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CBC Interpretition

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  • 1. CBC --- Interpretations
  • 2. Abstract
    • Interpretation of different parameters reported on modern day analyzers is bit tricky and demand continuous monitoring and on-going learning. In present paper interpretation of different reported parameters has been discussed with approach to diagnosis of various abnormalities.
  • 3. objectives The CBC interpretation are useful in the diagnosis of various types of anemias. It can reflect acute or chronic infection, allergies, and problems with clotting.
  • 4.
    • Component of the CBC:
    • • Red Blood Cells (RBCs) • Hematocrit (Hct) • Hemoglobin (Hgb) • Mean Corpuscular Volume (MCV) • Mean Corpuscular Hemoglobin Concentration (MCHC)
    • - Red cell distribution width (RDW)
    • • White Blood Cells (WBCs) • Platelet
    CBC- complete blood count
  • 5. RBC
    • RBC (varies with altitude):
      • M: 4.7 to 6.1 x10^12 /L
      • F: 4.2 to 5.4 x10^12 /L
    • Biconcave disc shape with diameter
    • of about 8 µm
    • Function : - transport hemoglobin which carries oxygen from the lung to the tissues
    • -acid –base buffer.
    • Life span 100-120 days.
  • 6.
    • Hemoglobin :
      • M: 13.8 to 17.2 gm/dL
      • F: 12.1 to 15.1 gm/dL
    • Hematocrit : ( packed cell volume )
    • It is ratio of the volume of red cell to the volume of whole blood.
      • M: 40.7 to 50.3 %
      • F: 36.1 to 44.3 %
    Hemoglobin & Hematocrit
  • 7.
      • MCV = mean corpuscular volume HCT/RBC count= 80-100fL
        • small = microcytic
        • normal = normocytic
        • large = macrocytic
      • MCHC= mean corpuscular hemoglobin concentration HB/RBC count= 26-34%
        • decreased = hypochromic
        • normal = normochromic
    MCV&MCHC
  • 8.
    • MCH (mean corpuscular hemoglobin)
    • HB/HCT = 27-32 pg
    • RDW (red cell distribution width)
    • It is correlates with the degree of anisocytosis
    • _ Normal range from 10-15%
    MCH & RDW
  • 9.
    • This important value is needed in the evaluation of any anemia.
    • Normal range 1-2% 
    • Retic count goes up with
      • Hemolytic anemia
    • Retic goes down with 
      • Nutritional deficiencies
    • _ Diseases of the bone marrow itself
    The Reticulocyte Count
  • 10. Definition of Anaemia
    • Decrease in the number of circulating red blood cell mass and there by O 2 carrying capacity
    • Most common hematological disorder by far
    • Almost always a secondary disorder
    • As such, critical for all practitioners to know how to evaluate / determine its cause / treat
  • 11. First Question
    • The onset of Anaemia
    • Acute versus chronic
    • Clues
      • Hemodynamic stability
      • Previous CBC
      • Overt blood loss
  • 12. Types of Anaemia
  • 13. Screening Tests – Anaemia
    • Clinical Signs and symptoms of Anaemia
    • Look for bleeding – all possible sites
    • Look for the causes for anemia
    • Routine Hemoglobin examination
    • Cut off marks for Hb –
      • US < 13.5 g WHO < 12.5 g
      • Subcontinent Less than 12 g%
  • 14. Clinical Signs to be looked for
    • Skin / mucosal pallor,
    • Skin dryness, palmar creases
    • Bald tongue, Glossitis
    • Mouth ulcers, Rectal exam
    • Jaundice, Purpura
    • Lymph adenopathy
    • Hepato-splenomegaly
    • Breathlessness
    • Tachycardia, CHF
    • Bleeding, Occult Blood
  • 15. PCV or Hematocrit
    • 57% Plasma
    • 1% Buffy coat – WBC
    • 42% Hct (PCV)
  • 16. The Three Basic Measures
    • Measurement Normal Range
    • RBC count 5 million 4 to 6
    • Hemoglobin 15 g% 12 to 17
    • Hematocrit 45 38 to 50
    • A x 3 = B x 3 = C - This is the rule of thumb
    • Check whether this holds good in given results
    • If not -indicates micro or macrocytosis or hypochromia.
