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WBC Composite Histogram
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...
Histograms are graphic representation of
cell frequencies verses size.
Histogram provide information about
erythrocytes ,l...
Produced from thousands/millions of
signals generated by the cells passing
through detector where they are
differentiated ...
3-part differential usually cont
Granulocytes or large cells
Lymphocytes or small cells
Monocytes(mononuclear cells) or (m...
A sixth category designated “large unstained
cells” include cells larger than normal and lack the
peroxidase activity thi...
Hematology analyzer provide mathematical
results obtained by electrical and light
signals generated when blood cells pass
...
Cell counting
Coulter Principle
Dilution
Vacuum and
pressure
Electrical
impedance
Reagent systems
Sensing Zone
Red Blood Cell
The Coulter PrincipleThe Coulter Principle
A red cell
passes through
RBC aperture
Oscilloscope
Sensing Zone
Neutrophil
Oscilloscope
The Coulter PrincipleThe Coulter Principle
A white cell
passes through
WBC aperture
Before adding lysing reagent After
Cell diameter in μm fl
Neutrophils 10 - 15 120 - 250
Basophils 9 - 14 70 - 130
Eosinoph...
Discriminations thresholds
Platelet- with a volume of 8-12 fl are
counted from 2-30 fl.
RBC- with volume of 80-100 fl is d...
Normal Histogram
Threeparts differential whitebloodcells:
30 to 125µ3 : lymphocytes
125 to 160µ3 : monocyte
160 to 450 µ3 ...
WBC Composite Histogram
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70.0
80.0
90.0
0 50 100 150 200 250 300 350 400 450 500
Channel
...
Eos
Baso
Coulter WBC Histogram
Lymphs
30 – 90
fL
Monos
90 -160
fL
Neuts
160 - 450
fL
RBC HISTOGRAM
NORMALNORMAL
RBC HISTOGRAM
FRAGMENTS, MICROCYTIC RBCs, Giant PLTRAGMENTS, MICROCYTIC RBCs, Giant PLTDI RBCsDI RBCs
MACROCYTIC, TARGET C...
PLT HISTOGRAMS
NORMALNORMAL
PLT HISTOGRAMS
Giant Platelets
Small Platelets
WBC HISTOGRAMS
ImmNE2 Eosinophilia
ImmNE1 & ImmNE2
Blasts
Lymphocytosis
ImmNE1 = band forms ImmNE2 = immature neutrophils :
WBC
WBC Adults 4-10 x 103/μl
Childs till 12 x 103/μl
Newborns till 15 x 103/μl
Lymph. Adults -25-40 %
Childs, Newborns- till 70 %
MXD - Adults 3-13 %
Neutro. - Adults 50-70 %
Red Blood Cell Count
RBC Men 4.6-6.2 x 106/μl
Women 4.2-5.4 x 106/μl
HGB Men 14-18 g/dl
Women 12-16 g/dl
HCT Men 43-49 %
W...
MCV- 85-95 fl
MCH -27-33 pg
MCHC- 32-36 g/dl
RDW-SD 37-46 fl (Width in 20% of the Peak
hight)
RDW-CV 11-16 % (calc. width ...
PLATELET
PLT 150-400 x 103/μl x 109/l
PDW 9-14 fl (Width in 20% of the Peak hight)
MPV 8-12 fl
P-LCR 15-35 %
Anemia is not yet apparent
MCV still is in the normal
range
Peripheral Smearshows mild
Anisocytosis
BUT
RDWis increased (E...
Anemia is present, MCV is
very low, and the smearis
very abnormal
RDWis abnormally high;
Histogram remains abnormal.
The d...
The red cell count is
increasing,
MCV is not yet normal,
and
Two populations of red
cells are seen-preexisting
microcytes,...
EARLY FOLATE
DEFICIENCY-
• The MCV is still normal RBC
count and Hb slightly reduced
but
• RDW is clearly increased ,
even...
Normocytic recovery
a small peakof cells in the
normal range
• RDWis higherthan untreated
megaloblastic anemia due to
two ...
Case -
12 yrold boy with purpura,
marked pallor, fever
•Pancytopenia
•MCV 100.5, RDW15.9%
•RBC histogram skewed to
right
•...
