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Interpretation of cbc
This document provides information on interpreting a complete blood count (CBC). It defines various CBC parameters such as anisopokilocytosis, cytometry, and Coulter principle. The importance of the CBC is discussed as it can provide information about the blood, bone marrow, and health of other organs. The CBC evaluates components of the blood including red blood cell count, hemoglobin, hematocrit, and red cell indices. Abnormalities in these values can indicate conditions like anemia, bone marrow aplasia, and malignancies. Peripheral blood smear examination is also important for identifying red blood cell morphologies.
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Interpretation of cbc
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- 2. TERMS Anisopokilocytosis: variationin size and shape Cytometry: measurment of the cell either visual or automated Cluster analysis: analysis that is based upon the instrument‟s ability to cluster different populations, together based upon size, staining, absorption or other parameter Contour grating: analysis where information is plotted three dimentionally, that can be separate subpopulation of cells Coulter principle (electrical impedence): sizing and counting cells by detecting and measuring changes in electrical resistance when cell passes through small aperture. Dimorphic : two population of cells in single blood sample Forward angle light scatter: light from laser source is scatter in forward direction (0 degree) when it strike a cell or particle, larger object more forward light scatter Forward high angle light scatter: similar to forward angle light scatter, but angle is 5 to 15 degree variation Forward low angle light scatter: similar to forward angle light scatter, but angle is 2 to 3 degree variation
- 3. Introduction Haematology compriseof „Haima‟ = blood in Greek „Logos‟ = study Haematology is a unique super speciality in medicine which encompasses the fields of pathology, physiology, biochemistry, molecular biology, obstetrics and gynecology, medicine and paediatrics
- 4. CBC A completeblood count is a series of tests used to evaluate the composition and concentration of the various cellular component of the blood. Is a basic test Most informative single investigation Tests consists of 1. Counts of RBC, WBC, Platelets 2. Haemoglobin, haematocrit, and red cell indices 3. TLC, DLC 4. Platelet count, mean platelet volume, plateletcrit, PDW 5. Histogram of RBC, WBC, Platelets
- 5. How important isCBC ? To know the importance of CBC we need to know….. What is CBC? Why CBC? What are various parameter of CBC? What are variation in parameter of CBC? What these variation can tell us? How these variations affect the assessesment and care of patients?
- 6. Why CBC? CBCis an inexpensive tool and powerful tool which provide information about Blood, also about Marrow, Health or disease state of other organ of body
- 7. CBC USES To diagnose 1.Anemia 2. Haemoglobinopathies 3. Bone marrow aplasia 4. Nutritional deficiencies 5. Thrombocytopenia 6. Autoimmune conditions 7. Infections and Parasitemia 8. Malignancies, response to drug, chemotherapy etc.
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- 9. RBC producedin marrow and requires Iron, copper, magnease, cobalt Vitamins; especially B12, folic acid Regulated by erythropoietin, thyroid hormone, androgens Counts depend upon age, sex, altitude, exercise, drug, tobacco use etc. Life span - 120 days
- 10. Clinical importanceof assessment of RBC is to: measures oxygen carrying capacity of blood Normal values Newborn 4.1-6.1 million/mm3 Children 3.6-5.5 million/mm3 Adult (M) 4.6-6.0 million/mm3 Adult (F) 4.2-5.0 million/mm3
- 11. Decreased RBCs Blood lossImpaired production Increased destruction • Trauma • Surgery • GI bleed • Gynecological disturbance • Pure red cell aplasia • Pernicious anemia • Megaloblastic anemia • Iron deficiency anemia • Thalassemia • Anemia of prematurity • Anemia of chronic disorder Intra-corpuscular • Hereditary spherocytosis • Sickle cell anemia • Abetalipoprotienimia • G6PD • Pyruvate kinase deficiency • PNH Extra-corpuscular • Autoimmune • Haemolytic disease of newborn • Mismatch transfusion • Microangiopathic haemolytic anemia TTP, HUS • DIC • infections
- 12. • Increased RBCs •Polycethemia vera • High altitude • chronic obstructive pulmonary disease(COPD, emphysema, chronic bronchitis), • pulmonary hypertension, • Hypoventilation syndrome, • congestive heart failure • obstructive sleep apnea, • poor blood flow to the kidneys, and
- 13. Haemoglobin Oxygen carryingcomponent of blood Synthesize in polychromatic normoblast stage of red cell development Values Newborn 15.5-24.5 g/L Adult male 13.5-16.5 g/L Adult female 12.0-15.5 g/L
- 14. Hb estimation Cynemethamoglobin Method:Recommended 20 microL blood + diluent (potassium cynide and potassium fericynide) Mixed and read in photo colorimeter Photo colorimeter is used to determine the concentration Hb% =(test sample absorbance/ standard sample absorbance)x concentration of standard x dilution factor Advantage – haemoglobin, methamoglobin and carboxyhaemoglobin are used in measurment. Disadvantage – sulphamethamoglobin cannot be included in measurment, takes more time for estimation
- 15. Hb estimation: othermethod Sahli acid haematin Alkaline haematin method Sulphahaemoglobin method Oxyhaemoglobin method
