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CBC Part 2 - WBC Differential & Morphology.pdf

This document provides instructions for a multi-part study exercise on the complete blood cell count (CBC). It focuses on the second part which covers the white blood cell (WBC) differential count and morphology. A peripheral blood smear stained with Wright's stain is used for microscopic examination to identify and classify WBCs, including immature and abnormal cell types. Performing a WBC differential count provides information on the frequency distribution of different WBC lineages and can help identify diseases.

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The Complete Blood Cell Count (CBC) CBC – Part 2 WBC Differential Count and Morphology Louisiana State University Health Sciences Center Department of Pathology New Orleans, Louisiana by Carolyn Sue Walters, MHS, MT(ASCP) A Clinical Pathology 201 Study Module click here to continue School of Medicine ©01-07-03 DO NOT REPRODUCE THIS EXERCISE.
C. Sue Walters, MHS, MT(ASCP) click here to continue Associate Professor Department of Pathology LSU Health Sciences Center New Orleans, LA csw lsuhsc 2001
csw lsuhsc 2001 This study exercise is the property of Carolyn Sue Walters, MHS, MT(ASCP) and the Department of Pathology, LSU Health Sciences Center in New Orleans, LA. All rights are reserved. It is intended for use solely within the LSUHSC campus network. No part of this exercise may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (to include but not be restricted to electronic, mechanical, recording, and photo-copying) without prior written permission from the author. The CBC click here to continue
csw lsuhsc 2001 Special thanks is given to Ms. Angela Foley, MS, MT(ASCP), Department of Clinical Laboratory Sciences, LSUHSC School of Allied Health in New Orleans, LA for the use of some of her images of blood cells and for her assistance in the art of creating image files. Special Acknowledgment click here to continue
csw lsuhsc 2001 The CBC click here to continue This is the second module of a 4-part study exercise regarding the CBC. The 4 parts are entitled: CBC – Part 1 The hemogram CBC – Part 2 WBC differential & blood morphology CBC – Part 3 RBC morphology & platelet estimate CBC – Part 4 Post-test The review of hematopoiesis and blood cell morphology (i.e., Hematology Atlas located on the LSUHSC server) is recommended as a prerequisite for the CBC exercise.
Feedback Feedback as to the quality and usefulness of this exercise is solicited and suggestions for improvement are welcomed. Please forward your remarks by E-mail cwalte@lsuhsc.edu or via US MAIL: C. Sue Walters, MHS, MT(ASCP) LSUHSC Department of Pathology 1901 Perdido Street New Orleans, LA 70112 click here to continue csw lsuhsc 2001
Directions csw lsuhsc 2001 The directions for navigating through the exer- cise are given on the next 3 pages. They are the same as those used in the other modules of this 5-part exercise. Click on: to visit the directions before continuing with the exercise. to go directly to the Main Menu. or
Directions, continued csw lsuhsc 2001 in the upper left hand corner of every page to return to the previous page menu in the upper right corner of the page to return to the Main Menu selection. The following directional icons are provided throughout the exercise for your convenience. You can click on: csw lsuhsc 2001 click here to continue
Directions, continued csw lsuhsc 2001 You can click on: in the lower right corner of the page to continue. Quit in the lower right corner of the Main Menu page to Quit (i.e., end the exercise).
Directions, continued csw lsuhsc 2001 “Hot points” (symbols, words, phrases) have been inserted on the pages as navigational tools and can be identified by their “gold” color. If it’s “gold”, click on it to move to the next text/data entry. Also, sounds have been added in a few places for emphasis. Remember, if it’s gold, click on it. Try it! Caution, failure to follow the structured order of the “hot points” may result in confusion. If you use the mouse without placing the cursor directly on the “hot point” , you may skip over vital information.
Special Comments csw lsuhsc 2001 This exercise has numerous images. You may note that, when a page contains images, there may be a rather long delay before you regain control of the cursor. Please be patient. I think you will find the images are worth the wait. NOTE: Some animation and/or interactive affects may be lost if you attempt to replay a page by re- turning to the previous page and then advanc- ing to that page again. Now, click on the gold to begin.
csw lsuhsc 2001 CBC - Part 2 The Complete Blood Cell Count (CBC) Part 2 WBC Differential Count & Morphology
MAIN MENU Introduction & Review of WBC Morphology csw lsuhsc 2001 Quit Manual differential WBC count Total WBC count vs. differential WBC count Relative % vs. absolute number Review: mature & immature WBC; non- neoplastic WBC alterations; neoplastic WBC alterations
Introduction & Review of WBC Morphology csw lsuhsc 2001 menu
WBC distribution & morphology Evaluation of the distribution and morphology of white blood cells is one of the most valuable procedures used in examination of the blood. The information obtained may furnish the diagnosis, serve as a guide to therapy and as an indicator of harmful effects of radiotherapy and chemotherapy. csw lsuhsc 2001 menu
continued csw lsuhsc 2001 menu A study of white blood cell morphology and distribution of blood cells is an essential part of the clinical description of practically every disease. A normal number and distribution of cells in the blood are so important as physiologic constants that some authorities say the absence of disease cannot be determined until this information is available.
What WBC are present in normal peripheral blood? csw lsuhsc 2001 menu 1. granulocytes In normal peripheral blood, there are three basic types of leukocytes (illustrated below). monocytes 3. eosinophils basophils neutrophils lymphocytes 2. normal atypical (few) mature band
Are white blood cell abnormalities associated with disease? csw lsuhsc 2001 menu An abnormal number and/or distribution of leuko- cytes (WBC) may be seen in disease. Immature WBC and/or WBC with abnormal alterations may also be seen. The immature and abnormal cells are distinguishable from normal cells by their morphologic characteristics. Recognition and identification of these abnormal- ities play a major role in the diagnosis and treat- ment of true blood diseases and numerous other pathologic processes. continue w/o review Review immature and abnormal WBC or
Examples of immature WBC: granulocytes (various stages) myeloblasts lymphoblasts monoblasts csw lsuhsc 2001 menu
Examples of granulocytes in various stages of maturation: 1 late myeloblast or early promyelocyte 1 2 late promyelocyte or early myelocyte 2 3 myelocyte 3 3 4 metamyelocyte 4 4 4 4 4 5 band neutrophil 5 5 5 5 5 6 mature segmented neutrophil (PMN) 6 6 7 eosinophil 7 8 Whoa! 8 That’s not a WBC. It’s a nucleated RBC but will also be included in the total WBC count. menu csw lsuhsc 2001
Now, Can you Identify the stages of granulocytes just illustrated? 1 1 late myeloblast or early promyelocyte 2 2 late promyelocyte or early myelocyte 3 3 3 myelocyte 4 4 4 4 4 4 metamyelocyte 5 5 5 5 5 5 band neutrophil 6 6 6 mature segmented neutrophil (PMN) 7 7 eosinophil 8 menu NRBC csw lsuhsc 2001 8
Overview of the stages of granulocytes just illustrated: 1 1 late myeloblast or early promyelocyte 2 2 late promyelocyte or early myelocyte 3 3 3 myelocyte 4 4 4 4 4 4 metamyelocyte 5 5 5 5 5 5 band neutrophil 6 6 6 mature segmented neutrophil (PMN) 7 7 eosinophil 8 menu NRBC csw lsuhsc 2001 8 review granulocytes again or continue
Another look at the granulocytes just illustrated: 1 1 late myeloblast or early promyelocyte 2 2 late promyelocyte or early myelocyte 3 3 3 myelocyte 4 4 4 4 4 4 metamyelocyte 5 5 5 5 5 5 band neutrophil 6 6 6 mature segmented neutrophil (PMN) 7 7 eosinophil 8 menu NRBC csw lsuhsc 2001 8
Examples of WBC with acquired non-neoplastic alterations: neutrophils in bacterial infections with Dohle bodies and/or toxic granulation in megaloblastic anemias with nuclear hypersegmen- tation (ie, > 5 lobes) lymphocytes in viral infections with reactive (atypical) changes inherited disorders csw lsuhsc 2001 menu
Examples of WBC with inherited non-neoplastic alterations: Pelger-Huet Anomaly hyposegmented nuclei May-Hegglin Anomaly cytoplasmic blue bodies Alder-Reilly Anomaly cytoplasmic black granules csw lsuhsc 2001 Chediak-Higashi Syndrome cytoplasmic large black granules menu
Examples of neoplastic WBC alterations: hairy cell lymphocytes hairy cell leukemia & myeloblasts w/ Auer rod(s) acute myelocytic leukemias csw lsuhsc 2001 menu
What can be learned from a differential WBC count? csw lsuhsc 2001 menu Because the total WBC count does not differen- tiate WBCs as to cell lines, a differential WBC count (“diff”) is performed to provide informa- tion regarding the frequency distribution of WBCs and to identify increases or decreases when they occur in one or more of the cell lines. A morphologic study of the various blood cells (i.e., WBC, RBC, & platelets) is made during the differentiation process to detect and identify atypical and/or abnormal cells.