Case -
WBC
LYM%
MXD%
NEUT%
+ 23.8 x 109/L
8.1%
7.9%
84.0%
Case -
WBC 7.9 x 109/L
LYM% + 64.7%
MXD% 15.8%
NEUT% – 19.5%
Case
WBC 7.7 x 109/L
LYM% F1 * 13.2%
MXD% F2 * 37.7%
NEUT% 49.1%
Case
WBC 4.3 x 109/L
LYM% 18,3%
MXD% + 62,2%
NEUT% 19.5%
Case -
Case
WBC 2.3 x 109/L
LYM% 39.7%
MXD% 32.2%
NEUT% 28.1%
Case -6
RBC 4.48 x1012/L
HGB 8.8g/dl
HCT 29.3%
MCV 65.4fl
MCH 19.6pg
MCHC 30.0g/dl
RDW-CV 18.2%
Case-
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
1.64 x1012/L
6.2g/dl
18.2%
110.0fl
37.8pg
34.1g/dl
15.2%
Case
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
4.15 x1012/L
14.0g/dl
40.8%
98.3fl
33.7pg
34.3g/dl
22.7%
Anisocytosis
Case
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
3.62 x1012/L
11.1g/dl
31.9%
88.1fl
30.7pg
34.8g/dl
+ 25.5%
Poikilocytosis
Case
PLT
PDW
MPV
P-LCR
71 x109/L
PU
DW
DW
Giant platelet
Although the wide distribution on the PLT
histogram suggests the appearance of large
platelets, the distribution curve int...
Case
WBC
LYM%
MXD%
NEUT %
PLT
PDW
MPV
P-LCR
6.0 x109/L
27.5%
7.9%
64.4%
86 x109/L
18.6fl
12.8fl
43.7%
Platelet Aggregation
The smear clearly shows that platelets are
aggregating. The WBC histogram shows a
peak in the ghost a...
Case
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
2.23 x1012/L
14.4g/dl
24.9%
111.7fl
64.6pg
57.8g/dl
25.4fl
Cold Agglutinins
Incubation 30 min
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
4.35 x1012/L
14.5g/dl
43.5%
100.0fl
33.3pg
33.3g/dl
14.7fl
Because in this case erythrocytes have
passed through the detector as clusters of
several cells, the RBC, HCT,MCH, MCV,
MC...
Case
WBC
LYM%
MXD%
NEUT %
49.4 x109/L
-.---
-.---
-.---
Insufficient Lysing of Erythrocytes
The histogram show On the WBC
histogram the distribution curve intersects
the WBC lower discrimination line at an
abnormal...
This is frequently seen with blood samples
taken from hepatic disease patients or
newborns. These problems are solved by
d...
RL: Abnormal height at lower discriminator
of RBC Histogram (LD)
RU: Abnormal height at upper discriminator
of RBC Histogr...
WL: Abnormal height at lower discriminator
of WBC Histogram (LD)
WU: Abnormal height at upper
discriminator of WBC Histogr...
PL: Abnormal height at lower discriminator
of PLT Histogram (LD)
PU: Abnormal height at upper discriminator
of PLT Histogr...
Mark “ RL “, abnormal height
at lower discriminator
Possible causes:
• Giant Platelets
• Micro-Erythrocytes
• Platelet Clu...
Mark “ RU “, abnormal height at the upper
discriminator
Possible causes:
Cold Agglutinins (check MCHC > 40 g/dl)
Erythrobl...
MP “, multiple peaks found
Possible causes:
Iron deficiency in therapy
Infection or Tumor Anemia (visceral iron
deficiency...
“DW “, abnormal histogram distribution
Distribution curve does not cross 20% level
twice.
The overall height of the curve ...
Thrombocyte-Histogram
MPV (mean PLT volume) Ref range: 8 - 12 fl
P-LCR (ratio of large platelets)
Ref range: 15 - 35 %
Inc...
PDW, (platelet distribution width at 20 % of
peak height Ref range: 9 - 14 fl
Increase could be a sign for:
PLT Clumps
Mic...
