CBC Interpretition


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CBC Interpretition

  1. 1. CBC --- Interpretations
  2. 2. Abstract <ul><li>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. </li></ul>
  3. 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. 4. <ul><li>Component of the CBC: </li></ul><ul><li>• Red Blood Cells (RBCs) • Hematocrit (Hct) • Hemoglobin (Hgb) • Mean Corpuscular Volume (MCV) • Mean Corpuscular Hemoglobin Concentration (MCHC) </li></ul><ul><li>- Red cell distribution width (RDW) </li></ul><ul><li>• White Blood Cells (WBCs) • Platelet </li></ul>CBC- complete blood count
  5. 5. RBC <ul><li>RBC (varies with altitude): </li></ul><ul><ul><li>M: 4.7 to 6.1 x10^12 /L </li></ul></ul><ul><ul><li>F: 4.2 to 5.4 x10^12 /L </li></ul></ul><ul><li>Biconcave disc shape with diameter </li></ul><ul><li>of about 8 µm </li></ul><ul><li>Function : - transport hemoglobin which carries oxygen from the lung to the tissues </li></ul><ul><li>-acid –base buffer. </li></ul><ul><li>Life span 100-120 days. </li></ul>
  6. 6. <ul><li>Hemoglobin : </li></ul><ul><ul><li>M: 13.8 to 17.2 gm/dL </li></ul></ul><ul><ul><li>F: 12.1 to 15.1 gm/dL </li></ul></ul><ul><li>Hematocrit : ( packed cell volume ) </li></ul><ul><li>It is ratio of the volume of red cell to the volume of whole blood. </li></ul><ul><ul><li>M: 40.7 to 50.3 % </li></ul></ul><ul><ul><li>F: 36.1 to 44.3 % </li></ul></ul>Hemoglobin & Hematocrit
  7. 7. <ul><ul><li>MCV = mean corpuscular volume HCT/RBC count= 80-100fL </li></ul></ul><ul><ul><ul><li>small = microcytic </li></ul></ul></ul><ul><ul><ul><li>normal = normocytic </li></ul></ul></ul><ul><ul><ul><li>large = macrocytic </li></ul></ul></ul><ul><ul><li>MCHC= mean corpuscular hemoglobin concentration HB/RBC count= 26-34% </li></ul></ul><ul><ul><ul><li>decreased = hypochromic </li></ul></ul></ul><ul><ul><ul><li>normal = normochromic </li></ul></ul></ul>MCV&MCHC
  8. 8. <ul><li>MCH (mean corpuscular hemoglobin) </li></ul><ul><li>HB/HCT = 27-32 pg </li></ul><ul><li>RDW (red cell distribution width) </li></ul><ul><li>It is correlates with the degree of anisocytosis </li></ul><ul><li>_ Normal range from 10-15% </li></ul>MCH & RDW
  9. 9. <ul><li>This important value is needed in the evaluation of any anemia. </li></ul><ul><li>Normal range 1-2%  </li></ul><ul><li>Retic count goes up with </li></ul><ul><ul><li>Hemolytic anemia </li></ul></ul><ul><li>Retic goes down with  </li></ul><ul><ul><li>Nutritional deficiencies </li></ul></ul><ul><li>_ Diseases of the bone marrow itself </li></ul>The Reticulocyte Count
  10. 10. Definition of Anaemia <ul><li>Decrease in the number of circulating red blood cell mass and there by O 2 carrying capacity </li></ul><ul><li>Most common hematological disorder by far </li></ul><ul><li>Almost always a secondary disorder </li></ul><ul><li>As such, critical for all practitioners to know how to evaluate / determine its cause / treat </li></ul>
  11. 11. First Question <ul><li>The onset of Anaemia </li></ul><ul><li>Acute versus chronic </li></ul><ul><li>Clues </li></ul><ul><ul><li>Hemodynamic stability </li></ul></ul><ul><ul><li>Previous CBC </li></ul></ul><ul><ul><li>Overt blood loss </li></ul></ul>
  12. 12. Types of Anaemia