What methods can be used for the differential WBC count ? The differential WBC count and blood cell study may be performed by one of several methods, e.g.: csw lsuhsc 2001 menu • An automated multi-channel instrument (in this exercise, it is a Coulter STK-S 5-part differential), which is discussed in the auto- mated CBC section. OR • A manual microscopic examination of a Wright’s (or Wright’s Giemsa) stained peripheral blood smear.
End of Introduction csw lsuhsc 2001 This concludes the Introduction to the Differential WBC Count. Select one of the following: Go to Manual Differential WBC Count, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
Manual Differential WBC Count csw lsuhsc 2001 menu
What kind of blood smear is used ? csw lsuhsc 2001 menu A peripheral blood film (made from a drop of blood from an EDTA anticoagulated tube or skin puncture) is stained with Wright (or Wright-Giemsa) stain and microscopically examined using scanning (10x), high-dry (40x), and oil (100x) objectives. Refer to the Clinical Pathology 202 Course Manual for the complete procedure.
What studies will be performed on the stained blood smear? csw lsuhsc 2001 menu A complete differential WBC count (“diff”) which includes identification of mature and (if any) immature WBC and description of WBC morph- ologic alterations. A complete description of RBC morphology which includes (if any) a description of RBC morphologic alterations and, if present, the number of NRBC per 100 WBC. Platelet estimate of adequacy which includes (if any) abnormal morphologic alterations, distribution, and clumps.
continued: csw lsuhsc 2001 menu This section is limited to the differential count and morphology of white blood cells. RBC morphology and platelet estimate discus- sions are addressed later in other sections.
How are the WBC identified and classified? csw lsuhsc 2001 menu Typical nuclear and cytoplasmic morphologic features provide a means by which WBC can be identified and classified as to: • cell line (i.e., granulocytes [neutrophils, eosino- phils, or basophils], lymphocytes, or mono- cytes) • maturity (i.e., mature cell or specific immature stage of development). • abnormal morphology (i.e., nuclear or cyto- plasmic alterations)
How are the WBC differentiated and enumerated? csw lsuhsc 2001 menu At least 100 WBC are counted and a tabulation is made as to the number of each leukocytic cell type included in the count. The 100 cell count provides the RELATIVE number (or percent) of each white blood cell type present in the peripheral blood.
How can you determine whether there is an increase or decrease of one or more of the cell lines? csw lsuhsc 2001 menu Increases or decreases in a white blood cell line (or type) can then be determined by comparing the number obtained on the differential count with established reference ranges.
Reference Range (Relative %) csw lsuhsc 2001 menu segmented neutrophils 50-70% band neutrophils 0- 5% eosinophils 1-5% lymphocytes 20-40% monocytes 1-6% Reference ranges (values considered to be normal) for differential WBC counts may vary among laboratories, but are usually about:
What terminology is used to indicate an increased or decreased number of a specific white blood cell line? csw lsuhsc 2001 menu Cell Line Increased: Decreased: Neutrophils Lymphocytes Monocytes Eosinophils Basophils Neutrophilia Neutropenia Lymphocytosis Lymphocytopenia Monocytosis Monocytopenia Eosinophilia Eosinopenia Basophilia Basopenia
csw lsuhsc 2001 menu continue without review Review WBC morphology or Review Morphology?
WBC in Normal Blood (Adults): PMN band (neutrophils) eosinophil basophil monocyte lymphocyte ATL (few) (atypical lymphocyte) csw lsuhsc 2001 menu
Examples of immature WBC: granulocytes (various stages) myeloblasts lymphoblasts monoblasts csw lsuhsc 2001 menu
Examples of granulocytes in various stages of maturation: 1 late myeloblast or early promyelocyte 1 2 late promyelocyte or early myelocyte 2 3 myelocyte 3 3 4 metamyelocyte 4 4 4 4 4 5 band neutrophil 5 5 5 5 5 6 mature segmented neutrophil (PMN) 6 6 7 eosinophil 7 8 8 It’s a nucleated RBC but will also be included in the WBC count. menu csw lsuhsc 2001
Examples of WBC with acquired non-neoplastic alterations: neutrophils in bacterial infections with Dohle bodies and/or toxic granulation in megaloblastic anemias with nuclear hypersegmen- tation (ie, > 5 lobes) lymphocytes in viral infections with reactive (atypical) changes csw lsuhsc 2001 menu
Examples of WBC with inherited non-neoplastic alterations: Pelger-Huet Anomaly hyposegmented nuclei May-Hegglin Anomaly cytoplasmic blue bodies Alder-Reilly Anomaly cytoplasmic black granules csw lsuhsc 2001 Chediak-Higashi Syndrome cytoplasmic large black granules menu
Examples of neoplastic WBC alterations: hairy cell lymphocytes hairy cell leukemia myeloblasts w/ Auer rod(s) acute myelocytic leukemias csw lsuhsc 2001 menu
Examples of nucleated RBC in various stages of maturation. proerythroblast (earliest form w/ nucleoli) basophilic erythroblast (ill-defined or absent nucleoli) polychromatophilic erythroblast (cytoplasmic evidence of HGB) orthochromatophilic erythroblast (last stage before extrusion of nucleus) csw lsuhsc 2001 menu
End of Manual Differential WBC Count & Morphology csw lsuhsc 2001 This concludes the Manual WBC Differential Count and Morphology section. Select one of the following: Go to Total WBC Count vs. Differential WBC Count, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
Total WBC Count vs. Differential WBC Count csw lsuhsc 2001 menu
How does the differential WBC count differ from the total WBC count? csw lsuhsc 2001 menu The total WBC count reflects the total number of all leukocytes in circulation but does not differ- entiate leukocytes as to their various cell lines (e.g., neutrophils, lymphocytes), stage of matur- ity, (e.g., band, metamyelocyte), or abnormalities when present (e.g., toxic granulation, hyperseg- mented nuclei). A differential WBC count must be performed to provide that information.
