompute absolute retic count

Hb 45Hb 45 RBC 1.5 x 10RBC 1.5 x 101212 / L / L

Retic count: 0.016Retic count: 0.016

ANSWERANSWER

24,000 / uL24,000 / uL

4/4 Quiz show4/4 Quiz show

Which presents as a microcytic anemiaWhich presents as a microcytic anemiaA.A. B-thalassemiaB-thalassemia

B.B. Hemolytic AnemiaHemolytic Anemia

C.C. Aplastic AnemiaAplastic Anemia

D.D. Anemia 2 blood lossAnemia 2 blood loss

ANSWERANSWER

AA

B- ThalassemiaB- Thalassemia

Which is the pbs of px with vit B12 Which is the pbs of px with vit B12 deficiency?deficiency?

AnswerAnswer

77

Which is pbs of px with iron Which is pbs of px with iron deficiency?deficiency?

12

AnswerAnswer

1