  • 17. Causes of Anaemia
    • Decreased production of Red Cells
      • - Hypoproliferative, marrow failure
    • Increased destruction of Red Cells
      • - Hemolysis (decreased survival of RBC)
    • Loss of Red Cells due to bleeding
      • - Acute / chronic blood loss (hemorrhagic)
  • 18. Anaemia – First Test
    • RETICULOCYTE COUNT %
    Normal Less than 2%
    • ‘ RBC to be’ or Apprentice RBC
    • Fragments of nuclear material
    • RNA strands which stain blue
  • 19. Reticulocytes Leishman’s Supravital
  • 20. Anaemia Hypoproliferative Hemolytic Retics < 2 Retics > 2 Hb% < 12, Hct < 38%
  • 21. Normal CBC
  • 22. Workup – Second Test
    • The next step is ‘What is the size of RBC’ ?
    • MCV indicates the Red cell volume (size)
    • Both the MCH & MCHC tell Hb content of RBC
    • If the Retic count is 2 or less
    • We are dealing with either
      • Hypoproliferative anaemia (lack of raw material)
      • Maturation defect with less production
      • Bone marrow suppression (primary/ secondary)
  • 23. Mean Cell Volume (MCV)
    • RBC volume (rather) is measured by
    • The Mean Cell Volume or MCV and RDW
    Microcytic < 80 fl MCV Normocytic Macrocytic 80 -100 fl > 100 fl < 6.5 µ 6.5 - 9 µ > 9 µ
  • 24. Anaemia Workup - MCV Microcytic MCV Normocytic Macrocytic Iron Deficiency IDA Chronic Infections Thalassemias Hemoglobinopathies Sideroblastic Anemia Chronic disease Early IDA Hemoglobinopathies Primary marrow disorders Combined deficiencies Increased destruction Megaloblastic anemias Liver disease/alcohol Hemoglobinopathies Metabolic disorders Marrow disorders Increased destruction
  • 25. Red cell Distribution Width - RDW Normal Population Uniform RDW High Population Double
  • 26. Anaemia Workup - 4 th Test Peripheral Smear Study
    • Are all RBC of the same size ?
    • Are all RBC of the same normal discoid shape ?
    • How is the colour (Hb content) saturation ?
    • Are all the RBC of same colour/ multi coloured ?
    • Are there any RBC inclusions ?
    • Are intra RBC there any hemo-parasites ?
    • Are leucocytes normal in number and D.C ?
    • Is platelet distribution adequate ?
  • 27. IDA -CBC
  • 28. Microcytic Hypochromic - IDA
  • 29. IDA – Special Tests Iron related tests Normal IDA Serum Ferritin (pmo /L) 33-270 < 33 TIBC ( µg/dL) 300-340 > 400 Serum Iron ( µg/dL) 50-150 < 30 Saturation % 30-50 < 10 Bone marrow Iron ++ Absent
  • 30. IDA Summary
    • Microcytic MCV < 80 fl, RBC < 6 µ
    • RDW Widened with low MCV
    • Hypochromic MCH < 27 pg, MCHC < 30%
    • RI < 2
    • Serum ferritin Very low < 30 (p mols/L)
    • TIBC Increased > 400 (µg/dL)
    • Serum Iron Very low < 30 (µg/dL)
    • BM Fe Stain Absent Fe
    • Response to Fe Rx. Excellent
  • 31. IDA- Some Nuggets
    • Look for occult blood loss – 2 days non veg. free
    • Pica and Pagophagia – Ice sucking
    • Absorption of Haem Iron > Fe ++ > Fe +++
    • Food, Phytates, Ca, Phosphate, antacids ↓ absorption
    • Ascorbic acid ↑ absorption
    • Oral iron Rx. always is the best, ? Carbonyl Fe
    • FeSO 4 is the best. Reserve parenteral Rx.