Total WBC count = total number of leukocytes without differentiation: csw lsuhsc 2001 menu
“Diff” - differentiates and enumerates WBC according to cell type, e.g.: csw lsuhsc 2001 menu neutrophils, mature lymphocytes monocytes eosinophils basophils
“Diff” - provides frequency distribution (relative % and absolute number/mL, e.g. total WBC = 10,000/mL): csw lsuhsc 2001 menu neutrophils, mature 65% 6500/mL lymphocytes 28% 2800/mL monocytes 3% 300/mL eosinophils 3% 300/mL basophils 1% 100/mL
Total WBC count - mature and (if present) immature WBC w/o differentiation, e..g.: csw lsuhsc 2001 menu blast promyelocyte myelocyte metamyelocyte band
“Diff” - differentiates and enumerates mature and (if present) immature WBC, e.g.: csw lsuhsc 2001 menu mature neutrophil eosinophil basophil lymphocyte monocyte blast promyelocyte myelocyte metamyelocyte neutrophilic band immature
“Diff” - provides frequency distribution (relative % and absolute number e.g., total WBC=50,000/mL): csw lsuhsc 2001 menu neutrophil, bands 15% 7500/mL neutrophil, mature 50% 25000/mL metamyelocyte 12% 6000/mL myelocyte 7% 3500/mL promyelocyte, 2% 1000/mL blast 1% 500/mL eosinophil 5% 2500/mL basophil 3% 1500/mL lymphocyte 5% 2500/mL monocyte 0% 0/mL
Total WBC count - normal and abnormal WBC without differentiation, e.g.: csw lsuhsc 2001 menu acquired WBC alterations
“Diff” - differentiates abnormal WBC with acquired alterations, e.g.: csw lsuhsc 2001 menu reactive/atypical lymphocytes Dohle bodies toxic granulation hypersegmented neutrophils
Total WBC count - normal and abnormal WBC without differentiation, e.g.: csw lsuhsc 2001 menu inherited WBC alterations
“Diff” - differentiates abnormal WBC with inherited alterations, e.g.: csw lsuhsc 2001 menu Pelger-Huet Anomaly May-Hegglin Anomaly Alder-Reilly Anomaly Chediak-Higashi Syndrome
Total WBC count - normal and (if pre- sent) neoplastic WBC w/o differentiation: csw lsuhsc 2001 menu e.g., leukemic alterations
“Diff” - differentiates WBC with neoplastic alterations, e.g.: csw lsuhsc 2001 menu or hairy cell lymphocyte myeloblast w/ Auer rod
End of Total vs. Differential WBC Counts csw lsuhsc 2001 This concludes the Introduction to the Differential WBC Count. Select one of the following: Go to Relative % vs. Absolute Number, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
Relative % vs. Absolute Number csw lsuhsc 2001 menu
What is meant by the relative % and absolute number of WBC ? csw lsuhsc 2001 menu Relative % is based on the differential count of 100 white blood cells and reflects the per cent of each cell type present in circulation. If the total number of white cells in circulating blood is known and the relative per cent of each white cell type is known, then the absolute number of each cell type per mL of blood can be calculated.
continued: csw lsuhsc 2001 menu For example: given a patient with a total WBC count of 8,000/mL and the differential WBC count shown below (i.e., the number observed for each cell type in the 100 white cell count): Segmented neutrophils 60% Band neutrophils 5% Lymphocytes 30% Monocytes 2% Eosinophils 2% Basophils 1%
continued: csw lsuhsc 2001 menu Then the absolute number of each cell type/mL can be calculated by multiplying the per cent of each cell type by the total number of WBC/mL. x 8,000 = 4,800 x 8,000 = 400 x 8,000 = 2,400 x 8,000 = 160 x 8,000 = 160 x 8,000 = 80 = 8,000 Segmented neutrophils 60% Band neutrophils 5% Lymphocytes 30% Monocytes 2% Eosinophils 2% Basophils 1% Total = 100%
What are the relative reference ranges for leukocytes? csw lsuhsc 2001 menu Cell Type Reference Ranges (Relative %) (bands) 0-5 Eosinophils 0-6 Basophils 0-0.2 Lymphocytes 24- 45 Monocytes 0.4 - 10 Neutrophils 40-72 (PMN)
Do the relative values always indicate which cell line is or ? csw lsuhsc 2001 menu If the total WBC count is “normal” (i.e., within the established reference range), the relative values are a good reflection of the number of each cell type present, including increases or decreases. However, if the total WBC count is abnormal (i.e., increased or decreased), the relative percentage must be converted to an absolute number of each cell type present in order to determine which cell line is involved.
How is the relative % converted to an absolute number ? csw lsuhsc 2001 menu For each white blood cell line, multiply the percentage of cells counted (i.e., during the 100 cell count) by the total white blood cell count to obtain the absolute number for the cell line. For example: Total WBC/mL x relative % = absolute no./mL
Given a patient whose total WBC is 8,000/mL, csw lsuhsc 2001 menu and the relative distribution of leukocytes on the peripheral blood smear is as shown below: segmented neutrophils 65% band neutrophils 5% eosinophils 2% lymphocytes 25% monocytes 3% How are the absolute numbers determined?
How are the absolute numbers calculated (total WBC = 8,000/mL)? csw lsuhsc 2001 menu Cell Type Relative % Absolute No. (8,000 x 0.05) 65 Neutrophil (mature segmented) (8,000 x 0.65) 5,200/mL Neutrophil (band) 5 400/mL
continued: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Eosinophil Lymphocyte Monocyte 2 (8,000 x 0.02) 160/mL 3 25 2,000/mL (8,000 x 0.25) 240/mL (8,000 x 0.03)
Total WBC 8,000/mL x Relative %: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Neutrophil (band) 5 400/mL Monocyte 3 240/mL Lymphocyte 25 2,000/mL Eosinophil 2 160/mL Neutrophil (mature segmented) 5,200/mL 65 Total 100 8,000/mL
What are the absolute reference ranges for leukocytes? csw lsuhsc 2001 menu The total WBC count reference range for adults is 4,500- 11,000/mL at Charity & University Hospitals, but may vary slightly among laboratories: CELL TYPE RELATIVE % ABSOLUTE NO./mL Segmented neutrophils 42 - 72 1800 - 8000 Neutrophilic bands 0 - 5 0 - 550 Eosinophils 1 - 6 45 - 550 Basophils 0 – 0.2 0 - 200 Lymphocytes 24 - 45 1100 - 5000 Monocytes 0.4 - 10 200 - 1100 Reference Ranges
In this case, did the relative per cents reflect the absolute numbers ? csw lsuhsc 2001 menu The total WBC count was within the reference range. Therefore, because both the total and relative frequencies are within reference ranges, the relative % is a reflection of the absolute numbers in terms of normal or abnormal. The relative per cent for each cell type was within reference range.
However, given a patient whose total WBC is 15,000/mL, csw lsuhsc 2001 menu with a relative distribution of leukocytes on the peripheral blood smear the same as the previous patient: segmented neutrophils 65% band neutrophils 5% eosinophils 2% lymphocytes 25% monocytes 3% Is the interpretation the same for both patients?
What are the calculated absolute numbers in this case (i.e., total WBC = 15,000/mL)? csw lsuhsc 2001 menu 15000 x 0.65 = 9750 segmented neutrophils 15000 x 0.05 = 750 band neutrophils 15000 x 0.02 = 300 eosinophils 0.25 15000 x = 3750 lymphocytes 15000 x 0.03 = 450 monocytes The relative per cents are normal, but how do these absolute numbers compare with the established reference ranges?