Mark “ PL “, abnormal height at lower
discriminator
Possible cause:
High blank value
Cell fragments
Mark “ PU “, abnormal height at upper
discriminator
Possible Cause :
• PLT Clumps EDTA-Incombatibility Clotted
sample
• Gi...
Mark “ MP “, Multi Peaks found
Possible Cause:
Platelet transfusion
Mark “ DW “, Distribution With
The distribution can not be detected
because the Histogram does not cross the
20 % limit tw...
Leukocyte-Histogram
Flag “ WL “, Curve does not begin at the basis line
Possible causes :
• PLT Clumps EDTA-
Incombatibili...
RBC Histogram
ABN / INDICATOR PROBABLE CAUSE COMMENT
Left of curve does
not touch baseline
Schistocytes and
extremely smal...
WBC Histogram
ABN / INDICATOR PROBABLE CAUSE COMMENT
Trail extending downward
at extreme left, or lymph
peak not starting ...
WBC Histogram
ABN / INDICATOR PROBABLE CAUSE COMMENT
WBC histogram
(lymph peak) does
not start at baseline
Giant platelets...
Platelet Histogram
ABN / INDICATOR PROBABLE CAUSE COMMENT
Peak or spike at left
end of histogram (2-
8 fl)
Cytoplasmic
fra...
R1- RBC precursors, Giant or clumped
platelets, cryoglobulins.
R2- Blast, basophilia, eosinophilia,
monocytosis,plasma cel...
CONCLUSION
Histogram in conjunction with absolute
counts give valuable information about the
abnormality of the sample & t...
Take home messages
Shapes of histograms identified pathology
before the blood smear could be examined.
Newer parameter lik...
Histograms Interpretation
LYMPH% 31,2 %
MXD% 6,8 %
NEUT% 62,0 %
LYMPH# 1,8 x103
/µl
MXD# 0,4 x103
/µl
NEUT# 3,6 x103
/µl
2...
Known interfering substance
RBCs
• High WBCs esp if RBCs is low →
↑RBCs
• Agglutinated RBCs → ↓ RBCs
Hb
Turbidity of the b...
MCV
Red cell agglutination
↑ number of large platelets
HT
Red cell agglutination
RDW
Agglutination of RBCs
Nutritiona...
WBCs interferring subs.
Normoblasts → ↑ WBCs
Unlysed RBCs → ↑ WBCs
MM → ↑ WBCs (ppt protein)
Hemolysis → ↑ WBCs (red c...
Platelets
RBCs fragments → ↑ plat (microcytes)
WBCs fragments → ↑ plat (microcytes)
Chemotherapy → ↓ plat (↑ plat. frag...
Lymphocytes
Nucleated RBCs → ↑ lymph
Parasites → ↑ lymph
Resistent RBCs → ↑ lymph
Monocytes
↑ in large lymphocytes, at...
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
 CBC Histogram DR NARMADA PRASAD TIWARI
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CBC Histogram DR NARMADA PRASAD TIWARI

HISTOGRAM

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CBC Histogram DR NARMADA PRASAD TIWARI

  1. 1. WBC Composite Histogram 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 0 50 100 150 200 250 300 350 400 450 500 Channel Count INTERPRETATION OF HISTOGRAM
  2. 2. Histograms are graphic representation of cell frequencies verses size. Histogram provide information about erythrocytes ,leukocytes and platelet frequency and distribution as well as presence of subpopulation. Shift in one direction or another can be of diagnostic importance.
  3. 3. Produced from thousands/millions of signals generated by the cells passing through detector where they are differentiated by: Their size Frequency of occurrence in the population
  4. 4. 3-part differential usually cont Granulocytes or large cells Lymphocytes or small cells Monocytes(mononuclear cells) or (middle cells) 5-part classify cells to Neutrophils Eosinophils Basophils Lymphocytes Monocytes
  5. 5. A sixth category designated “large unstained cells” include cells larger than normal and lack the peroxidase activity this include ◦ Atypical lymphocytes ◦ Various other abnormal cells. Other counters identifies 7 categories including ◦ Large immature cells(composed of blasts and immature granulocytes) ◦ Atypical lymphocytes(including blast cells).
