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Spurious Augmentation of Mean Corpuscular Hemoglobin Concentration: Facts and Denotations

In everyday practice in hematology laboratories, fake elevated mean corpuscular hemoglobin concentration (MCHC) initiates a logical alert and needs instant corrective action to guarantee the conveyance of the right outcomes to the clinicians. The point of this perspective was to set up a (choice chart). Modern-day hematology instrumentation has become more and more innovative and dependable regarded to spurious MCHC, which may help to prevent inappropriate investigations or treatment.

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Clinical Research in Hematology  •  Vol 3  •  Issue 2  •  2020 8
INTRODUCTION
C
omplete hemogram abnormality identified with
at least one of the deliberate parameters red blood
cells (RBC), hemoglobin (HGB), mean cell volume
(MCV), mean cell hemoglobin (MCH), or hematocrit
(HCT) contributes to abnormal calculated RBC indices,
particularly mean corpuscular hemoglobin concentration
(MCHC). MCHC is one of the most characteristic
irregularities produced by hematology analyzers, alarming
the users about a spurious result. Raised MCHC is an
uncommon event in routine laboratory practice; however,
it should be overseen appropriately.[1]
MCHC is also having
to render and evaluate when validating the complete blood
count test results, as well as troubleshoot where applicable.
In everyday practice, the MCHC limit is determined by
hematological analyzers (Sysmex XB 300, Japan) and is set
at 36.5 g/dl. This “flag” has to be viewed in an accreditation
context to evaluate the accuracy of stated parameters. It
may only be an artifact, or it is a real pathological specimen.
Indeed, different etiologies lead to false outcomes of RBC,
HCT, or HGB estimations: 1 The presence of abnormal
RBC: In cold agglutination or erythrocyte disease, and 2
the presence of abnormal plasma: In lipemic, Icteric, or
hemolytic conditions.[2]
In laboratory practice, this leads to an incorrect reduction
in the number of RBC, a false increase in cell volume, and,
consequently, to wrong erythrocyte indexes.[1]
If acquired
or genetic disorders, a change in erythrocyte volume
homeostasis is observed mainly with dehydration. Water loss
produces diminished cell volume and increased HGB.[3]
In
conclusion, in uncommon instances, increased MCHC can
be found in patients with severe ionic troubles or those who
have been regaled with some drugs.[1]
Normal MCHC does
not preclude lipemia or icterus, just due to plasma opacity/
turbidity may not be high enough to bring the level above
the normal scope, or due to the MCHC is low to start with,
due to iron deficiency for instance.[2]
Increasing the overall
concentration of erythrocytes is one of the useful signs that
alert us to the possibility of hyperlipidemia, or opacity usually
represented resulting from various components. When this
happens, it is necessary to check the credibility of the test
for HBG or MCHC and work to amend it.[3]
In hemolysis,
the RBC count may be falling. Free plasma HGB may have
detected, falsely high HBG, leading to a high MCHC.[1]
PERSPECTIVE ARTICLE
Spurious Augmentation of Mean Corpuscular
Hemoglobin Concentration: Facts and Denotations
Bashir Abdrhman Bashir
Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Sudan
ABSTRACT
In everyday practice in hematology laboratories, fake elevated mean corpuscular hemoglobin concentration (MCHC)
initiates a logical alert and needs instant corrective action to guarantee the conveyance of the right outcomes to the clinicians.
The point of this perspective was to set up a (choice chart). Modern-day hematology instrumentation has become more and
more innovative and dependable regarded to spurious MCHC, which may help to prevent inappropriate investigations or
treatment.
Key words: Choice chart, hematology analyzers, laboratory practice, spurious MCHC
Address for correspondence:
Dr. Bashir Abdrhman Bashir, Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia
College, Sudan.
https://doi.org/10.33309/2639-8354.030202 www.asclepiusopen.com
© 2020 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.