    • Packed cell transfusion in emergency
    • Continue Fe Rx at least 2 months after normal Hb
    • 1 gram ↑ in Hb every week can be expected
    • Always supplement protein for the Globin component
  • 32. Microcytic Anaemias MCV < 80 fl Serum Iron TIBC BM Perls stain Iron Def. Anemia ↓↓ ↑↑ 0 Chronic Infection ↓↓ ↓↓ + + Thalassemia ↑↑ N + + + + Hemoglobinopathy N N + + Lead poisoning N N + + Sideroblastic ↑↑ N + + + +
  • 33. Macrocytic Anaemias
    • A. Megaloblastic Macrocytic – B12 and Folate ↓
    • B. Non Megaloblastic Macrocytic Anaemias
      • Liver disease/alcohol
      • Hemoglobinopathies
      • Metabolic disorders, Hypothyroidism
      • Myelodystrophy, BM infiltration
      • Accelerated Erythropoesis - ↑ destruction
      • Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants)
  • 34. Anemia - Macrocytic (MCV > 100)
      • Premature gray hair – consider MBA
      • 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 B 12 deficiency
  • 35. MBA
  • 36. Macrocytosis -MBA
  • 37. HSN - MBA
  • 38. Basophilic Stippling - MBA BS occurs in Lead poisoning also
  • 39. MBA - BM
  • 40. Pernicious Anaemia - Tongue Bald, smooth, lemon yellowish red tongue
  • 41. Normocytic Anaemias
    • Chronic disease
    • Early IDA
    • Hemoglobinopathies
    • Primary marrow disorders
    • Combined deficiencies
    • Increased destruction
    • Anaemia of investigations -ICU
  • 42. Anaemia of Chronic Disease
    • Thyroid diseases
    • Malignancy
    • Collagen Vascular Disease
      • Rheumatoid Arthritis
      • SLE
      • Polymyositis
      • Polyarteritis Nodosa
    • IBD
      • – Ulcerative Colitis
      • – Crohn’s Disease
    • Chronic Infections
    • – HIV, Osteomyelitis
    • – Tuberculosis
    • Renal Failure
  • 43. ‘ Dimorphic’ Anaemia
    • Folate & Fe deficiency (pregnancy, alcoholism)
    • B 12 & Fe deficiency (PA with atrophic gastritis)
    • Thalassemia minor & B 12 or folate deficiency
    • Fe deficiency & hemolysis (prosthetic valve)
    • Folate deficiency & hemolysis (Hb SS disease)
    • Peripheral smear exam is critical to assess these
    • RDW is increased very much
  • 44. RBC Size – Anisocytosis Different sizes of RBC
  • 45. Poikilocytosis Different Shapes of RBC
  • 46. Polychromasia - Spherocytosis
  • 47. Target Cells
    • Liver Disease
    • Thalassemia
    • Hb D Disease
    • Post splenectomy
  • 48.
    • WBCs are involved in the immune response.
    • The normal range: 4 – 11x10^9 /L
    • Two types of WBC:
    • 1) Granulocytes consist of:
      • Neutrophils: 50 - 70%
      • Eosinophils: 1 - 5%
      • Basophils: up to 1%
      • 2) Agranulocytes consist of:
    • - Lymphocytes: 20 - 40%
      • Monocytes : 1 - 6%
    WBC
  • 49. WBC
    • The type of cell affected depends upon its primary function:
      • In bacterial infections, neutrophils are most commonly affected
      • In viral infections, lymphocytes are most commonly affected
      • In parasitic infections, eosinophils are most commonly affected.
  • 50.
    • polymorphneuclear leukocytes (PMN,s)
    • Nucleus 3-5 lobes.