  6. 6. Hematology analyzer provide mathematical results obtained by electrical and light signals generated when blood cells pass through sensing zone of the machine. Two method- 1- electrical impedance counting 2- light scatter method.
  7. 7. Cell counting Coulter Principle Dilution Vacuum and pressure Electrical impedance Reagent systems
  8. 8. Sensing Zone Red Blood Cell The Coulter PrincipleThe Coulter Principle A red cell passes through RBC aperture Oscilloscope
  9. 9. Sensing Zone Neutrophil Oscilloscope The Coulter PrincipleThe Coulter Principle A white cell passes through WBC aperture
  10. 10. Before adding lysing reagent After Cell diameter in μm fl Neutrophils 10 - 15 120 - 250 Basophils 9 - 14 70 - 130 Eosinophils 11 - 16 80 - 140 Monocytes 12 - 20 60 - 120 Lymphocytes 7 – 12 30 - 80
  11. 11. Discriminations thresholds Platelet- with a volume of 8-12 fl are counted from 2-30 fl. RBC- with volume of 80-100 fl is detected from 30 -250 fl. WBC- RBC are lysed by lytic reagent .the different WBC discriminator set at different levels between the ranges of 30-450 fl.
  12. 12. Normal Histogram Threeparts differential whitebloodcells: 30 to 125µ3 : lymphocytes 125 to 160µ3 : monocyte 160 to 450 µ3 : granulocytes
  13. 13. WBC Composite Histogram 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 0 50 100 150 200 250 300 350 400 450 500 Channel Count
  14. 14. Eos Baso Coulter WBC Histogram Lymphs 30 – 90 fL Monos 90 -160 fL Neuts 160 - 450 fL
  15. 15. RBC HISTOGRAM NORMALNORMAL
  16. 16. RBC HISTOGRAM FRAGMENTS, MICROCYTIC RBCs, Giant PLTRAGMENTS, MICROCYTIC RBCs, Giant PLTDI RBCsDI RBCs MACROCYTIC, TARGET CELLS, DI RMACROCYTIC, TARGET CELLS, DI RB COLDAGGLUTININCOLDAGGLUTININ Post TransfusionPost Transfusion
  17. 17. PLT HISTOGRAMS NORMALNORMAL
  18. 18. PLT HISTOGRAMS Giant Platelets Small Platelets
  19. 19. WBC HISTOGRAMS ImmNE2 Eosinophilia ImmNE1 & ImmNE2 Blasts Lymphocytosis ImmNE1 = band forms ImmNE2 = immature neutrophils :
  20. 20. WBC WBC Adults 4-10 x 103/μl Childs till 12 x 103/μl Newborns till 15 x 103/μl
  21. 21. Lymph. Adults -25-40 % Childs, Newborns- till 70 % MXD - Adults 3-13 % Neutro. - Adults 50-70 %
  22. 22. Red Blood Cell Count RBC Men 4.6-6.2 x 106/μl Women 4.2-5.4 x 106/μl HGB Men 14-18 g/dl Women 12-16 g/dl HCT Men 43-49 % Women 36-46 %
  23. 23. MCV- 85-95 fl MCH -27-33 pg MCHC- 32-36 g/dl RDW-SD 37-46 fl (Width in 20% of the Peak hight) RDW-CV 11-16 % (calc. width of the 68 % Peak hight)
  24. 24. PLATELET PLT 150-400 x 103/μl x 109/l PDW 9-14 fl (Width in 20% of the Peak hight) MPV 8-12 fl P-LCR 15-35 %
  25. 25. Anemia is not yet apparent MCV still is in the normal range Peripheral Smearshows mild Anisocytosis BUT RDWis increased (Earliest Indicator) Histogramis Unimodal but is wider Increased RDWcombined with normal RBC values (MCV , Hb , Hct ) distinguishes
  26. 26. Anemia is present, MCV is very low, and the smearis very abnormal RDWis abnormally high; Histogram remains abnormal. The diagnosis is easily made at this point, but earlier identification would improve management
  27. 27. The red cell count is increasing, MCV is not yet normal, and Two populations of red cells are seen-preexisting microcytes, and newly formed normocytes. Thetwo populations are distinguishedeasilyonthe redcell histogrambut not so easilyontheperipheral bloodsmear.
