1. A 5-year-old girl presented with bruising and bleeding from her mouth. Her blood work showed low platelets but normal other counts. She likely has immune thrombocytopenic purpura (ITP) following a recent infection. 2. An 18-month-old boy drinks a lot of milk and eats dirt, but has low iron levels based on his blood work. He is diagnosed with iron-deficiency anemia likely caused by his poor diet. 3. Bone marrow examinations are important for diagnosing diseases like leukemia, myelofibrosis, and multiple myeloma that commonly involve the bone marrow. It can confirm diagnoses and detect conditions not seen on normal blood tests.

1. •Dr.Wahid Helmi
•Pediatric consultant
•Zarka hospital (Demiate).

2. Sites of hematopoiesis

3. physiologic anemia of infancy
• Normal HB (g/dl) at birth = 14-20 gm/dl
• After birth →↑blood Oxygen saturation → ↓erythropiotine
production → hemoglobin decline to reach at about 8-12
weeks of age :-
1. a nadir of 10-11 gm/dl in fullterm .
2. a nadir (7-9 gm/dl in preterm)
3. Then restimulation of erythropiotine release ..
• Hemoglobin Nadir is reached earlier in preterm due to:
- Decreased RBCs survival.
- Rapid rate of growth.
-Vitamin E deficiency.
• Why does the physiologic anemia of infancy occur?

4. Hemoglobin (Hb) composition

5. switch from HbF to HbA
– switch from HbF to HbA
• HbF decreases about 3% per week
• at 6 mo. HbF represents only 2% of total Hb
• switch to HbA provides for greater unloading of
oxygen to tissues d/t lower oxygen affinity of HbA
relative to HbF.
– seldom produces symptoms
– not altered by nutritional supplements.

6. Normal Hemopoiesis

7. FACTORS REGULATINGFACTORS REGULATING
Hemopoiesis
– (RBCs).
IRON ,“TISSUE O2” & ERYTHROPOIETIN.
– Thrombopoietin → (platelets) .
– . Cytokines → WBCs:-
e,g (G- CSF: granulocyte colony-
stimulating factor).
– B12&folic acide for all cells .

10. The causes of a hypochromic microcytic
anaemia.

11. colony-forming unit (CFU or cfu)

12. Normal blood smear showing,
red cells (R), aneutrophil (N), a lymphocyte (L), eosinophil (E),
basophil (B), monocyte (M), and platelets (P)

13. Variations in size and shape of red cells:-
• (A) Microcytic hypochromic red cells in iron deficiency
anemia;
• (B) Oval macrocytes and a hypersegmented neutrophil in
megaloblastic anemia;
• (C) Sickle cells in sickle cell anemia;

14. Variations in size and shape of red cells:-
• (D) Spherocytes in hereditary spherocytosis;
• (E) schistocytes (Helmet cell ) as in patient with cardiac valve
replacement .
• (F) Target cells (e.g., in patients with iron deficiency or
thalassemia trait).

15. • (G) Burr cells in chronic renal failure;
• (H) Tear drop red cells in myelofibrosis;
• (I) Bite cells and (J) Blister cell in glucose-6-
phosphate dehydrogenase deficiency

17. WBCs, facts and figures

18. WBCs
•Total Leukocyte Count-
REFERENCE RANGES•
• At birth: 10,000-26000/μl.
• 1 year: 6,000-16,000/μl.
• 6-12 years: 5,000-13,000/μl
• Adults: 4000-11,000/μl.
• CRITICAL VALUESTotal leukocyte count<
2000/μl or > 50000/μl.

19. leukemoid reaction
• - Acute leukaemia → (↑total leucocytic count mostly exceed
100,000+ Blast cells in peripheral blood +↓platelets +↓RBCs )
• leukemoid reaction (like = oid ) → ↑total leucocytic count more
than 50,000 (rarely exceed 50,000+ no blast cells + Bandeamia
+normal platelets + normal RBCs ) .
• Normal leucocytes secrete leucocytic alkaline phosphatase but in
leukemic leucocytes never secrete so in leukemoid reaction
alkalinephosphatase is very ↑ ↑↑.
• leukoerythroblastic reaction :- leucocytes & RBCs blasts appear
on Peripheral blood due to bone marrow infiltration (lymphoma -
leukaemia , lymphoma , T.B. , myeloma) .

20. - 10 year old boy ,with
- fever, fatigue, sore throat, and swollen lymph glands.
-Mild hepato-splenomegaly .
-CBC, HBG 13 ,platlets 200,ooo,WBCs 35,0000 with atypical lymphocytosis.

21. - Infectious mononucleosis (Epstein-Barr virus ) .
- increase of white blood cells that are mononuclear (with a single nucleus) "Mono" .

