Basic guide to Clinical Haematology with compilation from Standard textbooks. More inclined to clinical applications of Haematology.

1. CLINICAL HAEMATOLOGY
Basic Guide
Presented by Kushan Singh

2. Clinical Haematology
It acts as a practical guide to the
diagnosis and treatment of disorders of
red blood cells, white blood cells, and
haemostasis.

3. Common Haematological Tests
1. CBC & PBS
2. Marrow Examination
3. Red Blood Cell Mass
4. Iron Supply Studies
5. Serum Folate
6. Serum B-12
7. Complement system studies
8. Genetic studies

4. Complete Blood Count
C. White Cells
1. Total Leukocyte Count
2. Differential Leukocyte Count
D. Platelet Count
E. PBS
1. Cell Size
2. Haemoglobin Content
3. Anisocytosis
4. Poikilocytosis
5. Polychromasisa
A. Red Cells
1. Red Cell Count
2. Haemoglobin
3. Haematocrit
4. Reticulocyte Count
B. Red Blood Cell Indices
1. MCV
2. MCH
3. MCHC
4. RDW

5. RED CELL COUNT
Number of red cells in a unit volume of blood
Normal Range
Male : 4.5 — 6.5 x 106/mm3
Female : 3.8 — 5.8 x 106/mm3

6. HAEMOGLOBIN
AGE/SEX HEMOGLOBIN g/dl
BIRTH 17
CHILDHOOD 12
ADOLOSCENCE 13
ADULT MAN 16 ± 2
ADULT WOMAN (menstruating) 13 ± 2
ADULT WOMAN (postmenopausal) 14 ± 2
DURING PREGNANCY 12 ± 2
Mass of haemoglobin after lysis of red cells present in a unit volume of blood

7. HAEMATOCRIT
AGE/SEX HEMATOCRIT
BIRTH 52
CHILDHOOD 36
ADOLOSCENCE 40
ADULT MAN 47 ± 6
ADULT WOMAN (menstruating) 40 ± 6
ADULT WOMAN
(postmenopausal)
42 ± 6
DURING PREGNANCY 37 ± 6
Volume occupied by red cells in a unit volume of blood
Rule of 3 : Haematocrit = Haemoglobin x 3

8. Red Blood Cell Mass
Absolute volume occupied by red cells in blood
Normal Range (mL/kg)
Note: It is not a ratio and does not change with change in plasma volume
Red Blood Cell
Volume
Plasma Volume
Total Blood
Volume
Men 30 ± 5 35 ± 5 65 ± 8
Women 25 ± 5 35 ± 5 60 ± 7

9. Erythrocytosis
ABSOLUTE ERYTHROCYTOSIS
Red Blood Cell Mass is increased
RELATIVE ERYTHROCYTOSIS
Haematocrit is increased but Red Blood Cell Mass is not raised

10. Differentials for
Erythrocytosis

11. Polycythaemia vera
WHO Diagnostic Criteria (2007)
Major criteria
1. Hb > 18.5 g/dL in men; Hb > 16.5 g/dL in women Or
Increased red cell mass ( > 36 mL/kg in men; > 32 mL/kg in women )
2. JAK2 V617F mutation present
Minor criteria
• Prominent leukocytosis, thrombocytosis, or bone marrow hypercellularity
involving all cell lines
• EPO levels: <4 mU/ml (or normal reference range)
• BFU-E hypersensitivity to EPO

12. Approach to DDs of
patients with ↑Hb

13. RETICULOCYTE COUNT (or RPI)
Ratio of reticulocytes to red cells in the blood expressed as percentage
• To check Marrow response
• Haematologist counts 1000 red cells
• The number of reticulocytes observed are expressed in percentage
RPI is falsely elevated in anaemia
Therefore, corrections are applied

14. CORRECTION
CORRECTION I (for anemia) :
Reticulocyte count x [ Hb of the patient / Hb normal for the age ]
When to apply? : This correction is applied when there is low hematocrit
Why to apply? : The percentage of reticulocytes may be falsely elevated
because the whole blood contains fewer RBCs

15. CORRECTION II (for longer life of prematurely released reticulocytes
in the blood) :
Haemoglobin Correction / Maturation Time Correction
When to apply? : When polychromatophilic macrocytes are present in
PBS
Why to apply? : The normal ~1 day of maturation time of reticulocytes
increases, therefore, the immature red cells are remaining in peripheral
blood for >1 day, giving falsely elevated number of reticulocytes
CORRECTION

16. CORRECTION
Shift Factor or Maturation Time Correction Factor
Marrow normoblasts Peripheral blood
and reticulocytes (days) reticulocytes (days)
3.5 1.0
3.0 1.5
2.5 2.0
2.5 2.5
45
35
25
15
Haematocrit (%)