  13. 13. Screening Tests – Anaemia <ul><li>Clinical Signs and symptoms of Anaemia </li></ul><ul><li>Look for bleeding – all possible sites </li></ul><ul><li>Look for the causes for anemia </li></ul><ul><li>Routine Hemoglobin examination </li></ul><ul><li>Cut off marks for Hb – </li></ul><ul><ul><li>US < 13.5 g WHO < 12.5 g </li></ul></ul><ul><ul><li>Subcontinent Less than 12 g% </li></ul></ul>
  14. 14. Clinical Signs to be looked for <ul><li>Skin / mucosal pallor, </li></ul><ul><li>Skin dryness, palmar creases </li></ul><ul><li>Bald tongue, Glossitis </li></ul><ul><li>Mouth ulcers, Rectal exam </li></ul><ul><li>Jaundice, Purpura </li></ul><ul><li>Lymph adenopathy </li></ul><ul><li>Hepato-splenomegaly </li></ul><ul><li>Breathlessness </li></ul><ul><li>Tachycardia, CHF </li></ul><ul><li>Bleeding, Occult Blood </li></ul>
  15. 15. PCV or Hematocrit <ul><li>57% Plasma </li></ul><ul><li>1% Buffy coat – WBC </li></ul><ul><li>42% Hct (PCV) </li></ul>
  16. 16. The Three Basic Measures <ul><li>Measurement Normal Range </li></ul><ul><li>RBC count 5 million 4 to 6 </li></ul><ul><li>Hemoglobin 15 g% 12 to 17 </li></ul><ul><li>Hematocrit 45 38 to 50 </li></ul><ul><li>A x 3 = B x 3 = C - This is the rule of thumb </li></ul><ul><li>Check whether this holds good in given results </li></ul><ul><li>If not -indicates micro or macrocytosis or hypochromia. </li></ul>
  17. 17. Causes of Anaemia <ul><li>Decreased production of Red Cells </li></ul><ul><ul><li>- Hypoproliferative, marrow failure </li></ul></ul><ul><li>Increased destruction of Red Cells </li></ul><ul><ul><li>- Hemolysis (decreased survival of RBC) </li></ul></ul><ul><li>Loss of Red Cells due to bleeding </li></ul><ul><ul><li>- Acute / chronic blood loss (hemorrhagic) </li></ul></ul>
  18. 18. Anaemia – First Test <ul><li>RETICULOCYTE COUNT % </li></ul>Normal Less than 2% <ul><li>‘ RBC to be’ or Apprentice RBC </li></ul><ul><li>Fragments of nuclear material </li></ul><ul><li>RNA strands which stain blue </li></ul>
  19. 19. Reticulocytes Leishman’s Supravital
  20. 20. Anaemia Hypoproliferative Hemolytic Retics < 2 Retics > 2 Hb% < 12, Hct < 38%
  21. 21. Normal CBC
  22. 22. Workup – Second Test <ul><li>The next step is ‘What is the size of RBC’ ? </li></ul><ul><li>MCV indicates the Red cell volume (size) </li></ul><ul><li>Both the MCH & MCHC tell Hb content of RBC </li></ul><ul><li>If the Retic count is 2 or less </li></ul><ul><li>We are dealing with either </li></ul><ul><ul><li>Hypoproliferative anaemia (lack of raw material) </li></ul></ul><ul><ul><li>Maturation defect with less production </li></ul></ul><ul><ul><li>Bone marrow suppression (primary/ secondary) </li></ul></ul>
  23. 23. Mean Cell Volume (MCV) <ul><li>RBC volume (rather) is measured by </li></ul><ul><li>The Mean Cell Volume or MCV and RDW </li></ul>Microcytic < 80 fl MCV Normocytic Macrocytic 80 -100 fl > 100 fl < 6.5 µ 6.5 - 9 µ > 9 µ
  24. 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. 25. Red cell Distribution Width - RDW Normal Population Uniform RDW High Population Double
  26. 26. Anaemia Workup - 4 th Test Peripheral Smear Study <ul><li>Are all RBC of the same size ? </li></ul><ul><li>Are all RBC of the same normal discoid shape ? </li></ul><ul><li>How is the colour (Hb content) saturation ? </li></ul><ul><li>Are all the RBC of same colour/ multi coloured ? </li></ul><ul><li>Are there any RBC inclusions ? </li></ul><ul><li>Are intra RBC there any hemo-parasites ? </li></ul><ul><li>Are leucocytes normal in number and D.C ? </li></ul><ul><li>Is platelet distribution adequate ? </li></ul>