22. WBCs

23. WBCs

24. WBCs

25. WBCs

26. WBCs

27. value of Bone marrow examination
• bone marrow examination is diagnostic and confirmatory .
• Not only diagnostic but bone marrow examination is mandatory .
• All these diseases need bone marrow examination :-
1- multiple myeloma(plasma cell myeloma ) → plasma cells inside bone
marrow .
2- myelofibrosis → fibrous tissues inside bone marrow .
3- A leukaemic leukaemia → blasts not in peripheral blood blood but
highly infiltrating bonemarrow.
4- aplastic anaemia .
5 - sidroblastic anaemia .
6- I.T.P . why ? inspite of being easily diagnosed .Baby may be Aleukaemic
leukaemia

28. Seven RBC parameters

30. (HBG) REFERENCE RANGES (WHO)

32. Packed Cell Volume

33. PCV

34. Measurement Normal Range
A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit45 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 hypochro .

35. Juvenile red cells
In the Neonates, Count is 2 – 6/Cu.mm.
Falls to <1 in the first week of life.

36. corrected reticulocyte count or Reticulocyte Production
Index (RPI)
• Maturation of reticulocytes to erythrocytes takes 24-48 hours.
• indicates whether the bone marrow is responding appropriately to the
anemia.
• The corrected “retic count” should be elevated if the bone marrow is
working properly and has all the right nutrients for making RBCs,
including iron, folate, and vitamin B12.
• an RPI > 3 suggests increased production and implies
either hemolysis or blood loss.
• an RPI < 2 suggests decreased production or ineffective
production for the degree of anemia.

37. • To be useful the reticulocyte count must be adjusted for
the patient's hematocrit.
Thus:
• Corrected retic. = Patients retic. x (Patients Hct/45)
• Reticulocyte index (RPI) = corrected retic. count/Maturation time
( Maturation time = 1 for Hct=45%,
Maturation time = 1.5 for Hct=35%,
Maturation time = 2 for 25%,
and Maturation time = 2.5 for Hct=15%.)
• Absolute reticulocyte count = retic x RBC number.

40. Red Cell Indices

41. MEAN CELL VOLUME
- Size of red cells (from 2-10 years) (MCV) :-
− Microcytic (MCV < 70 + age) .
− Normocytic (MCV > 70 + age and < 100) .
− Macrocytic (MCV > 100)
- Normal MCV is 80-100 fl.
- Causes of Increased MCV :-
• Megaloblastic anemia
• Non-megaloblastic macrocytosis as in liver disease,
hypothyroidism, reticulocytosis .
• Newborns ( 90-118 fl) .

42. MCV
• help provide a quick screen of the possible causes of anemia
What is a quick rule of thumb for approximating MCV?

43. - Causes of Low MCV :-
• Microcytic hypochromic anemia .
-MCV is normal in normocytic normochromic anemia ,
(acute blood loss, hemolysis, aplastic anemia).
-In the presence of large number of abnormal red cells
like sickle cells, and in dimorphic anemia (e.g. mixed
normocytic and microcytic).
- MCV may be normal (since it is an average value) and
thus unreliable for morphological classification .
-Mentzer index
- is derived by dividing MCV with red cell count.
-Ratio of less than 13 is seen in thalassemia while ratio is more
than 13 in iron deficiency anemia.

44. What is the Mentzer index?
• MCV/RBC.
-This is one of the formulas that is used to distinguish the
hypochromic, microcytic anemias of the thalassemia trait
from iron deficiency.
-As a general rule, iron deficiency causes alterations in
RBCs that tend to be variable, whereas thalassemia
generally results in more uniformly smaller cells.
-In patients with the b-thalassemia trait, the Mentzer index is
usually less than 13.
- in patients with iron deficiency, it is usually greater than 13.

45. Thalasemia trait
• Peripheral smear in beta- thalassemia minor
showing microcytes (M), target cells (T), and
poikilocytes.

46. the overall sizes and shapes of the RBC's
are less uniform (increased anisocytosis
and poikilocytosis).

47. Calculation of the Mentzer index

48. MEAN CELL HEMOGLOBIN (MCH)
• MCH is the average amount of hemoglobin in
a single red cell.
• It is obtained by dividing hemoglobin value
by red cell count.
•1 picogram = 1.0 × 10-12
grams
•More sensitive than MCV

49. MCHC
It is important in diagnosis of congenital Spherocytosis (MCHC > 35)

51. red cell distribution width (RDW)
• RDW = anisocytosis .
• The RDW is a quantification of anisocytosis (variation in RBC
size).
• In children, normal values range from about 11.5% to
14.5% but can vary among instruments.
• When elevated in a patient with microcytosis, it suggests that
iron deficiency is a more likely cause of anemia than the
thalassemia trait.
• Children with the thalassemia trait tend to have values that
overlap with normal RDW values.
-RDW is low in thalassemia trait .
- RDW is high in iron deficiency anemia.
- RDW is normal in anemia of chronic disease.