17. Normal Marrow Response to Anaemia
HAEMOGLOBIN(g/dL) PRODUCTION INDEX RETICULOCYTE COUNT/μL
15 1 50000
11 2 — 2.5 100000 — 150000
8 3 — 4 300000 — 400000
This table is used to check the marrow response
But, as reticulocyte count is not generally available as absolute
number of reticulocytes, therefore in anaemia % values cannot be
trusted without correction

18. Interpreting RPI
Broadly, corrected RPI can hint us in two directions:
1. RPI < 2% :
• Hypoproliferative
• Red Cell Maturation Defect
2. RPI > 3% :
• Decreased Red Cell Survival

19. MCV
Mean volume occupied by a red cell
MCV = { [ Haematocrit (%) x 10 ] / RBC count in million } fL
Normal range : 90 ± 8 fL

20. CLASSIFICATION OF
ANEMIA ON THE BASIS OF
MCV
MICROCYTIC (MCV<82fL) NORMOCYTIC (82-98fL) MACROCYTIC (MCV>98fL)
1. SIDEROBLASTIC ANEMIA
2. IRON DEFICIENCY
ANEMIA (<80fL)
3. ANEMIA OF CHRONIC
INFLAMMATION (>75fL)
4. THALESSEMIA (<70fL)
5. HAEMOGLOBINOPATHIES
(70-80fL)
1. NON MEGALOBLASTIC
• APLASTIC ANEMIA
• CHRONIC LIVER
DISEASE
• ALCOHOLOISM
2. MEGALOBLASTIC
• FOLATE DEFICIENCY
• VIT B12 DEFICIENCY
• MYELODYSPLASIA
1. HEMOLYTIC ANEMIA
2. APLASTIC ANEMIA
3. ANEMIA OF RENAL
DISEASE
4. ANEMIA OF CHRONIC
INFLAMMATION (<85fL)
5. HYPOMETABOLIC
STATES

21. MCH
Mean mass of haemoglobin present in a red cell
MCH = { [ Haemoglobin (g/dL) x 10 ] / RBC count in million } pg
Normal Range : 30 ± 3 pg

22. MCHC
Mean mass of haemoglobin in 1dL of packed red cells
MCHC = { [ Haemoglobin (g/dL) / Haematocrit (of 100 mL) ] x 100 } %
OR
MCHC = { [ MCH/MCV ] x 100 } %
Normal Range: 33 ± 2 %

23. MCH & MCHC Interpretation
Normal values imply Normochromic picture:
1. Negative Iron balance
2. Iron deficient erythropoiesis
3. Marrow Damage
• Infiltration/Fibrosis
• Aplasia
4. Decreased Stimulation
• Inflammation
• Renal disease
• Metabolic Defect

24. Decreased values imply Hypochromic picture:
1. Iron Deficiency Anaemia
2. Thalassemia
3. Hb E Disease/trait
4. Sideroblastic Anaemia
MCH & MCHC Interpretation

25. RDW
RDW = { ( Standard Deviation of MCV/ MCV ) x 100 } %
Normal range: 11—14 %

26. RDW & MCV
Lippi G, Plebani M. Recent developments and innovations in red blood cell
diagnostics. J Lab Precis Med 2018.
Normal RDW:
1. Thalassemia
2. Sickle Cell Trait
3. Anaemia in Chronic
Disease
4. Aplastic Anaemia
5. Chronic Leukaemia
6. Acute Haemorrhage

27. TOTAL LEUKOCYTE COUNT
Number of leukocytes in a unit volume of blood
Normal Range: 4 — 11 x 10³ / mm³

28. DIFFERENTIAL LEUKOCYTE COUNT
Neutrophils 40 — 70 % 2.0 — 7.5 x 10³/mm³
Lymphocyte 20 — 40 % 1.5 — 4.0 x 10³/mm³
Monocyte 2 — 10 % 0.2 — 0.8 x 10³/mm³
Eosinophil 1 — 6 % 0.04 — 0.4 x 10³/mm³
Basophil 0 — 2 % 0.01 — 0.1 x 10³/mm³

29. Neutrophilia
Adults: >7000/μL
Infants & children: >8,500/μL
Newborn: >25,000/μL
• Most important cause: Acute Infection
• Causes:
1. ↑ production: drug induced (glucocorticoids), infections,
inflammation, myeloprofirerative diseases (PV, CML)
2. ↑ marrow release: glucocorticoids, acute infection (endotoxin)
3. ↓ margination: drugs (epi., NSAIDs, glucocorticoids), Adr. rush
(stress, excitement, vigorous exercise), LAD

30. Neutropaenia
<1000/μL: sharp ↑ in
susceptibility to infections
<500/μL: impaired control of
endogenous microbial flora
(e.g., gut, mouth)
<200/μL: local inflammatory
response absent