  27. 27. IDA -CBC
  28. 28. Microcytic Hypochromic - IDA
  29. 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. 30. IDA Summary <ul><li>Microcytic MCV < 80 fl, RBC < 6 µ </li></ul><ul><li>RDW Widened with low MCV </li></ul><ul><li>Hypochromic MCH < 27 pg, MCHC < 30% </li></ul><ul><li>RI < 2 </li></ul><ul><li>Serum ferritin Very low < 30 (p mols/L) </li></ul><ul><li>TIBC Increased > 400 (µg/dL) </li></ul><ul><li>Serum Iron Very low < 30 (µg/dL) </li></ul><ul><li>BM Fe Stain Absent Fe </li></ul><ul><li>Response to Fe Rx. Excellent </li></ul>
  31. 31. IDA- Some Nuggets <ul><li>Look for occult blood loss – 2 days non veg. free </li></ul><ul><li>Pica and Pagophagia – Ice sucking </li></ul><ul><li>Absorption of Haem Iron > Fe ++ > Fe +++ </li></ul><ul><li>Food, Phytates, Ca, Phosphate, antacids ↓ absorption </li></ul><ul><li>Ascorbic acid ↑ absorption </li></ul><ul><li>Oral iron Rx. always is the best, ? Carbonyl Fe </li></ul><ul><li>FeSO 4 is the best. Reserve parenteral Rx. </li></ul><ul><li>Packed cell transfusion in emergency </li></ul><ul><li>Continue Fe Rx at least 2 months after normal Hb </li></ul><ul><li>1 gram ↑ in Hb every week can be expected </li></ul><ul><li>Always supplement protein for the Globin component </li></ul>
  32. 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. 33. Macrocytic Anaemias <ul><li>A. Megaloblastic Macrocytic – B12 and Folate ↓ </li></ul><ul><li>B. Non Megaloblastic Macrocytic Anaemias </li></ul><ul><ul><li>Liver disease/alcohol </li></ul></ul><ul><ul><li>Hemoglobinopathies </li></ul></ul><ul><ul><li>Metabolic disorders, Hypothyroidism </li></ul></ul><ul><ul><li>Myelodystrophy, BM infiltration </li></ul></ul><ul><ul><li>Accelerated Erythropoesis - ↑ destruction </li></ul></ul><ul><ul><li>Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants) </li></ul></ul>
  34. 34. Anemia - Macrocytic (MCV > 100) <ul><ul><li>Premature gray hair – consider MBA </li></ul></ul><ul><ul><li>Macrocytic anemias may be asymptomatic until </li></ul></ul><ul><ul><li>the Hb is as low as 6 grams </li></ul></ul><ul><li>MCV 100-110 fl </li></ul><ul><ul><li>must look for other causes of macrocytosis </li></ul></ul><ul><li>MCV > 110 fl </li></ul><ul><ul><li>almost always folate or B 12 deficiency </li></ul></ul>
  35. 35. MBA
  36. 36. Macrocytosis -MBA
  37. 37. HSN - MBA
  38. 38. Basophilic Stippling - MBA BS occurs in Lead poisoning also
  39. 39. MBA - BM
  40. 40. Pernicious Anaemia - Tongue Bald, smooth, lemon yellowish red tongue
  41. 41. Normocytic Anaemias <ul><li>Chronic disease </li></ul><ul><li>Early IDA </li></ul><ul><li>Hemoglobinopathies </li></ul><ul><li>Primary marrow disorders </li></ul><ul><li>Combined deficiencies </li></ul><ul><li>Increased destruction </li></ul><ul><li>Anaemia of investigations -ICU </li></ul>
  42. 42. Anaemia of Chronic Disease <ul><li>Thyroid diseases </li></ul><ul><li>Malignancy </li></ul><ul><li>Collagen Vascular Disease </li></ul><ul><ul><li>Rheumatoid Arthritis </li></ul></ul><ul><ul><li>SLE </li></ul></ul><ul><ul><li>Polymyositis </li></ul></ul><ul><ul><li>Polyarteritis Nodosa </li></ul></ul><ul><li>IBD </li></ul><ul><ul><li>– Ulcerative Colitis </li></ul></ul><ul><ul><li>– Crohn’s Disease </li></ul></ul><ul><li>Chronic Infections </li></ul><ul><li> – HIV, Osteomyelitis </li></ul><ul><li> – Tuberculosis </li></ul><ul><li>Renal Failure </li></ul>