- 16. Reticulocyte Normal value0.5% - 1.5%. Hence 0.5% - 1.5% RBCs are replaced per day Uses To evaluate anemia Response to treatment of anemia Note If the disease causing the anemia is inside the marrow, the reticulocyte count is decreased If the disease causing the anemia is outside the marrow, the reticulocyte count is increased
- 17. Methods Manual reticulocytecount using supravital stain Automated reticulocyte count by flouroscent method - gives immature reticulocyte fraction (IRF) and removes errors like Howell-Jolly bodies, pappenheimer bodies Reticulocyte production index or corrected reticulocyte count: an index corrected according to level of anemia Reticulocyte index = reticulocyte count x patient‟s haematocrit/ normal haematocrit
- 18. Reticulocyte proliferationindex: Index is used to determine if a person's bone marrow is properly responding to the body's need for red blood cells Shift correction factor: normal reticulocyte count survive 3.5 days in marrow and 1 day in peripheral circulation at normal PCV. In case of variation in PCV the survival time is increased which is termed as shift correction factor Reticulocyte proliferation index = reticulocyte index/ shift correction factorShift correlation factor PCV% Maturation days = shift correction factor 45 1 35 1.5 25 2 15 2.5
- 19. Increased reticulocyte count Haemolytic anemia Recent haemorrhage Thalassemia Pregnancy Response to treatment Hypoxia Leukamia Decrease reticulocyte count Aplastic anemia Megaloblastic anemia Anemia of chronic disease Cirrhosis Radiation Decrease ACTH and pitutary hormones
- 20. Reticulocyte haemoglobin measurement (RET-He) Reticulocyte Hemoglobin (Ret-He) is a direct assessment of the incorporation of iron into erythrocyte hemoglobin. It is a direct estimate of the recent functional availability of iron (2–3 days). Traditional chemistry tests used for iron assessment (serum iron, Tsat, ferritin) are indirect measurements. As a direct measurement, Ret-He may identify iron deficiency earlier than traditional parameters. It is an established parameter used in KDOQI (Kidney Disease Outcome Quality Initiative) guidelines for assessing iron status
- 21. Haematocrit Ratio ofthe volume of erythrocytes to that of the whole blood in percentage Most precise method for determining the degree of anemia or polycythemia i.e. increase or decrease RBC concentration Normal values Newborn 42-68% Upto 1 year age 29-41% Adult Male 39-47% Adult female 36-44% Rule of 3:– RBC x 3 = Hb and Hb x 3 = Hct
- 22. High Polycythemia vera Dehydration Low oxygen in blood Congenital heart disease Cor pulmonale Smoking Haemoconcentration (Dengue) Low Anemia Blood loss Haemolysis Bone marrow aplasia Leukamia Malnutrition An elevated haematocrit may be due to spleen hyper function, and reduced haematocrit may indicate low thymus function
- 23. Mean corpuscular volume Measures average volume of RBC MCV = haematocrit/ red cell count x100 Normal values Newborn 103-106fL Child upto 1 year 78 fL Adult 79-98fL Classified accordingly as Microcyte – MCV <79 Macrocytic – MCV >98 Presence of microcytic and macrocytic cells in same sample may result in normal MCV MCV <72 without heterogeneity, is a sensitive and specific predictor of thalassemia trait
- 24. Microcytic MCV Hypochromic Iron deficiency Thalessemia Lead poisoning Porphyria Normochromic Anemia of chronic disease haemoglobinopath ies Macrocytic MCV Megaloblastic anemia Pernicious anemia Sprue Di Gulielmo disease MDS Post spleenectomy Alcoholism Liver disease Drugs (anticonvulscents, anticancer etc) • Normocytic MCV • Acute haemorrhage • Diamorphic anemia • Haemoglobinopathi es • Endocrinopathies
- 25. Interference in MCV Cold and warm antibodies Marked hyperglycemia Marked leukocytosis Marked reticulocytosis Methanol poisoning
- 26. Mean corpuscular haemoglobin MCH =haemoglobin/ red cell count x 100 Normal range Newborn 36-38% Upto 1 year age 23-27% Adult 26.7-31.9%
- 27. MCH decreasedin Microcytic and normocytic anemias MCH increased in Macrocytic anemias Infants and newborns Interference in MCH Lipemia Marked leukocytosis Cold agglutinin Monoclonal protein in blood
- 28. Mean corpuscular haemoglobin concentration MCHC= haemoglobin/ haematocrit x 10 Normal range Newborn 34-36% Upto 1 year age 31-33% Adult 32-36%
- 29. MCHC decreasedin Hypocromic microcytic anemia MCHC increased in Heridietery spherocytosis Infant and newborns Autoagglutinations Interference in MCHC Marked leukocytosis Haemolysis Cold aggutinins Rouleaux
- 30. Red cell distributionwidth (RDW) Red cell distribution is a quantative measure or numerical expression of anisocytosis. It is a coefficient of variation of the distribution of individual RBC volume In microcytes, RDW increased in iron deficiency anemia but in thalessemia it is not raised
- 31. RDW-CV:It isthe ratio of standard deviation to the mean corpuscular volume RDW-CV = standard deviatiom of RBC volume/ mean MCV x 100 value 11.5%-14.5% RDW-SD: It is the actual measurnment of the width of the RBCdistribution curve Values 35-45 fL
- 32. RBCs on peripheralsmear
- 33. Preparation The wedgeslide (push slide) technique was developed by Maxwell Wintrobe as is a standard method The “zone of morphology” (area of optimal thickness for light microscopy examination) should be at least 2cm in length. The smear should occupy the central area of the slide and be margin free at the edges.