31. Eosinophilia
>500 eosinophils/μL

32. Eosinopaenia
Causes:
• Acute bacterial infection
• Glucocorticoid treatment
There is no known adverse effect of Eosinopaenia

33. PLATELET COUNT
Number of platelets in a unit volume of blood
Normal Range : 1.5 — 4.5 x 10⁵ / mm³

34. Malignancy Clinical Presentation
White Cells
(cells/μL)
Anaemia
(Hb in g/dL)
Platelets
(cells/μL)
Marrow Response/
Cellularity
AML
Fatigue, Anorexia,
Wt. Loss, Fever,
Bruising, Bone Pain,
Splenomegaly &
Hepatomegaly
Median ~15,000
25-40%: <5,000
20%: >100,000
Not severe;
Normocytic,
Normochromic; d/t ↑
destruction
Bizarre shaped
~75%: <100,000
~25%: <25,000
RPI ↓
CML
Anaemia sx, LUQ
pain, Splenomegaly
(20-70%),
Hepatomegaly &
Lymphadenopathy (5-
10% each)
10,000-500,000;
Left shift;
↑Basophils &
Eosinophils;
Blasts ≤5%
In 1/3rd patients
Thrombocytosis
(>450,000): More
common;
Thrombocytopenia
(<100,000): Rare &
Worse prognosis
M : E = 15-20 : 1
ALL
Early: Anaemia sx,
infection & bleed
Late: LN enlargement,
hepatosplenomegaly,
Meningeosis
leukemica
Only 16%: >100,000;
Neutropaenia;
In 8%: 0 Leukemic
blasts in PB
47%: Hb >9
33%: Hb 7-9
20%: Hb <7
Thrombocytopenia;
1/5th pts: <20,000 Leukemic blasts are
predominant
CLL
Lymphadenopathy,
Splenomegaly,
Hepatomegaly
↑TLC w/ Lymphocyte
predominance; Flow
Cytometry: Clonal B
cell count ≥5000
AIHA in 10% pts
<100,000 in Stage C
of Binet Staging
System Abnormal white cells

35. Peripheral Blood Smear
Cell size
Normocytic, Microcytic, Macrocytic
Hb Content
Normochromic, Hypochromic
Anisocytosis
Difference in size of cells
Poikilocytosis
Difference in shape of cells
Polychromasia
Purple-grey staining reticulocytes with Wright’s stain

36. Normocytic, Normochromic

37. Macrocytic, Normochromic
SMALL
LYMPHOCYTE
DDs:
Macrocytic
Anaemias

38. Target cells
BULL’S EYE
APPEARANCE
DDs:
Thalassemia,
Liver disease

39. Microcytic, Hypochromic w/ Anisopoikilocytosis
SMALL
LYMPHOCYTE
TEAR
DROP
CELL
CIGAR
SHAPED
CELL
CENTRAL
PALLOR
>40%
DDs: Iron deficiency
anaemia, Anaemia of
chronic disease

40. Burr cells
red cells w/ numerous, small regularly spaced spiny projections
BURR CELL
OR
ECHINOCYTE
INDICATE:
Uraemia
DDs: CKD, Liver
Disease,
Haemolytic
Anaemia

41. Stomatocytosis
DDs: Liver
Disease,
Haemolytic
anaemia
SLIT LIKE
OPENING

42. Reticulocytes in NMB Stain
RETICULOCYTE

43. • Serum Iron: 50-150 μg/dL
• TIBC: 300-360 μg/dL
• Serum Ferritin:
Men: ~100 μg/L
Women: ~30 μg/L
• Transferrin saturation = [(SI/TIBC) x 100]: 25-50%
Iron Supply Studies

44. Stages of Iron
deficiency
Serum ferritin: 1st to be
affected
Serum ferritin < 15 μg/L:
No marrow iron stores

45. Dx of Microcytic Anaemia

46. Dx of Hypoproliferative Anaemias
Burr cells in PBS

47. Serum Folate
Normal Range
2 — 15 μg/L
Low levels: Dietary deficiency, Malabsorption, Excess utilization or
losses (pregnancy, prematurity, homocysteinuria, CHF)
High levels: Cobalamin deficiency (b/o block in conversion of MTHF
to THF)

48. Serum B-12
Normal Range: 160 — 1000 ng/L
Borderline: 100 — 200 ng/L
Deficiency of either Folate or Cobalamin can cause Megaloblastic
Anaemia