Bashir:Spurious MCHC: Facts and denotations
 Clinical Research in Hematology  •  Vol 3  •  Issue 2  •  2020
CONSIDERATIONS
MCH and MCHC, as good as the MCV, reflect average levels
and may not adequately reflect RBC changes when mixed
RBC populations exist, such as dual RBC populations in
sideroblastic anemia or combined iron deficiency anemia
(decreased MCV and MCH) and megaloblastic anemia
(increased MCV and MCH). An elevated RDW will provide
a hint to the heterogenous red cell size (anisocytosis) and/or
the presence of two red-cell populations, and peripheral blood
smear review can help substantiate the above determinations.
Genuinely increased MCHC usually occurs in hereditary
spherocytosis or some cases homozygous sickle cell disease
or HGB C disease.[4]
Faced with a sample with an MCHC level of ≥36.5 g/dl,
a suspect “flag” appears and the sample must be verified
(plasma aspect, RBC distribution width curve, and presence
or absence of morphological abnormalities of RBC on a blood
smear). The common process of monitoring these samples
is time-consuming and simultaneously delays the report of
genuine outcomes to clinicians.[1]
Curiously, a new version
of the hematology analyzer by the Sysmex organization
proposes new parameters acquired by the optical method such
as RBC-O or HGB-O, in corresponding with the impedance
technique for erythrocyte or photometry for HGB. These new
parameters related to those for reticulocytes may improve the
administration of MCHC 36.5 g/dl.Avariety of actions may
be necessary due to the findings [Figure 1].
Choice Chart
MCHC 36.5 g/dl
MCHC  36.5 g/dl
Look for RBC morphology
RBC clumps
If MCHC gets diminished
+ve -ve
Positive Cryoglobulinemia
Reanalyze  36.5 g/dl – report lower level
Spherocytes  anisocytosis
Direct  indirect coomb’s test
C3 IgG Test for cryoglobulin
If normal RBC morphology
Warm the sample at 37°C  return
perform DCT at 37°C  4°C with IgG  C3
Positive Negative
CAD PCH
Centrifuge the sample
Perform Osmotic fragility
AIHA
Hereditary spherocytosis Hemolysis Lipemia/ Icteric
Replace the plasma by add equal
Volume of diluent
Reanalyze
Redraw
sample
Figure 1: “Choice Tree” defined in case of raised MCHC 36.5 g/dl. Various actions may be needed as a result of the findings,
MCHC: Mean corpuscular hemoglobin concentration, DCT: Direct Coombs test, PCH: Paroxysmal cold hemoglobinuria, AIHA:
Autoimmune hemolytic anemia, IgG: Immunoglobulin gamma, CAD: Cold agglutinin disease
Bashir:Spurious MCHC: Facts and denotations
Clinical Research in Hematology  •  Vol 3  •  Issue 2  •  2020 10
CONCLUSION
Modern-day hematology instrumentation has become
increasinglyadvancedanddependable;however,anawareness
of the spectrum of cell counter-related spurious MCHC
results may serve to prevent inappropriate investigations or
treatment. In this perspective, we propose a “choice chart”
flowchart devoted to the quick management of high MCHC
levels, using a standardized laboratory validation procedure.
Moreover, these were significantly improved the result
delivered to the clinicians and help them in their diagnosis
approach.
REFERENCES
1.	 Godon A, Genevieve F, Marteau-Tessier A, Zandecki M.
Automated hematology analysers and spurious counts
Part 3. Haemoglobin, red blood cells, cell count and indices,
reticulocytes. Ann Biol Clin 2012;70:155-68.
2.	 Berentsen S, Tjønnfjord GE. Diagnosis andtreatment of cold
agglutinin mediatedautoimmune hemolytic anemia. Blood Rev
2012;26:107-15.
3.	 Haddad BY, Faure C, Boubaya M, Arpin M, Cointe S,
Frankel D, et al. Increased meancorpuscular haemoglobin
concentration: Artefactor pathological condition? Int J Lab
Hem 2017;39:32-41.
4.	 Elghetany MT, Banki K. Erythrocytic disorders. In:
McPherson RA, Pincus MR, editors. Henry’s Clinical
Diagnosis and Management by Laboratory Methods. 22nd
ed.