    • Diameter 10-14 µm
    • 50-70% WBC
    • =2.5-7.5x10^9/ L
    • Function: Phagocytosis of bacteria and cell debris
    • Numbers rise with all manner of stress, especially bacterial infections
    Neutrophil
  • 51.
    • Neutrophil disorders
      • Neutrophilia – an increase in neutrophils
      • Conditions associated with neutrophilia are:
          • 1-Bacterial infections (most common cause)
          • 2-Tissue destruction
          • e.g. tissue infarctions, burns.
          • 3- leukemoid reaction
          • 4-Leukemia
    Neutrophil
  • 52.
      • Neutropenia – this may result from
        • 1-Decreased bone marrow production
        • e.g. BM hypoplasia.
        • 2-Ineffective bone marrow production
          • E.g. megaloblastic anemias and myelodysplastic syndromes.
    • 3- post acute infection
    • _ e.g. typhoid fever, brucellosis.
    Neutrophil
  • 53. Eosinophil
    • Bilobed nucleus
    • 1-5% of WBC
    • =0.04-0.4x10^9/L
    • Diameter about 10-14 µm
    • Function: Involved in allergy, parasitic infections
    • Contains: eosinophilic granules
  • 54.
      • Eosinophilia may be found in
        • Parasitic infections
        • Allergic conditions and hypersensitivity reaction
    Eosinophil
  • 55.
    • No specific granules
    • 20-40% of WBC
    • =1.55-3.5x10^9/ L
    • Diameter 8-10 µm
    • T cells: cellular
    • (for viral infections)
    • B cells: humoral (antibody)
    • Natural Killer Cells
    Lymphocyte
  • 56.
    • Lymphocytosis – may indicate
          • _ Viral infection
          • e.g. Infectious mononucleosis, CMV or pertussis.
          • _ Bacterial infection
          • e.g. TB
        • Lymphopenia – caused by
        • _Stress.
        • _Steroid therapy
        • _ Irradiation
    Lymphocyte
  • 57. Abnormal result of WBC
    • (Leukocytosis) may indicate:
    • _ Infectious diseases
    • _Inflammatory disease (such as rheumatoid arthritis or allergy)
    • _Leukemia
    • _Severe emotional or physical stress
    • _Tissue damage (e.g. necrosis,or burns)
    • (Leukopenia) may result from:
    • _ Decreased WBC production from BM.
    • _ Irradiation.
    • _ Exposure to chemical or drugs.
  • 58.
    • Fever
    • Malaise
    • Weakness
    • Others depend on each system which is involved
    • e.g. » chest: cough, SOB and chest pain
    • » abdomen: diarrhea, vomiting, dehydration.
    • »CNS: headache, visual disturbance,
    • Neck stiffness
    • and so 0n.
    Manifestation of leukocytosis
  • 59.
    • Infection of the mouth and throat.
    • Painful skin ulceration.
    • Recurrent infection.
    • Septicemia.
    Manifestation of leukopenia
  • 60. Platelets
    • Small granular non-nucleated discs.
    • Diameter about 2-4 µm
    • Nor mal range; 150-300x10^9 /L
    • Destroyed by macrophage cells in the spleen.
    • Function; involved in coagulation and blood haemostasis.
    • Life span 7-10 days
  • 61.
    •  
    • Numbers of platelets
      • Increased (Thrombocythemia)
        • Pregnancy.
        • Exercise.
        • High attitudes.
        • splenectomy
      • Decreased (Thrombocytopenia)
        • Menstruation.
        • Haemorrhage.
        • Bone marrow destruction or suppression e.g. leukemia  
    • The values have to fit the clinical situation.
    Platelets
  • 62.
    • Petechial hemorhage.
    • Easy bruising.
    • Mucosal bleeding
    • e.g. _ epistaxes.
    • _ gum bleeding
    Manifestaton of thrombocytopenia