Are the absolute numbers still within the reference ranges? csw lsuhsc 2001 menu Neutrophils (mature) Neutrophils (bands) Eosinophils Lymphocytes Monocytes Cell Type Patient Reference Ranges Absolute No./mL 1800 - 8000 9750 0 - 550 750 0 - 600 300 1100 - 5000 3750 200 - 1100 450 H H
Comparison of relative % and absolute numbers: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Neutrophil (band) 5 750/mL Monocyte 3 450/mL Lymphocyte 25 3,750/mL Eosinophil 2 300/mL Neutrophil (mature segmented) 9,750/mL 65 Total 100 15,000/mL N H N H
Do the relative and absolute values have the same interpretation in this case? csw lsuhsc 2001 menu The relative percentages for all cell types for this patient were within the reference range (i.e., normal). However, in this case, there is neutrophila when converted to absolute numbers based on a total WBC count of 15,000/mL because:  segmented (mature) neutrophils = 9,750/mL which exceeds the reference range (1800 - 8000/mL)  band neutrophils = 750/mL which also exceeds the reference range (0 - 550/mL).
Given another patient whose total WBC is 15,000/mL, csw lsuhsc 2001 menu and a relative distribution of leukocytes on the peripheral blood smear as shown below: segmented neutrophils 75% band neutrophils 5% eosinophils 2% lymphocytes 15% monocytes 3% How are these data interpreted?
How are the absolute numbers calculated (total WBC = 15,000/mL)? csw lsuhsc 2001 menu Cell Type Relative % Absolute No. (15,000 x 0.05) 75 Neutrophil (mature segmented) (15,000 x 0.75) 11,250/mL Neutrophil (band) 5 750/mL
csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Eosinophil Lymphocyte Monocyte 2 (15,000 x 0.02) 300/mL 15 2,250/mL (15,000 x 0.15) 3 450/mL (15,000 x 0.03)
Total WBC 15,000/mL x Relative %: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Neutrophil (band) 5 750/mL Monocyte 3 450/mL Lymphocyte 15 2,250/mL Eosinophil 2 300/mL Neutrophil (mature segmented) 11,250/mL 75 Total 100 15,000/mL H H N H N N L N N N
Do the relative and absolute values have the same interpretation? csw lsuhsc 2001 menu According to the relative percentages, this patient had increased neutrophils (neutrophilia) and decreased lymphocytes (lymphocytopenia). When converted to absolute numbers based on a total WBC count of 15,000/mL, • there is indeed neutrophilia (11,250/mL) which exceeds the reference range (11 - 5000/mL) • but the number of lymphocytes (i.e., 2,250/mL) is within the reference range (1000-5000/mL).
What if the patient’s total WBC is decreased? For example… csw lsuhsc 2001 menu If a patient’s total WBC count is 2,500/mL and the following relative distribution is found on the differential WBC count, what interpretation can be made regarding increased or decreased cell lines? 50% neutrophils lymphocytes 50%
How are these data interpreted? csw lsuhsc 2001 menu 50% neutrophils 50% lymphocytes According to the relative reference ranges (i.e., neutrophils 40-72% and lymphocytes 24-45%), the relative values for: • Neutrophils (50%) were within “normal” range. • Lymphocytes (50%) were increased. Does this patient have lymphocytosis?
What was your evaluation? csw lsuhsc 2001 menu 1250/mL neutrophils When evaluated with the total WBC count of 2500/mL, the absolute numbers are: If you responded yes (i.e., lymphocytosis), you were wrong. The patient has neutropenia. Although the relative % of PMN is “normal”, the absolute number (1250/mL) is less than the lower limit of “normal” 1800/mL). Also, even though the relative % for lymphocytes is increased, the absolute number (1250/mL) is within “normal” range (1100 - 5000/mL). lymphocytes 1250/mL
Summary of relative % vs. absolute number: csw lsuhsc 2001 menu An increase or decrease in a cell line is determined by the absolute number of that type of cell in circulating peripheral blood. To determine the absolute number, the total WBC count and frequency distribution must be determined. Relative % is reliable as an indicator of normal only if both the percent and the total number of WBC are within normal.
End of Relative % vs. Absolute Number csw lsuhsc 2001 This concludes the Introduction to the Differential WBC Count. Select one of the following: Go to Review of White Blood Cell Morphology, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
Review of WBC Morphology csw lsuhsc 2001 menu
What other study of WBC is included in a “diff”? csw lsuhsc 2001 menu In addition to the differential WBC count, the leukocytes are examined as to maturity and morphology. Are immature cells present? Do the cells show abnormal acquired or inherited morphologic alterations?
E.g., are the WBC mature or immature? csw lsuhsc 2001 menu immature neutrophils mature cells or
For example, if the mature and immature cells shown in the example “diff” were present in the percentage shown below: csw lsuhsc 2001 menu 70% 2% 20% 3% 2% 3%
What leukocytic cells can be identified? csw lsuhsc 2001 menu 2% 20% 3% 2% 3% eosinophil metamyelocyte 70% PMN lymphocyte myelocyte band neutrophil mature immature
Are the immature cells shown in the example ever seen in normal blood? csw lsuhsc 2001 menu 3% 2% 3% band neutrophil (normally may be present in blood up to about 5%) neutrophilic metamyelocyte (are not normally present in blood) neutrophilic myelocyte (are not normally present in blood)
Examples of acquired non-neoplastic alterations that can be differentiated on a “diff”, e.g.? csw lsuhsc 2001 menu hypersegmented neutrophil atypical/reactive lymphocyte and toxic granulation neutrophil with Dohle bodies 1 2 4 7 6 3 5
Examples of inherited abnormal non- neoplastic alterations of neutrophils that can be differentiated on a “diff”. csw lsuhsc 2001 menu hyposegmented neutrophil in Pelger-Huet anomaly cytoplasmic blue bodies in May-Hegglin anomaly cytoplasmic black granules in Alder-Reilly anomaly cytoplasmic large black granules in Chediak-Higashi syndrome
Examples of neoplastic WBC alterations that can be differentiated on a “diff”: hairy cell lymphocytes seen in hairy cell leukemia Auer rods seen in some variants of acute myelocytic leukemias csw lsuhsc 2001 menu
Are cell types other than WBC differ- entiated and enumerated as part of the “diff”? proerythroblast polychromatophilic erythroblast orthochromatophilic erythroblast csw lsuhsc 2001 menu Although NRBC are not included in the 100 white blood cell count, identification and enumeration of the number of NRBC/100 WBC is a part of the information provided by a “diff”. For example, the number of basophilic erythroblast
End of CBC - 2 csw lsuhsc 2001 This concludes the CBC – Part 2 segment of the study module, “The Complete Blood Cell Count (CBC)”. Click on Main Menu to review a section. OR Click on to quit the exercise.
THE END csw lsuhsc 2001 quit Additional modules of the CBC are presented in: CBC – Part 1 The hemogram Review of “Hematology Atlas”, a module on normal and abnormal blood cell morphology and maturation is recommended as a prerequisite for the CBC modules. CBC - Part 3 RBC morphology & platelet estimate CBC – Part 4 Post-test

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CBC Part 2 - WBC Differential & Morphology.pdf

  • 1.
    The Complete BloodCell Count (CBC) CBC – Part 2 WBC Differential Count and Morphology Louisiana State University Health Sciences Center Department of Pathology New Orleans, Louisiana by Carolyn Sue Walters, MHS, MT(ASCP) A Clinical Pathology 201 Study Module click here to continue School of Medicine ©01-07-03 DO NOT REPRODUCE THIS EXERCISE.
  • 2.