  28. 28. EARLY FOLATE DEFICIENCY- • The MCV is still normal RBC count and Hb slightly reduced but • RDW is clearly increased , even before apparent anemia. SEVERE FOLATE DEFICIENCY – • RBC Count is low. • MCV is high. •RDW is increased
  29. 29. Normocytic recovery a small peakof cells in the normal range • RDWis higherthan untreated megaloblastic anemia due to two cell population contributing to the heterogeneity. Microcytic recovery Two Cell population is clearly seen in this histogram– old macrocytes and newly produced microcytes . Concomitant iron deficiency has been unmasked. RDWis markedly increased..
  30. 30. Case - 12 yrold boy with purpura, marked pallor, fever •Pancytopenia •MCV 100.5, RDW15.9% •RBC histogram skewed to right •WBC histogram: lymphocyte peak, faint dome of neutrophils •PLT histogram- abn shape,descending slope not touching baseline •BMBx confirmed AA
  31. 31. Case - WBC LYM% MXD% NEUT% + 23.8 x 109/L 8.1% 7.9% 84.0%
  32. 32. Case - WBC 7.9 x 109/L LYM% + 64.7% MXD% 15.8% NEUT% – 19.5%
  33. 33. Case WBC 7.7 x 109/L LYM% F1 * 13.2% MXD% F2 * 37.7% NEUT% 49.1%
  34. 34. Case WBC 4.3 x 109/L LYM% 18,3% MXD% + 62,2% NEUT% 19.5%
  35. 35. Case -
  36. 36. Case WBC 2.3 x 109/L LYM% 39.7% MXD% 32.2% NEUT% 28.1%
  37. 37. Case -6 RBC 4.48 x1012/L HGB 8.8g/dl HCT 29.3% MCV 65.4fl MCH 19.6pg MCHC 30.0g/dl RDW-CV 18.2%
  38. 38. Case- RBC HGB HCT MCV MCH MCHC RDW 1.64 x1012/L 6.2g/dl 18.2% 110.0fl 37.8pg 34.1g/dl 15.2%
  39. 39. Case RBC HGB HCT MCV MCH MCHC RDW 4.15 x1012/L 14.0g/dl 40.8% 98.3fl 33.7pg 34.3g/dl 22.7%
  40. 40. Anisocytosis
  41. 41. Case RBC HGB HCT MCV MCH MCHC RDW 3.62 x1012/L 11.1g/dl 31.9% 88.1fl 30.7pg 34.8g/dl + 25.5%
  42. 42. Poikilocytosis
  43. 43. Case PLT PDW MPV P-LCR 71 x109/L PU DW DW
  44. 44. Giant platelet
  45. 45. Although the wide distribution on the PLT histogram suggests the appearance of large platelets, the distribution curve intersects the discrimination line at a high point
  46. 46. Case WBC LYM% MXD% NEUT % PLT PDW MPV P-LCR 6.0 x109/L 27.5% 7.9% 64.4% 86 x109/L 18.6fl 12.8fl 43.7%
  47. 47. Platelet Aggregation The smear clearly shows that platelets are aggregating. The WBC histogram shows a peak in the ghost area ( ) , PLT histogram shows a wide distribution. Although these large particles usually affect the leucocyte counts, the leukocytes distribution of case 1 is well separated from the ghost area on the WBC histogram, probably without any effect of small particles in the ghost area. There is no WL Alarm given .
  48. 48. Case RBC HGB HCT MCV MCH MCHC RDW 2.23 x1012/L 14.4g/dl 24.9% 111.7fl 64.6pg 57.8g/dl 25.4fl
  49. 49. Cold Agglutinins
  50. 50. Incubation 30 min RBC HGB HCT MCV MCH MCHC RDW 4.35 x1012/L 14.5g/dl 43.5% 100.0fl 33.3pg 33.3g/dl 14.7fl
  51. 51. Because in this case erythrocytes have passed through the detector as clusters of several cells, the RBC, HCT,MCH, MCV, MCHC and RDW values are abnormal. The RBC histogram shows a second peak. After the clusters have been dissolved by incubation, all erythrocytes aredetected as single cells. Therefore the second peak on the RBC histogram doesnot appear and the RBC, HCT, MCV, MCH, MCHC and RDW values are
  52. 52. Case WBC LYM% MXD% NEUT % 49.4 x109/L -.--- -.--- -.---
  53. 53. Insufficient Lysing of Erythrocytes
  54. 54. The histogram show On the WBC histogram the distribution curve intersects the WBC lower discrimination line at an abnormally high point.
