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CBC Interpretition
 

CBC Interpretition

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    CBC Interpretition CBC Interpretition Presentation Transcript

    • CBC --- Interpretations
    • 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.
    • 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.
      • 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
    • 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.
      • 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
        • 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
      • 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
      • 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
    • 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
    • First Question
      • The onset of Anaemia
      • Acute versus chronic
      • Clues
        • Hemodynamic stability
        • Previous CBC
        • Overt blood loss
    • Types of Anaemia
    • 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%
    • 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
    • PCV or Hematocrit
      • 57% Plasma
      • 1% Buffy coat – WBC
      • 42% Hct (PCV)
    • 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.
    • 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)
    • Anaemia – First Test
      • RETICULOCYTE COUNT %
      Normal Less than 2%
      • ‘ RBC to be’ or Apprentice RBC
      • Fragments of nuclear material
      • RNA strands which stain blue
    • Reticulocytes Leishman’s Supravital
    • Anaemia Hypoproliferative Hemolytic Retics < 2 Retics > 2 Hb% < 12, Hct < 38%
    • Normal CBC
    • 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)
    • 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
    • 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
    • Red cell Distribution Width - RDW Normal Population Uniform RDW High Population Double
    • 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 ?
    • IDA -CBC
    • Microcytic Hypochromic - IDA
    • 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
    • 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
    • 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
    • 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 + + + +
    • 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)
    • 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
    • MBA
    • Macrocytosis -MBA
    • HSN - MBA
    • Basophilic Stippling - MBA BS occurs in Lead poisoning also
    • MBA - BM
    • Pernicious Anaemia - Tongue Bald, smooth, lemon yellowish red tongue
    • Normocytic Anaemias
      • Chronic disease
      • Early IDA
      • Hemoglobinopathies
      • Primary marrow disorders
      • Combined deficiencies
      • Increased destruction
      • Anaemia of investigations -ICU
    • 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
    • ‘ 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
    • RBC Size – Anisocytosis Different sizes of RBC
    • Poikilocytosis Different Shapes of RBC
    • Polychromasia - Spherocytosis
    • Target Cells
      • Liver Disease
      • Thalassemia
      • Hb D Disease
      • Post splenectomy
      • 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
    • 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.
      • 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
      • 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
        • 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
    • 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
        • Eosinophilia may be found in
          • Parasitic infections
          • Allergic conditions and hypersensitivity reaction
      Eosinophil
      • 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
      • 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
    • 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.
      • 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
      • Infection of the mouth and throat.
      • Painful skin ulceration.
      • Recurrent infection.
      • Septicemia.
      Manifestation of leukopenia
    • 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
      •  
      • 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
      • Petechial hemorhage.
      • Easy bruising.
      • Mucosal bleeding
      • e.g. _ epistaxes.
      • _ gum bleeding
      Manifestaton of thrombocytopenia