    C. Sue Walters,MHS, MT(ASCP) click here to continue Associate Professor Department of Pathology LSU Health Sciences Center New Orleans, LA csw lsuhsc 2001
  • 3.
    csw lsuhsc 2001 This study exerciseis the property of Carolyn Sue Walters, MHS, MT(ASCP) and the Department of Pathology, LSU Health Sciences Center in New Orleans, LA. All rights are reserved. It is intended for use solely within the LSUHSC campus network. No part of this exercise may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (to include but not be restricted to electronic, mechanical, recording, and photo-copying) without prior written permission from the author. The CBC click here to continue
  • 4.
    csw lsuhsc 2001 Special thanks isgiven to Ms. Angela Foley, MS, MT(ASCP), Department of Clinical Laboratory Sciences, LSUHSC School of Allied Health in New Orleans, LA for the use of some of her images of blood cells and for her assistance in the art of creating image files. Special Acknowledgment click here to continue
  • 5.
    csw lsuhsc 2001 The CBC clickhere to continue This is the second module of a 4-part study exercise regarding the CBC. The 4 parts are entitled: CBC – Part 1 The hemogram CBC – Part 2 WBC differential & blood morphology CBC – Part 3 RBC morphology & platelet estimate CBC – Part 4 Post-test The review of hematopoiesis and blood cell morphology (i.e., Hematology Atlas located on the LSUHSC server) is recommended as a prerequisite for the CBC exercise.
  • 6.
    Feedback Feedback as tothe quality and usefulness of this exercise is solicited and suggestions for improvement are welcomed. Please forward your remarks by E-mail cwalte@lsuhsc.edu or via US MAIL: C. Sue Walters, MHS, MT(ASCP) LSUHSC Department of Pathology 1901 Perdido Street New Orleans, LA 70112 click here to continue csw lsuhsc 2001
  • 7.
    Directions csw lsuhsc 2001 The directions fornavigating through the exer- cise are given on the next 3 pages. They are the same as those used in the other modules of this 5-part exercise. Click on: to visit the directions before continuing with the exercise. to go directly to the Main Menu. or
  • 8.
    Directions, continued csw lsuhsc 2001 in theupper left hand corner of every page to return to the previous page menu in the upper right corner of the page to return to the Main Menu selection. The following directional icons are provided throughout the exercise for your convenience. You can click on: csw lsuhsc 2001 click here to continue
  • 9.
    Directions, continued csw lsuhsc 2001 You canclick on: in the lower right corner of the page to continue. Quit in the lower right corner of the Main Menu page to Quit (i.e., end the exercise).
  • 10.
    Directions, continued csw lsuhsc 2001 “Hot points”(symbols, words, phrases) have been inserted on the pages as navigational tools and can be identified by their “gold” color. If it’s “gold”, click on it to move to the next text/data entry. Also, sounds have been added in a few places for emphasis. Remember, if it’s gold, click on it. Try it! Caution, failure to follow the structured order of the “hot points” may result in confusion. If you use the mouse without placing the cursor directly on the “hot point” , you may skip over vital information.
  • 11.
    Special Comments csw lsuhsc 2001 This exercisehas numerous images. You may note that, when a page contains images, there may be a rather long delay before you regain control of the cursor. Please be patient. I think you will find the images are worth the wait. NOTE: Some animation and/or interactive affects may be lost if you attempt to replay a page by re- turning to the previous page and then advanc- ing to that page again. Now, click on the gold to begin.
  • 12.
    csw lsuhsc 2001 CBC -Part 2 The Complete Blood Cell Count (CBC) Part 2 WBC Differential Count & Morphology
  • 13.
    MAIN MENU Introduction &Review of WBC Morphology csw lsuhsc 2001 Quit Manual differential WBC count Total WBC count vs. differential WBC count Relative % vs. absolute number Review: mature & immature WBC; non- neoplastic WBC alterations; neoplastic WBC alterations
  • 14.
    Introduction & Review ofWBC Morphology csw lsuhsc 2001 menu
  • 15.
    WBC distribution &morphology Evaluation of the distribution and morphology of white blood cells is one of the most valuable procedures used in examination of the blood. The information obtained may furnish the diagnosis, serve as a guide to therapy and as an indicator of harmful effects of radiotherapy and chemotherapy. csw lsuhsc 2001 menu
  • 16.
    continued csw lsuhsc 2001 menu A study ofwhite blood cell morphology and distribution of blood cells is an essential part of the clinical description of practically every disease. A normal number and distribution of cells in the blood are so important as physiologic constants that some authorities say the absence of disease cannot be determined until this information is available.
  • 17.
    What WBC arepresent in normal peripheral blood? csw lsuhsc 2001 menu 1. granulocytes In normal peripheral blood, there are three basic types of leukocytes (illustrated below). monocytes 3. eosinophils basophils neutrophils lymphocytes 2. normal atypical (few) mature band
  • 18.
    Are white bloodcell abnormalities associated with disease? csw lsuhsc 2001 menu An abnormal number and/or distribution of leuko- cytes (WBC) may be seen in disease. Immature WBC and/or WBC with abnormal alterations may also be seen. The immature and abnormal cells are distinguishable from normal cells by their morphologic characteristics. Recognition and identification of these abnormal- ities play a major role in the diagnosis and treat- ment of true blood diseases and numerous other pathologic processes. continue w/o review Review immature and abnormal WBC or
  • 19.
    Examples of immatureWBC: granulocytes (various stages) myeloblasts lymphoblasts monoblasts csw lsuhsc 2001 menu
  • 20.
    Examples of granulocytesin various stages of maturation: 1 late myeloblast or early promyelocyte 1 2 late promyelocyte or early myelocyte 2 3 myelocyte 3 3 4 metamyelocyte 4 4 4 4 4 5 band neutrophil 5 5 5 5 5 6 mature segmented neutrophil (PMN) 6 6 7 eosinophil 7 8 Whoa! 8 That’s not a WBC. It’s a nucleated RBC but will also be included in the total WBC count. menu csw lsuhsc 2001
  • 21.
    Now, Can youIdentify the stages of granulocytes just illustrated? 1 1 late myeloblast or early promyelocyte 2 2 late promyelocyte or early myelocyte 3 3 3 myelocyte 4 4 4 4 4 4 metamyelocyte 5 5 5 5 5 5 band neutrophil 6 6 6 mature segmented neutrophil (PMN) 7 7 eosinophil 8 menu NRBC csw lsuhsc 2001 8
  • 22.
    Overview of thestages of granulocytes just illustrated: 1 1 late myeloblast or early promyelocyte 2 2 late promyelocyte or early myelocyte 3 3 3 myelocyte 4 4 4 4 4 4 metamyelocyte 5 5 5 5 5 5 band neutrophil 6 6 6 mature segmented neutrophil (PMN) 7 7 eosinophil 8 menu NRBC csw lsuhsc 2001 8 review granulocytes again or continue
  • 23.
    Another look atthe granulocytes just illustrated: 1 1 late myeloblast or early promyelocyte 2 2 late promyelocyte or early myelocyte 3 3 3 myelocyte 4 4 4 4 4 4 metamyelocyte 5 5 5 5 5 5 band neutrophil 6 6 6 mature segmented neutrophil (PMN) 7 7 eosinophil 8 menu NRBC csw lsuhsc 2001 8
  • 24.
    Examples of WBCwith acquired non-neoplastic alterations: neutrophils in bacterial infections with Dohle bodies and/or toxic granulation in megaloblastic anemias with nuclear hypersegmen- tation (ie, > 5 lobes) lymphocytes in viral infections with reactive (atypical) changes inherited disorders csw lsuhsc 2001 menu
  • 25.
    Examples of WBCwith inherited non-neoplastic alterations: Pelger-Huet Anomaly hyposegmented nuclei May-Hegglin Anomaly cytoplasmic blue bodies Alder-Reilly Anomaly cytoplasmic black granules csw lsuhsc 2001 Chediak-Higashi Syndrome cytoplasmic large black granules menu
  • 26.