49. CASE STUDIES

50. Case-1
• 55y/F
• H/o DM 7-8y, dysnea 3mo , burning micturition 3mo, B/L pedal
oedema 3mo, melena 3mo
• GPE: pallor, b/l pitting pedal oedema, bounding pulse, tachycardia
• Endoscopy: Upper GI bleed
PARAMETERS RESULT NORMAL RANGE INTERPRETATION
HEMOGLOBIN (g/dl) 6 12 — 16 ↓
HEMATOCRIT (%) 18.9 36 — 48 ↓
RBC COUNT (in million/μL) 2.39 3.8 — 5.8 ↓
MCV (fL) 79 90 — 98 ↓
MCH (pg) 25.3 27 — 33 ↓
MCHC (g/dL) 32.1 31 — 35 N
RDW-CV (%) 22.1 11-14 ↑

51. According to CBC,
Microcytic, Hypochromic , w/ ↑RDW
DDs: Iron deficiency, Inflammation, Sideroblastic Anaemia
Thalassemia can be ruled out: because RDW is raised
Dx of Microcytic Anaemia requires Iron studies
Case-1…contd.

52. Case-1…contd.
PARAMETERS RESULT NORMAL RANGE INTERPRETATION
Serum Iron (μg/dL) 15 50 — 150 ↓
TIBC (μg/dL) 148 300 — 360 ↓
Serum Ferritin (μg/L) 311 50 — 200 ↑
As ferritin stores are raised; serum iron is reduced and so is TIBC. It indicates
inflammation. Upper GI bleed justify severe anaemia d/t blood loss.
Dx: Anaemia of Inflammation superimposed on Anaemia of Blood Loss

53. Case-2
• 70y/M
• H/o recurrent epistaxis, fatigue. Past h/o PTB, ATT intake 20y back
• GPE: pallor; USG Abdomen: Prostatomegaly, Splenomegaly
PARAMETERS RESULT NORMAL RANGE INTERPRETATION
HEMOGLOBIN (g/dl) 4.6 14 — 18 ↓
HEMATOCRIT (%) 14.8 41 — 53 ↓
RBC COUNT (10⁶/μL) 1.73 4.5 — 6.5 ↓
MCV (fL) 85 90 — 98 ↓
MCH (pg) 26.5 27 — 33 ↓
MCHC (g/dL) 31.0 31 — 35 N
RDW-CV (%) 21.1 11 — 14 ↑
TLC (10³/μL) 5.8 4 — 11 N
Platelet Count (10³/μL) 200 → 100 after 2 days 150 — 450 ↓

54. RPI Uncorrected: 2.75%
PBS: Mild shift to left with leucoerythroblastic blood picture
RPI Correction
Hb Correction: 2.75 x (4.6/16) = 0.79%
Maturation Time Correction: Hb Correction/2.5 = 0.32%
RPI↓
Case-2…contd.

55. Case-2…contd.
PARAMETERS RESULT NORMAL RANGE INTERPRETATION
Serum Iron (μg/dL) 61 50 — 150 N
TIBC (μg/dL) 180 300 — 360 ↓
Serum Ferritin (μg/L) 1163 50 — 200 ↑
Conclusion: Hypoproliferative state, w/ thrombocytopenia, and splenomegaly, and
recurrent epistaxis which may be due to thrombocytopenia
Dx: AML (very rare)
Further investigations: BM aspirate

56. Case-3
• 70y/M
• H/o silicosis, oliguria 5-7 days, steroid intake
• GPE: pallor; Crt: 10.3, Urea: 319
PARAMETERS RESULT NORMAL RANGE INTERPRETATION
HEMOGLOBIN (g/dl) 8.6 14 — 18 ↓
HEMATOCRIT (%) 29.2 41 — 53 ↓
RBC COUNT (10⁶/μL) 2.64 4.5 — 6.5 ↓
MCV (fL) 111 90 — 98 ↑
MCH (pg) 32.6 27 — 33 N
MCHC (g/dL) 29.5 31 — 35 N
RDW-CV (%) 18 11 — 14 ↑
Platelet Count (10³/μL) 128 150 — 450 ↓

57. Macrocytic, Normochromic
B-12: 153 ng/L
Folate: 12.6 μg/L
B-12 at borderline
Case-3…contd.
PARAMETERS RESULT NORMAL RANGE INTERPRETATION
Serum Iron (μg/dL) 24 50 — 150 ↓
TIBC (μg/dL) 139 300 — 360 ↓
Serum Ferritin (μg/L) 1854 50 — 200 ↑
Dx: B-12 deficiency w/ Anaemia of Renal Disease

58. THANKYOU
BIBLIOGRAPHY
1. Harrison's Principles of Internal Medicine, 21e Loscalzo J, Fauci A, Kasper D, Hauser
S, Longo D, Jameson J. Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D,
& Jameson J(Eds.),Eds. Joseph Loscalzo, et al.
2. RS Hillman et al: Hematology in Clinical Practice, 5th ed. New York, McGraw-Hill,
2010.
3. Lippi G, Plebani M. Recent developments and innovations in red blood cell diagnostics.
J Lab Precis Med 2018.