  55. 55. This is frequently seen with blood samples taken from hepatic disease patients or newborns. These problems are solved by diluting the sample or replacing plasma with cellpack. The smear photo shows large platelets and acantocytes, suggesting hepatic diseases
  56. 56. RL: Abnormal height at lower discriminator of RBC Histogram (LD) RU: Abnormal height at upper discriminator of RBC Histogram (UD) MP: Multiple peaks: Distinguish ?? of two RBC Populations DW:The distribution (RDW) can not be detected because the Histogram does not cross the 20 % limit twice
  57. 57. WL: Abnormal height at lower discriminator of WBC Histogram (LD) WU: Abnormal height at upper discriminator of WBC Histogram (UD) T1: Valley 1 not found T2: Valley 2 not found F1, F2, F3: Abnormal height at the points T1 or T2; adjacent fractions are marked
  58. 58. PL: Abnormal height at lower discriminator of PLT Histogram (LD) PU: Abnormal height at upper discriminator of PLT Histogram (UD) MP: Multiple Peaks found DW:The distribution (PDW) can not be detected because the Histogram does not cross the 20 % limit twice
  59. 59. Mark “ RL “, abnormal height at lower discriminator Possible causes: • Giant Platelets • Micro-Erythrocytes • Platelet Clumps
  60. 60. Mark “ RU “, abnormal height at the upper discriminator Possible causes: Cold Agglutinins (check MCHC > 40 g/dl) Erythroblasts / Normoblasts
  61. 61. MP “, multiple peaks found Possible causes: Iron deficiency in therapy Infection or Tumor Anemia (visceral iron deficiency) Transfusions
  62. 62. “DW “, abnormal histogram distribution Distribution curve does not cross 20% level twice. The overall height of the curve is always 100 %. The width is calculated on the 20 % height of the curve. Hint for extreme Aniso- or. Poikilocytosis
  63. 63. Thrombocyte-Histogram MPV (mean PLT volume) Ref range: 8 - 12 fl P-LCR (ratio of large platelets) Ref range: 15 - 35 % Increase could be a sign for: • PLT Clumps • Giant PLT • Microerythrocytes
  64. 64. PDW, (platelet distribution width at 20 % of peak height Ref range: 9 - 14 fl Increase could be a sign for: PLT Clumps Microerythrocytes Fragments
  65. 65. Mark “ PL “, abnormal height at lower discriminator Possible cause: High blank value Cell fragments
  66. 66. Mark “ PU “, abnormal height at upper discriminator Possible Cause : • PLT Clumps EDTA-Incombatibility Clotted sample • Giant Platelets • Microerythrocytes
  67. 67. Mark “ MP “, Multi Peaks found Possible Cause: Platelet transfusion
  68. 68. Mark “ DW “, Distribution With The distribution can not be detected because the Histogram does not cross the 20 % limit twice. • This curve in only an example but could also show another course. • The overall height of the curve is always 100 %. The width is calculated on the 20 % height of the curve.