52. REFERENCE RANGES
• MCV: 80-100 fl
• MCH: 27-32 pg
• MCHC: 30-35 g/dl
• RDW: 11.5% -14.5

54. RBCs

55. Components of Blood
• White Blood Cells (Leukocytes)
– Margination
– Phagocytosis
The macrophage is using its internal
cytoskeleton to envelop cells of the fungus
Candida albicans.

56. Components of Blood
• Leukocytes (cont.)
– White Blood Cell Count
– Leukopoiesis
• Granulocytes
– Neutrophil
– Basophil
– Eosinophil
• Monocytes
• Lymphocytes Human Neutrophil:
Phagocytosis of Strep pyogenes

57. Acute leukaemia

58. Acute leukaemia

59. • A 5-year-old white female has multiple bruises on her lower
extremities and oral mucosal bleeding of 3 days’ duration.
• -Two weeks before these signs, she had a mild respiratory tract
infection.
• Physical examination reveals multiple ecchymoses and
petechiae.
• no lymphadenopathy or hepatosplenomegaly is noted.
• - CBC
WBC 6500/μL (4000-11,000/μL)
Hemoglobin 14.5 g/dL (13.5-17.5 g/dL)
Platelets 44,000/μL (150,000-400,000/μL)
Case1

60. Case 1 A
• (ITP) is an acute process that often follows an
upper respiratory tract infection.
• Leukemia is always a worrisome possibility
but is extremely unusual in the absence of
anemia, leukopenia or blasts,
lymphadenopathy, or hepatosplenomegaly.

61. • An 18-month-old male appears hungry; in fact, he drinks a
quart of whole milk a day and also eats dirt “picky eaters.”.
• Intake of solid foods is sporadic .
• Physical examination reveals mild pallor of the conjunctivae.
• He has no hepatosplenomegaly, and the rest of the
examination findings are normal.
• CBC :-↓↓ MCV + ↓↓ MCH + Normal Reticulocytic count
Case2

62. Case 2 A
• - This is a classic case of iron-deficiency anemia
- Iron therapy →Reticulocytosis peaks at 5—7 days.
- when the hemoglobin and hematocrit return to
normal , Continue iron for 4—8 weeks because
Stores of iron need to be repleted, and 4—8 weeks is
required.
- If the patient does not experience improvement in
his anemia , Gastrointestinal blood loss , Thalassemia
& Cow's milk protein allergy (CMPA) should be
explored .

63. Case 3

64. Case3A

65. Case 4
-A 22 month old boy presents to your office with a chief
complaint of pallor.
- CBC:-
WBC 6,100, Hgb 6.2 g/dl, Hct 19.8%, Plt 589,000,
MCV 54 fL, RDW 17%. Reticulocyte count is 1.8%.
- The lab reports microcytosis, hypochromia, mild anisocytosis
and polychromasia.

66. Case4 answer
• Anemia occurs when the red blood cell mass or hemoglobin
content is too low to meet a person's physiologic demands. In
children,
• "normal" levels vary with age, gender, and geographic
location (height above sea level).

67. Case 5
• A 12-month-old female is found to have Hgb 8 and
mean corpuscular volume (MCV) 65 on routine
complete blood (cell) count (CBC) screen. What is
the likely cause of these abnormal laboratory values?

68. Case5 ,Answer
• iron deficiency anemia is the most common
type of anemia in children, especially in
children 6-months to 3-years-old.
• in this age group, it is commonly caused by
inadequate nutritional intake.
• This child’s diet likely consists of only milk,
which would not supply adequate iron.
• A thalassemia disorder may also be
considered in this patient.

69. Case6
• An 8-month-old boy is found to have low
hemoglobin and low MCV on a routine CBC.
He is treated with iron supplementation for 5
months, but on repeat CBC, he is still anemic.
What is the likely cause of his anemia?.

70. Case6 ,Answer
• One option for his continued anemia is
noncompliance with medications
• if the child was not given his iron supplements, we
would not expect his anemia to improve.
• However, assuming he had good compliance with his
medications, he likely has alpha or beta thalassemia
trait in addition to a treated iron deficiency anemia,
diagnosed by hemoglobin electrophoresis.

71. Case7
• A 4-year-old boy is noted to be more pale and less
active over the past week.
• On physical exam you notice petechiae and bruising.
His mother denies recent episodes of epistaxis or gum
bleeding.
• CBC shows :-
1-WBC 8, Hgb 7.9, MCV 81, Plt 29K. Retic 1.5%.
2-Differential: 12 N, 75 L, 6 M, 2 E, 5 atypical
lymphocytes.
• What is in your differential diagnosis?

72. Case7 ,Answer
• The patient is anemic, thrombocytopenic, and
neutropenic.
• Possible etiologies include aplastic anemia,
leukemia, and viral suppression.
• Given the five atypical cells on the differential,
leukemia should be strongly considered.

75. Thank You