  43. 43. ‘ Dimorphic’ Anaemia <ul><li>Folate & Fe deficiency (pregnancy, alcoholism) </li></ul><ul><li>B 12 & Fe deficiency (PA with atrophic gastritis) </li></ul><ul><li>Thalassemia minor & B 12 or folate deficiency </li></ul><ul><li>Fe deficiency & hemolysis (prosthetic valve) </li></ul><ul><li>Folate deficiency & hemolysis (Hb SS disease) </li></ul><ul><li>Peripheral smear exam is critical to assess these </li></ul><ul><li>RDW is increased very much </li></ul>
  44. 44. RBC Size – Anisocytosis Different sizes of RBC
  45. 45. Poikilocytosis Different Shapes of RBC
  46. 46. Polychromasia - Spherocytosis
  47. 47. Target Cells <ul><li>Liver Disease </li></ul><ul><li>Thalassemia </li></ul><ul><li>Hb D Disease </li></ul><ul><li>Post splenectomy </li></ul>
  48. 48. <ul><li>WBCs are involved in the immune response. </li></ul><ul><li>The normal range: 4 – 11x10^9 /L </li></ul><ul><li>Two types of WBC: </li></ul><ul><li>1) Granulocytes consist of: </li></ul><ul><ul><li>Neutrophils: 50 - 70% </li></ul></ul><ul><ul><li>Eosinophils: 1 - 5% </li></ul></ul><ul><ul><li>Basophils: up to 1% </li></ul></ul><ul><ul><li>2) Agranulocytes consist of: </li></ul></ul><ul><li>- Lymphocytes: 20 - 40% </li></ul><ul><ul><li>Monocytes : 1 - 6% </li></ul></ul>WBC
  49. 49. WBC <ul><li>The type of cell affected depends upon its primary function: </li></ul><ul><ul><li>In bacterial infections, neutrophils are most commonly affected </li></ul></ul><ul><ul><li>In viral infections, lymphocytes are most commonly affected </li></ul></ul><ul><ul><li>In parasitic infections, eosinophils are most commonly affected. </li></ul></ul>
  50. 50. <ul><li>polymorphneuclear leukocytes (PMN,s) </li></ul><ul><li>Nucleus 3-5 lobes. </li></ul><ul><li>Diameter 10-14 µm </li></ul><ul><li>50-70% WBC </li></ul><ul><li>=2.5-7.5x10^9/ L </li></ul><ul><li>Function: Phagocytosis of bacteria and cell debris </li></ul><ul><li>Numbers rise with all manner of stress, especially bacterial infections </li></ul>Neutrophil
  51. 51. <ul><li>Neutrophil disorders </li></ul><ul><ul><li>Neutrophilia – an increase in neutrophils </li></ul></ul><ul><ul><li>Conditions associated with neutrophilia are: </li></ul></ul><ul><ul><ul><ul><li>1-Bacterial infections (most common cause) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2-Tissue destruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>e.g. tissue infarctions, burns. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>3- leukemoid reaction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>4-Leukemia </li></ul></ul></ul></ul>Neutrophil
  52. 52. <ul><ul><li>Neutropenia – this may result from </li></ul></ul><ul><ul><ul><li>1-Decreased bone marrow production </li></ul></ul></ul><ul><ul><ul><li>e.g. BM hypoplasia. </li></ul></ul></ul><ul><ul><ul><li>2-Ineffective bone marrow production </li></ul></ul></ul><ul><ul><ul><ul><li>E.g. megaloblastic anemias and myelodysplastic syndromes. </li></ul></ul></ul></ul><ul><li>3- post acute infection </li></ul><ul><li>_ e.g. typhoid fever, brucellosis. </li></ul>Neutrophil
  53. 53. Eosinophil <ul><li>Bilobed nucleus </li></ul><ul><li>1-5% of WBC </li></ul><ul><li>=0.04-0.4x10^9/L </li></ul><ul><li>Diameter about 10-14 µm </li></ul><ul><li>Function: Involved in allergy, parasitic infections </li></ul><ul><li>Contains: eosinophilic granules </li></ul>