Philadelphia, PA: Sauders, Elsevier Inc.; 2011. p. 557-600.
How to cite this article: Bashir BA. Spurious
Augmentation of Mean Corpuscular Hemoglobin
Concentration: Facts and Denotations. Clin Res Hematol
2020;3(2):8-10.
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Spurious Augmentation of Mean Corpuscular Hemoglobin Concentration: Facts and Denotations

  • 1. Clinical Research in Hematology  •  Vol 3  •  Issue 2  •  2020 8 INTRODUCTION C omplete hemogram abnormality identified with at least one of the deliberate parameters red blood cells (RBC), hemoglobin (HGB), mean cell volume (MCV), mean cell hemoglobin (MCH), or hematocrit (HCT) contributes to abnormal calculated RBC indices, particularly mean corpuscular hemoglobin concentration (MCHC). MCHC is one of the most characteristic irregularities produced by hematology analyzers, alarming the users about a spurious result. Raised MCHC is an uncommon event in routine laboratory practice; however, it should be overseen appropriately.[1] MCHC is also having to render and evaluate when validating the complete blood count test results, as well as troubleshoot where applicable. In everyday practice, the MCHC limit is determined by hematological analyzers (Sysmex XB 300, Japan) and is set at 36.5 g/dl. This “flag” has to be viewed in an accreditation context to evaluate the accuracy of stated parameters. It may only be an artifact, or it is a real pathological specimen. Indeed, different etiologies lead to false outcomes of RBC, HCT, or HGB estimations: 1 The presence of abnormal RBC: In cold agglutination or erythrocyte disease, and 2 the presence of abnormal plasma: In lipemic, Icteric, or hemolytic conditions.[2] In laboratory practice, this leads to an incorrect reduction in the number of RBC, a false increase in cell volume, and, consequently, to wrong erythrocyte indexes.[1] If acquired or genetic disorders, a change in erythrocyte volume homeostasis is observed mainly with dehydration. Water loss produces diminished cell volume and increased HGB.[3] In conclusion, in uncommon instances, increased MCHC can be found in patients with severe ionic troubles or those who have been regaled with some drugs.[1] Normal MCHC does not preclude lipemia or icterus, just due to plasma opacity/ turbidity may not be high enough to bring the level above the normal scope, or due to the MCHC is low to start with, due to iron deficiency for instance.[2] Increasing the overall concentration of erythrocytes is one of the useful signs that alert us to the possibility of hyperlipidemia, or opacity usually represented resulting from various components. When this happens, it is necessary to check the credibility of the test for HBG or MCHC and work to amend it.[3] In hemolysis, the RBC count may be falling. Free plasma HGB may have detected, falsely high HBG, leading to a high MCHC.[1] PERSPECTIVE ARTICLE Spurious Augmentation of Mean Corpuscular Hemoglobin Concentration: Facts and Denotations Bashir Abdrhman Bashir Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Sudan ABSTRACT In everyday practice in hematology laboratories, fake elevated mean corpuscular hemoglobin concentration (MCHC) initiates a logical alert and needs instant corrective action to guarantee the conveyance of the right outcomes to the clinicians. The point of this perspective was to set up a (choice chart). Modern-day hematology instrumentation has become more and more innovative and dependable regarded to spurious MCHC, which may help to prevent inappropriate investigations or treatment. Key words: Choice chart, hematology analyzers, laboratory practice, spurious MCHC Address for correspondence: Dr. Bashir Abdrhman Bashir, Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Sudan. https://doi.org/10.33309/2639-8354.030202 www.asclepiusopen.com © 2020 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.