  69. 69. Leukocyte-Histogram Flag “ WL “, Curve does not begin at the basis line Possible causes : • PLT Clumps EDTA- Incombatibility coagulated Sample • high osmotic resistant (Erythrocytes not lysed) • Erythroblasts • cold agglutinate
  70. 70. RBC Histogram ABN / INDICATOR PROBABLE CAUSE COMMENT Left of curve does not touch baseline Schistocytes and extremely small red cells Review smear CBC and Platelet histogram Bimodal peak Transfused cells, therapeutic response Review Smear Right portion of curve extended Red cell autoagglutination Review CBC & Smear Left shift of curve Microcytes Review smear & CBC Right shift of curve Macrocytes Review smear & CBC
  71. 71. WBC Histogram ABN / INDICATOR PROBABLE CAUSE COMMENT Trail extending downward at extreme left, or lymph peak not starting at baseline NRBC, Plt clumping, unlysed RBC, cryoproteins, parasites Review smear and correct WBC for NRBC Peak to the left of lymph peak or widening of lymph peak towards left NRBC Review smear & correct WBC for NRBC Widening of lymph peak to right Atypical lymphs, blasts, plasma cells, hairy cells, eosinophilia, basophilia Review smear Wider mono peak Monocytosis, plasma cells, eosinophilia, basophilia, blasts Review smear
  72. 72. WBC Histogram ABN / INDICATOR PROBABLE CAUSE COMMENT WBC histogram (lymph peak) does not start at baseline Giant platelets, NRBC, Plt clumping Review smear, correct WBC for NRBC Elevation of left portion of granulocyte Left Shift Review smear Elevation of right portion of granulocyte peak Neutrophilia Review smear
  73. 73. Platelet Histogram ABN / INDICATOR PROBABLE CAUSE COMMENT Peak or spike at left end of histogram (2- 8 fl) Cytoplasmic fragments Review smear Spike towards right end of histogram Schistocytes, microcytes, giant platelets Review smear + CBC ( MCV &  RDW) ( MPV &  PDW) Bimodal peak Cytoplasmic fragments Review smear
  74. 74. R1- RBC precursors, Giant or clumped platelets, cryoglobulins. R2- Blast, basophilia, eosinophilia, monocytosis,plasma cells and abnormal size lymphocytes. R3-eosinophilia and immature granulocytes. R4-absolute granulocytosis.
  75. 75. CONCLUSION Histogram in conjunction with absolute counts give valuable information about the abnormality of the sample & the need for follow up peripheral blood examination.Histogram should be used as quality check but not diagnostic for any pathological condition.The manual blood film remains the definitive tool for complete haematological analysis.
  76. 76. Take home messages Shapes of histograms identified pathology before the blood smear could be examined. Newer parameter like RDW and PDW have added new dimension to understand blood cells and classify there abnormality. The manual blood film remains the definitive tool for complete haematological analysis.
  77. 77. Histograms Interpretation LYMPH% 31,2 % MXD% 6,8 % NEUT% 62,0 % LYMPH# 1,8 x103 /µl MXD# 0,4 x103 /µl NEUT# 3,6 x103 /µl 250 RBC RDW-SD 40,0 fl 40 PLT PDW 13,1 fl MPV 10,4 fl P-LCR 28,1 % WBC 300THANYOU SPEAKER- DR NARMADA PRASAD TIWARI
  78. 78. Known interfering substance RBCs • High WBCs esp if RBCs is low → ↑RBCs • Agglutinated RBCs → ↓ RBCs Hb Turbidity of the blood sample → ↑ Hb • Elevated WBCs • Elevated lipids • Fetal bloods
  79. 79. MCV Red cell agglutination ↑ number of large platelets HT Red cell agglutination RDW Agglutination of RBCs Nutritional deficiency Blood transfusion
  80. 80. WBCs interferring subs. Normoblasts → ↑ WBCs Unlysed RBCs → ↑ WBCs MM → ↑ WBCs (ppt protein) Hemolysis → ↑ WBCs (red cell stroma) Leukemia → ↓ WBCs (↑ cell fragility) → In CLL small lymph not counted Cryoglobulin → ↑ all parameters of blood
  81. 81. Platelets RBCs fragments → ↑ plat (microcytes) WBCs fragments → ↑ plat (microcytes) Chemotherapy → ↓ plat (↑ plat. fragments) Hemolysis → ↑ Plat (red cell strom) ACD blood → ↓ plat (plat. Aggregation) RBCs inclusion → ↑ plat. (Malaria, H.j bodies) Plat. agglutination → ↓ plat
  82. 82. Lymphocytes Nucleated RBCs → ↑ lymph Parasites → ↑ lymph Resistent RBCs → ↑ lymph Monocytes ↑ in large lymphocytes, atypical lymph, blasts and basophils Granulocytes ↑ in eosinophilia, blasts, promyelo, myelo,

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