    Examples of neoplasticWBC alterations: hairy cell lymphocytes hairy cell leukemia & myeloblasts w/ Auer rod(s) acute myelocytic leukemias csw lsuhsc 2001 menu
  • 27.
    What can belearned from a differential WBC count? csw lsuhsc 2001 menu Because the total WBC count does not differen- tiate WBCs as to cell lines, a differential WBC count (“diff”) is performed to provide informa- tion regarding the frequency distribution of WBCs and to identify increases or decreases when they occur in one or more of the cell lines. A morphologic study of the various blood cells (i.e., WBC, RBC, & platelets) is made during the differentiation process to detect and identify atypical and/or abnormal cells.
  • 28.
    What methods canbe used for the differential WBC count ? The differential WBC count and blood cell study may be performed by one of several methods, e.g.: csw lsuhsc 2001 menu • An automated multi-channel instrument (in this exercise, it is a Coulter STK-S 5-part differential), which is discussed in the auto- mated CBC section. OR • A manual microscopic examination of a Wright’s (or Wright’s Giemsa) stained peripheral blood smear.
  • 29.
    End of Introduction csw lsuhsc 2001 Thisconcludes the Introduction to the Differential WBC Count. Select one of the following: Go to Manual Differential WBC Count, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
  • 30.
    Manual Differential WBCCount csw lsuhsc 2001 menu
  • 31.
    What kind ofblood smear is used ? csw lsuhsc 2001 menu A peripheral blood film (made from a drop of blood from an EDTA anticoagulated tube or skin puncture) is stained with Wright (or Wright-Giemsa) stain and microscopically examined using scanning (10x), high-dry (40x), and oil (100x) objectives. Refer to the Clinical Pathology 202 Course Manual for the complete procedure.
  • 32.
    What studies willbe performed on the stained blood smear? csw lsuhsc 2001 menu A complete differential WBC count (“diff”) which includes identification of mature and (if any) immature WBC and description of WBC morph- ologic alterations. A complete description of RBC morphology which includes (if any) a description of RBC morphologic alterations and, if present, the number of NRBC per 100 WBC. Platelet estimate of adequacy which includes (if any) abnormal morphologic alterations, distribution, and clumps.
  • 33.
    continued: csw lsuhsc 2001 menu This section islimited to the differential count and morphology of white blood cells. RBC morphology and platelet estimate discus- sions are addressed later in other sections.
  • 34.
    How are theWBC identified and classified? csw lsuhsc 2001 menu Typical nuclear and cytoplasmic morphologic features provide a means by which WBC can be identified and classified as to: • cell line (i.e., granulocytes [neutrophils, eosino- phils, or basophils], lymphocytes, or mono- cytes) • maturity (i.e., mature cell or specific immature stage of development). • abnormal morphology (i.e., nuclear or cyto- plasmic alterations)
  • 35.
    How are theWBC differentiated and enumerated? csw lsuhsc 2001 menu At least 100 WBC are counted and a tabulation is made as to the number of each leukocytic cell type included in the count. The 100 cell count provides the RELATIVE number (or percent) of each white blood cell type present in the peripheral blood.
  • 36.
    How can youdetermine whether there is an increase or decrease of one or more of the cell lines? csw lsuhsc 2001 menu Increases or decreases in a white blood cell line (or type) can then be determined by comparing the number obtained on the differential count with established reference ranges.
  • 37.
    Reference Range (Relative%) csw lsuhsc 2001 menu segmented neutrophils 50-70% band neutrophils 0- 5% eosinophils 1-5% lymphocytes 20-40% monocytes 1-6% Reference ranges (values considered to be normal) for differential WBC counts may vary among laboratories, but are usually about:
  • 38.
    What terminology isused to indicate an increased or decreased number of a specific white blood cell line? csw lsuhsc 2001 menu Cell Line Increased: Decreased: Neutrophils Lymphocytes Monocytes Eosinophils Basophils Neutrophilia Neutropenia Lymphocytosis Lymphocytopenia Monocytosis Monocytopenia Eosinophilia Eosinopenia Basophilia Basopenia
  • 39.
    csw lsuhsc 2001 menu continue without review ReviewWBC morphology or Review Morphology?
  • 40.
    WBC in NormalBlood (Adults): PMN band (neutrophils) eosinophil basophil monocyte lymphocyte ATL (few) (atypical lymphocyte) csw lsuhsc 2001 menu
  • 41.
    Examples of immatureWBC: granulocytes (various stages) myeloblasts lymphoblasts monoblasts csw lsuhsc 2001 menu
  • 42.
    Examples of granulocytesin various stages of maturation: 1 late myeloblast or early promyelocyte 1 2 late promyelocyte or early myelocyte 2 3 myelocyte 3 3 4 metamyelocyte 4 4 4 4 4 5 band neutrophil 5 5 5 5 5 6 mature segmented neutrophil (PMN) 6 6 7 eosinophil 7 8 8 It’s a nucleated RBC but will also be included in the WBC count. menu csw lsuhsc 2001
  • 43.
    Examples of WBCwith acquired non-neoplastic alterations: neutrophils in bacterial infections with Dohle bodies and/or toxic granulation in megaloblastic anemias with nuclear hypersegmen- tation (ie, > 5 lobes) lymphocytes in viral infections with reactive (atypical) changes csw lsuhsc 2001 menu
  • 44.
    Examples of WBCwith inherited non-neoplastic alterations: Pelger-Huet Anomaly hyposegmented nuclei May-Hegglin Anomaly cytoplasmic blue bodies Alder-Reilly Anomaly cytoplasmic black granules csw lsuhsc 2001 Chediak-Higashi Syndrome cytoplasmic large black granules menu
  • 45.
    Examples of neoplasticWBC alterations: hairy cell lymphocytes hairy cell leukemia myeloblasts w/ Auer rod(s) acute myelocytic leukemias csw lsuhsc 2001 menu
  • 46.
    Examples of nucleatedRBC in various stages of maturation. proerythroblast (earliest form w/ nucleoli) basophilic erythroblast (ill-defined or absent nucleoli) polychromatophilic erythroblast (cytoplasmic evidence of HGB) orthochromatophilic erythroblast (last stage before extrusion of nucleus) csw lsuhsc 2001 menu
  • 47.
    End of ManualDifferential WBC Count & Morphology csw lsuhsc 2001 This concludes the Manual WBC Differential Count and Morphology section. Select one of the following: Go to Total WBC Count vs. Differential WBC Count, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
  • 48.
    Total WBC Count vs. DifferentialWBC Count csw lsuhsc 2001 menu
  • 49.
    How does thedifferential WBC count differ from the total WBC count? csw lsuhsc 2001 menu The total WBC count reflects the total number of all leukocytes in circulation but does not differ- entiate leukocytes as to their various cell lines (e.g., neutrophils, lymphocytes), stage of matur- ity, (e.g., band, metamyelocyte), or abnormalities when present (e.g., toxic granulation, hyperseg- mented nuclei). A differential WBC count must be performed to provide that information.
  • 50.
    Total WBC count= total number of leukocytes without differentiation: csw lsuhsc 2001 menu
  • 51.
    “Diff” - differentiatesand enumerates WBC according to cell type, e.g.: csw lsuhsc 2001 menu neutrophils, mature lymphocytes monocytes eosinophils basophils
  • 52.
    “Diff” - providesfrequency distribution (relative % and absolute number/mL, e.g. total WBC = 10,000/mL): csw lsuhsc 2001 menu neutrophils, mature 65% 6500/mL lymphocytes 28% 2800/mL monocytes 3% 300/mL eosinophils 3% 300/mL basophils 1% 100/mL
  • 53.