  • 2. Bashir:Spurious MCHC: Facts and denotations Clinical Research in Hematology  •  Vol 3  •  Issue 2  •  2020 CONSIDERATIONS MCH and MCHC, as good as the MCV, reflect average levels and may not adequately reflect RBC changes when mixed RBC populations exist, such as dual RBC populations in sideroblastic anemia or combined iron deficiency anemia (decreased MCV and MCH) and megaloblastic anemia (increased MCV and MCH). An elevated RDW will provide a hint to the heterogenous red cell size (anisocytosis) and/or the presence of two red-cell populations, and peripheral blood smear review can help substantiate the above determinations. Genuinely increased MCHC usually occurs in hereditary spherocytosis or some cases homozygous sickle cell disease or HGB C disease.[4] Faced with a sample with an MCHC level of ≥36.5 g/dl, a suspect “flag” appears and the sample must be verified (plasma aspect, RBC distribution width curve, and presence or absence of morphological abnormalities of RBC on a blood smear). The common process of monitoring these samples is time-consuming and simultaneously delays the report of genuine outcomes to clinicians.[1] Curiously, a new version of the hematology analyzer by the Sysmex organization proposes new parameters acquired by the optical method such as RBC-O or HGB-O, in corresponding with the impedance technique for erythrocyte or photometry for HGB. These new parameters related to those for reticulocytes may improve the administration of MCHC 36.5 g/dl.Avariety of actions may be necessary due to the findings [Figure 1]. Choice Chart MCHC 36.5 g/dl MCHC 36.5 g/dl Look for RBC morphology RBC clumps If MCHC gets diminished +ve -ve Positive Cryoglobulinemia Reanalyze 36.5 g/dl – report lower level Spherocytes anisocytosis Direct indirect coomb’s test C3 IgG Test for cryoglobulin If normal RBC morphology Warm the sample at 37°C return perform DCT at 37°C 4°C with IgG C3 Positive Negative CAD PCH Centrifuge the sample Perform Osmotic fragility AIHA Hereditary spherocytosis Hemolysis Lipemia/ Icteric Replace the plasma by add equal Volume of diluent Reanalyze Redraw sample Figure 1: “Choice Tree” defined in case of raised MCHC 36.5 g/dl. Various actions may be needed as a result of the findings, MCHC: Mean corpuscular hemoglobin concentration, DCT: Direct Coombs test, PCH: Paroxysmal cold hemoglobinuria, AIHA: Autoimmune hemolytic anemia, IgG: Immunoglobulin gamma, CAD: Cold agglutinin disease
  • 3. Bashir:Spurious MCHC: Facts and denotations Clinical Research in Hematology  •  Vol 3  •  Issue 2  •  2020 10 CONCLUSION Modern-day hematology instrumentation has become increasinglyadvancedanddependable;however,anawareness of the spectrum of cell counter-related spurious MCHC results may serve to prevent inappropriate investigations or treatment. In this perspective, we propose a “choice chart” flowchart devoted to the quick management of high MCHC levels, using a standardized laboratory validation procedure. Moreover, these were significantly improved the result delivered to the clinicians and help them in their diagnosis approach. REFERENCES 1. Godon A, Genevieve F, Marteau-Tessier A, Zandecki M. Automated hematology analysers and spurious counts Part 3. Haemoglobin, red blood cells, cell count and indices, reticulocytes. Ann Biol Clin 2012;70:155-68. 2. Berentsen S, Tjønnfjord GE. Diagnosis andtreatment of cold agglutinin mediatedautoimmune hemolytic anemia. Blood Rev 2012;26:107-15. 3. Haddad BY, Faure C, Boubaya M, Arpin M, Cointe S, Frankel D, et al. Increased meancorpuscular haemoglobin concentration: Artefactor pathological condition? Int J Lab Hem 2017;39:32-41. 4. Elghetany MT, Banki K. Erythrocytic disorders. In: McPherson RA, Pincus MR, editors. Henry’s Clinical Diagnosis and Management by Laboratory Methods. 22nd ed. Philadelphia, PA: Sauders, Elsevier Inc.; 2011. p. 557-600. How to cite this article: Bashir BA. Spurious Augmentation of Mean Corpuscular Hemoglobin Concentration: Facts and Denotations. Clin Res Hematol 2020;3(2):8-10.