  54. 54. <ul><ul><li>Eosinophilia may be found in </li></ul></ul><ul><ul><ul><li>Parasitic infections </li></ul></ul></ul><ul><ul><ul><li>Allergic conditions and hypersensitivity reaction </li></ul></ul></ul>Eosinophil
  55. 55. <ul><li>No specific granules </li></ul><ul><li>20-40% of WBC </li></ul><ul><li>=1.55-3.5x10^9/ L </li></ul><ul><li>Diameter 8-10 µm </li></ul><ul><li>T cells: cellular </li></ul><ul><li>(for viral infections) </li></ul><ul><li>B cells: humoral (antibody) </li></ul><ul><li>Natural Killer Cells </li></ul>Lymphocyte
  56. 56. <ul><li>Lymphocytosis – may indicate </li></ul><ul><ul><ul><ul><li>_ Viral infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>e.g. Infectious mononucleosis, CMV or pertussis. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>_ Bacterial infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>e.g. TB </li></ul></ul></ul></ul><ul><ul><ul><li>Lymphopenia – caused by </li></ul></ul></ul><ul><ul><ul><li>_Stress. </li></ul></ul></ul><ul><ul><ul><li>_Steroid therapy </li></ul></ul></ul><ul><ul><ul><li>_ Irradiation </li></ul></ul></ul>Lymphocyte
  57. 57. Abnormal result of WBC <ul><li>(Leukocytosis) may indicate: </li></ul><ul><li>_ Infectious diseases </li></ul><ul><li>_Inflammatory disease (such as rheumatoid arthritis or allergy) </li></ul><ul><li>_Leukemia </li></ul><ul><li>_Severe emotional or physical stress </li></ul><ul><li>_Tissue damage (e.g. necrosis,or burns) </li></ul><ul><li>(Leukopenia) may result from: </li></ul><ul><li>_ Decreased WBC production from BM. </li></ul><ul><li>_ Irradiation. </li></ul><ul><li>_ Exposure to chemical or drugs. </li></ul>
  58. 58. <ul><li>Fever </li></ul><ul><li>Malaise </li></ul><ul><li>Weakness </li></ul><ul><li>Others depend on each system which is involved </li></ul><ul><li>e.g. » chest: cough, SOB and chest pain </li></ul><ul><li>» abdomen: diarrhea, vomiting, dehydration. </li></ul><ul><li>»CNS: headache, visual disturbance, </li></ul><ul><li>Neck stiffness </li></ul><ul><li>and so 0n. </li></ul>Manifestation of leukocytosis
  59. 59. <ul><li>Infection of the mouth and throat. </li></ul><ul><li>Painful skin ulceration. </li></ul><ul><li>Recurrent infection. </li></ul><ul><li>Septicemia. </li></ul>Manifestation of leukopenia
  60. 60. Platelets <ul><li>Small granular non-nucleated discs. </li></ul><ul><li>Diameter about 2-4 µm </li></ul><ul><li>Nor mal range; 150-300x10^9 /L </li></ul><ul><li>Destroyed by macrophage cells in the spleen. </li></ul><ul><li>Function; involved in coagulation and blood haemostasis. </li></ul><ul><li>Life span 7-10 days </li></ul>
  61. 61. <ul><li>  </li></ul><ul><li>Numbers of platelets </li></ul><ul><ul><li>Increased (Thrombocythemia) </li></ul></ul><ul><ul><ul><li>Pregnancy. </li></ul></ul></ul><ul><ul><ul><li>Exercise. </li></ul></ul></ul><ul><ul><ul><li>High attitudes. </li></ul></ul></ul><ul><ul><ul><li>splenectomy </li></ul></ul></ul><ul><ul><li>Decreased (Thrombocytopenia) </li></ul></ul><ul><ul><ul><li>Menstruation. </li></ul></ul></ul><ul><ul><ul><li>Haemorrhage. </li></ul></ul></ul><ul><ul><ul><li>Bone marrow destruction or suppression e.g. leukemia   </li></ul></ul></ul><ul><li>The values have to fit the clinical situation. </li></ul>Platelets
  62. 62. <ul><li>Petechial hemorhage. </li></ul><ul><li>Easy bruising. </li></ul><ul><li>Mucosal bleeding </li></ul><ul><li>e.g. _ epistaxes. </li></ul><ul><li>_ gum bleeding </li></ul>Manifestaton of thrombocytopenia