    Total WBC count- mature and (if present) immature WBC w/o differentiation, e..g.: csw lsuhsc 2001 menu blast promyelocyte myelocyte metamyelocyte band
  • 54.
    “Diff” - differentiatesand enumerates mature and (if present) immature WBC, e.g.: csw lsuhsc 2001 menu mature neutrophil eosinophil basophil lymphocyte monocyte blast promyelocyte myelocyte metamyelocyte neutrophilic band immature
  • 55.
    “Diff” - providesfrequency distribution (relative % and absolute number e.g., total WBC=50,000/mL): csw lsuhsc 2001 menu neutrophil, bands 15% 7500/mL neutrophil, mature 50% 25000/mL metamyelocyte 12% 6000/mL myelocyte 7% 3500/mL promyelocyte, 2% 1000/mL blast 1% 500/mL eosinophil 5% 2500/mL basophil 3% 1500/mL lymphocyte 5% 2500/mL monocyte 0% 0/mL
  • 56.
    Total WBC count- normal and abnormal WBC without differentiation, e.g.: csw lsuhsc 2001 menu acquired WBC alterations
  • 57.
    “Diff” - differentiatesabnormal WBC with acquired alterations, e.g.: csw lsuhsc 2001 menu reactive/atypical lymphocytes Dohle bodies toxic granulation hypersegmented neutrophils
  • 58.
    Total WBC count- normal and abnormal WBC without differentiation, e.g.: csw lsuhsc 2001 menu inherited WBC alterations
  • 59.
    “Diff” - differentiatesabnormal WBC with inherited alterations, e.g.: csw lsuhsc 2001 menu Pelger-Huet Anomaly May-Hegglin Anomaly Alder-Reilly Anomaly Chediak-Higashi Syndrome
  • 60.
    Total WBC count- normal and (if pre- sent) neoplastic WBC w/o differentiation: csw lsuhsc 2001 menu e.g., leukemic alterations
  • 61.
    “Diff” - differentiatesWBC with neoplastic alterations, e.g.: csw lsuhsc 2001 menu or hairy cell lymphocyte myeloblast w/ Auer rod
  • 62.
    End of Totalvs. Differential WBC Counts csw lsuhsc 2001 This concludes the Introduction to the Differential WBC Count. Select one of the following: Go to Relative % vs. Absolute Number, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
  • 63.
    Relative % vs.Absolute Number csw lsuhsc 2001 menu
  • 64.
    What is meantby the relative % and absolute number of WBC ? csw lsuhsc 2001 menu Relative % is based on the differential count of 100 white blood cells and reflects the per cent of each cell type present in circulation. If the total number of white cells in circulating blood is known and the relative per cent of each white cell type is known, then the absolute number of each cell type per mL of blood can be calculated.
  • 65.
    continued: csw lsuhsc 2001 menu For example: givena patient with a total WBC count of 8,000/mL and the differential WBC count shown below (i.e., the number observed for each cell type in the 100 white cell count): Segmented neutrophils 60% Band neutrophils 5% Lymphocytes 30% Monocytes 2% Eosinophils 2% Basophils 1%
  • 66.
    continued: csw lsuhsc 2001 menu Then the absolutenumber of each cell type/mL can be calculated by multiplying the per cent of each cell type by the total number of WBC/mL. x 8,000 = 4,800 x 8,000 = 400 x 8,000 = 2,400 x 8,000 = 160 x 8,000 = 160 x 8,000 = 80 = 8,000 Segmented neutrophils 60% Band neutrophils 5% Lymphocytes 30% Monocytes 2% Eosinophils 2% Basophils 1% Total = 100%
  • 67.
    What are therelative reference ranges for leukocytes? csw lsuhsc 2001 menu Cell Type Reference Ranges (Relative %) (bands) 0-5 Eosinophils 0-6 Basophils 0-0.2 Lymphocytes 24- 45 Monocytes 0.4 - 10 Neutrophils 40-72 (PMN)
  • 68.
    Do the relativevalues always indicate which cell line is or ? csw lsuhsc 2001 menu If the total WBC count is “normal” (i.e., within the established reference range), the relative values are a good reflection of the number of each cell type present, including increases or decreases. However, if the total WBC count is abnormal (i.e., increased or decreased), the relative percentage must be converted to an absolute number of each cell type present in order to determine which cell line is involved.
  • 69.
    How is therelative % converted to an absolute number ? csw lsuhsc 2001 menu For each white blood cell line, multiply the percentage of cells counted (i.e., during the 100 cell count) by the total white blood cell count to obtain the absolute number for the cell line. For example: Total WBC/mL x relative % = absolute no./mL
  • 70.
    Given a patientwhose total WBC is 8,000/mL, csw lsuhsc 2001 menu and the relative distribution of leukocytes on the peripheral blood smear is as shown below: segmented neutrophils 65% band neutrophils 5% eosinophils 2% lymphocytes 25% monocytes 3% How are the absolute numbers determined?
  • 71.
    How are theabsolute numbers calculated (total WBC = 8,000/mL)? csw lsuhsc 2001 menu Cell Type Relative % Absolute No. (8,000 x 0.05) 65 Neutrophil (mature segmented) (8,000 x 0.65) 5,200/mL Neutrophil (band) 5 400/mL
  • 72.
    continued: csw lsuhsc 2001 menu Cell Type Relative% Absolute No. Eosinophil Lymphocyte Monocyte 2 (8,000 x 0.02) 160/mL 3 25 2,000/mL (8,000 x 0.25) 240/mL (8,000 x 0.03)
  • 73.
    Total WBC 8,000/mLx Relative %: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Neutrophil (band) 5 400/mL Monocyte 3 240/mL Lymphocyte 25 2,000/mL Eosinophil 2 160/mL Neutrophil (mature segmented) 5,200/mL 65 Total 100 8,000/mL
  • 74.
    What are theabsolute reference ranges for leukocytes? csw lsuhsc 2001 menu The total WBC count reference range for adults is 4,500- 11,000/mL at Charity & University Hospitals, but may vary slightly among laboratories: CELL TYPE RELATIVE % ABSOLUTE NO./mL Segmented neutrophils 42 - 72 1800 - 8000 Neutrophilic bands 0 - 5 0 - 550 Eosinophils 1 - 6 45 - 550 Basophils 0 – 0.2 0 - 200 Lymphocytes 24 - 45 1100 - 5000 Monocytes 0.4 - 10 200 - 1100 Reference Ranges
  • 75.
    In this case,did the relative per cents reflect the absolute numbers ? csw lsuhsc 2001 menu The total WBC count was within the reference range. Therefore, because both the total and relative frequencies are within reference ranges, the relative % is a reflection of the absolute numbers in terms of normal or abnormal. The relative per cent for each cell type was within reference range.
  • 76.
    However, given apatient whose total WBC is 15,000/mL, csw lsuhsc 2001 menu with a relative distribution of leukocytes on the peripheral blood smear the same as the previous patient: segmented neutrophils 65% band neutrophils 5% eosinophils 2% lymphocytes 25% monocytes 3% Is the interpretation the same for both patients?
  • 77.
    What are thecalculated absolute numbers in this case (i.e., total WBC = 15,000/mL)? csw lsuhsc 2001 menu 15000 x 0.65 = 9750 segmented neutrophils 15000 x 0.05 = 750 band neutrophils 15000 x 0.02 = 300 eosinophils 0.25 15000 x = 3750 lymphocytes 15000 x 0.03 = 450 monocytes The relative per cents are normal, but how do these absolute numbers compare with the established reference ranges?
  • 78.
    Are the absolutenumbers still within the reference ranges? csw lsuhsc 2001 menu Neutrophils (mature) Neutrophils (bands) Eosinophils Lymphocytes Monocytes Cell Type Patient Reference Ranges Absolute No./mL 1800 - 8000 9750 0 - 550 750 0 - 600 300 1100 - 5000 3750 200 - 1100 450 H H
  • 79.
    Comparison of relative% and absolute numbers: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Neutrophil (band) 5 750/mL Monocyte 3 450/mL Lymphocyte 25 3,750/mL Eosinophil 2 300/mL Neutrophil (mature segmented) 9,750/mL 65 Total 100 15,000/mL N H N H
  • 80.
    Do the relativeand absolute values have the same interpretation in this case? csw lsuhsc 2001 menu The relative percentages for all cell types for this patient were within the reference range (i.e., normal). However, in this case, there is neutrophila when converted to absolute numbers based on a total WBC count of 15,000/mL because:  segmented (mature) neutrophils = 9,750/mL which exceeds the reference range (1800 - 8000/mL)  band neutrophils = 750/mL which also exceeds the reference range (0 - 550/mL).
  • 81.
    Given another patientwhose total WBC is 15,000/mL, csw lsuhsc 2001 menu and a relative distribution of leukocytes on the peripheral blood smear as shown below: segmented neutrophils 75% band neutrophils 5% eosinophils 2% lymphocytes 15% monocytes 3% How are these data interpreted?
  • 82.
    How are theabsolute numbers calculated (total WBC = 15,000/mL)? csw lsuhsc 2001 menu Cell Type Relative % Absolute No. (15,000 x 0.05) 75 Neutrophil (mature segmented) (15,000 x 0.75) 11,250/mL Neutrophil (band) 5 750/mL
  • 83.
    csw lsuhsc 2001 menu Cell Type Relative% Absolute No. Eosinophil Lymphocyte Monocyte 2 (15,000 x 0.02) 300/mL 15 2,250/mL (15,000 x 0.15) 3 450/mL (15,000 x 0.03)
  • 84.
    Total WBC 15,000/mLx Relative %: csw lsuhsc 2001 menu Cell Type Relative % Absolute No. Neutrophil (band) 5 750/mL Monocyte 3 450/mL Lymphocyte 15 2,250/mL Eosinophil 2 300/mL Neutrophil (mature segmented) 11,250/mL 75 Total 100 15,000/mL H H N H N N L N N N
  • 85.
    Do the relativeand absolute values have the same interpretation? csw lsuhsc 2001 menu According to the relative percentages, this patient had increased neutrophils (neutrophilia) and decreased lymphocytes (lymphocytopenia). When converted to absolute numbers based on a total WBC count of 15,000/mL, • there is indeed neutrophilia (11,250/mL) which exceeds the reference range (11 - 5000/mL) • but the number of lymphocytes (i.e., 2,250/mL) is within the reference range (1000-5000/mL).
  • 86.
    What if thepatient’s total WBC is decreased? For example… csw lsuhsc 2001 menu If a patient’s total WBC count is 2,500/mL and the following relative distribution is found on the differential WBC count, what interpretation can be made regarding increased or decreased cell lines? 50% neutrophils lymphocytes 50%
  • 87.
    How are thesedata interpreted? csw lsuhsc 2001 menu 50% neutrophils 50% lymphocytes According to the relative reference ranges (i.e., neutrophils 40-72% and lymphocytes 24-45%), the relative values for: • Neutrophils (50%) were within “normal” range. • Lymphocytes (50%) were increased. Does this patient have lymphocytosis?
  • 88.
    What was yourevaluation? csw lsuhsc 2001 menu 1250/mL neutrophils When evaluated with the total WBC count of 2500/mL, the absolute numbers are: If you responded yes (i.e., lymphocytosis), you were wrong. The patient has neutropenia. Although the relative % of PMN is “normal”, the absolute number (1250/mL) is less than the lower limit of “normal” 1800/mL). Also, even though the relative % for lymphocytes is increased, the absolute number (1250/mL) is within “normal” range (1100 - 5000/mL). lymphocytes 1250/mL
  • 89.
    Summary of relative% vs. absolute number: csw lsuhsc 2001 menu An increase or decrease in a cell line is determined by the absolute number of that type of cell in circulating peripheral blood. To determine the absolute number, the total WBC count and frequency distribution must be determined. Relative % is reliable as an indicator of normal only if both the percent and the total number of WBC are within normal.
  • 90.
    End of Relative% vs. Absolute Number csw lsuhsc 2001 This concludes the Introduction to the Differential WBC Count. Select one of the following: Go to Review of White Blood Cell Morphology, the next section, to continue with the exercise as designed. Return to the Main Menu and make an alternate selection. OR
  • 91.
    Review of WBCMorphology csw lsuhsc 2001 menu
  • 92.
    What other studyof WBC is included in a “diff”? csw lsuhsc 2001 menu In addition to the differential WBC count, the leukocytes are examined as to maturity and morphology. Are immature cells present? Do the cells show abnormal acquired or inherited morphologic alterations?
  • 93.
    E.g., are theWBC mature or immature? csw lsuhsc 2001 menu immature neutrophils mature cells or
  • 94.
    For example, ifthe mature and immature cells shown in the example “diff” were present in the percentage shown below: csw lsuhsc 2001 menu 70% 2% 20% 3% 2% 3%
  • 95.
    What leukocytic cellscan be identified? csw lsuhsc 2001 menu 2% 20% 3% 2% 3% eosinophil metamyelocyte 70% PMN lymphocyte myelocyte band neutrophil mature immature
  • 96.
    Are the immaturecells shown in the example ever seen in normal blood? csw lsuhsc 2001 menu 3% 2% 3% band neutrophil (normally may be present in blood up to about 5%) neutrophilic metamyelocyte (are not normally present in blood) neutrophilic myelocyte (are not normally present in blood)
  • 97.
    Examples of acquirednon-neoplastic alterations that can be differentiated on a “diff”, e.g.? csw lsuhsc 2001 menu hypersegmented neutrophil atypical/reactive lymphocyte and toxic granulation neutrophil with Dohle bodies 1 2 4 7 6 3 5
  • 98.
    Examples of inheritedabnormal non- neoplastic alterations of neutrophils that can be differentiated on a “diff”. csw lsuhsc 2001 menu hyposegmented neutrophil in Pelger-Huet anomaly cytoplasmic blue bodies in May-Hegglin anomaly cytoplasmic black granules in Alder-Reilly anomaly cytoplasmic large black granules in Chediak-Higashi syndrome
  • 99.
    Examples of neoplasticWBC alterations that can be differentiated on a “diff”: hairy cell lymphocytes seen in hairy cell leukemia Auer rods seen in some variants of acute myelocytic leukemias csw lsuhsc 2001 menu
  • 100.
    Are cell typesother than WBC differ- entiated and enumerated as part of the “diff”? proerythroblast polychromatophilic erythroblast orthochromatophilic erythroblast csw lsuhsc 2001 menu Although NRBC are not included in the 100 white blood cell count, identification and enumeration of the number of NRBC/100 WBC is a part of the information provided by a “diff”. For example, the number of basophilic erythroblast
  • 101.
    End of CBC- 2 csw lsuhsc 2001 This concludes the CBC – Part 2 segment of the study module, “The Complete Blood Cell Count (CBC)”. Click on Main Menu to review a section. OR Click on to quit the exercise.
  • 102.
    THE END csw lsuhsc 2001 quit Additional modulesof the CBC are presented in: CBC – Part 1 The hemogram Review of “Hematology Atlas”, a module on normal and abnormal blood cell morphology and maturation is recommended as a prerequisite for the CBC modules. CBC - Part 3 RBC morphology & platelet estimate CBC – Part 4 Post-test