- 34. RBCs in peripheralsmear Microcytic hypochromic Size smaller than the nucleus of small lymphocyte < 7 micron Markedly increase central pallor >1/3 of the diameter of RBC Causes Iron deficiency anemia Thalassemia Sideroblastic anemia Anemia of chronic disease Haemoglobinopathies
- 35. Macrocytic cells Size> 8.3 micron kin diameter Causes Vitamin B 12 and folic acid deficiency Alcoholism Liver disease Myleodysplastic syndrome Hypothyroidism Drug that impair DNA synthesis
- 36. Oval macrocytes Vitamin B 12 and folic acid deficiency Pernicious anemia Myleodysplastic syndrome Hypothyroidism Drug that impair DNA synthesis
- 37. Round hypochromicmacrocytes Alcoholism Hypothyroidism Liver disease Post splenectomy Blue tinged macrocytes Neonate Response to anemic stress
- 38. Target or bellcell They have a characteristic ringed appearance. This is because of the “increase surface area to volume ratio” i.e. increase in red cell membrane which get pooled at the centre of cells Causes Thalessemia Haemoglobinopathies Hb AC or CC, HbSS,SC Liver disease Post spleenectomy Severe iron deficiency anemia abetalipoprotenimia
- 39. Schistocytes „Schisto‟ =split or cleft Physical assault to erythrocytes with in the blood stream creates these cells which include Helmet cells Triangles Crescents Microspherocytes Horns Purse
- 40. Causes DIC Severehaemolytic anemia Microangiopathic haemolytic anemia HUS &TTP Prosthetic cardiac valves Connective tissue disorders Burns Acute tubular necrosis, glomerulonephritis Malignant hypertension
- 41. Tear drop cells(Dacrocytes) Pear shape cells, usually microcytic and hypochromic Seen in Newborn Thalassemia major Myleoproliferative disorder Leukoerythroblastic reaction
- 42. Spherocytes Ball shapedred cells, decreased surface: volume ratio, hyperdense (> MCHC) Seen in Hereditary spherocytes ABO incompatibility Autoimmune haemolytic anemia Microangiopathic haemolytic anemia SS disease Hyperspleenism Burns Posttransfusion
- 43. Elliptocytes Elliptical andnormochromic cells, seen normally in less than 1% of RBCs Causes Hereditary elliptocytosis Iron deficiency anemia (increased with severity) SS disease and SA trait Thalassemia Major Leukoerythroblastic reaction Malaria Megaloblastic anemia
- 44. Burr cells (Echinocytes) 10-30 spicules equal in size and evenly distributed over RBC surface; caused by alteration in extracellular environment Seen in Liver disease Renal failure Dehydration Pyruvate kinase deficiency Storage artefacts
- 45. Spur cell -Acanthocyte Acantho = thorn Cells with 5-10 specules of varying length, irregular in shape, thickness, with wide bases and appear smaller than normal cell because they assume spheroid shape Result from changes in membrane lipid content Seen in Spur cell anemia Alcoholism Hypothyroidism Abetalipoprotinemia Vitamin E deficiency Malsbsorption Postsplenectomy
- 46. Bite cell (Degmacyte) Appear as a cookie with a bite taken out Seen in G6PD When spleen removes the Heinz bodies from RBCs
- 47. Stomatocyte When examinedon dry smear, it has a central slit or stoma Seen in Few may be seen normally Various cardiovascular and pulmonary disorders Hereditary Alcoholism Liver disease Malignancies
- 48. Howell – Jollybodies Small well defined, rounded, densely stained inclusions, 1 micron in diameter, ecentric, that represent DNA fragments Associated with rapid or abnormal RBC formation Seen in Post spleenectomy Newborns Megaloblastic anemia Dyserythopoietic anemias Hereditary spherocyosis
- 49. Heinz Bodies Inclusionof denatured haemoglobin caused by oxidation of globin portion of haemoglobin Removal of Heinz body leads to formation of „bite cells‟ Causes Drugs Certain foods like fava beans and onion
- 50. Sideroblastic granules/ pappenheimer bodies Irregular dark blue iron containing granules occuring in small clusters, predominantly in periphery Seen in Sideroblastic anemia Spleenectomy Haemolytic anemia Myelodysplastic syndromes Lead poisoining Its presence can rule out iron deficiency anemia
- 51. Sickle cell Crescentshape cells develop in people homozygous for haemoglobin S Heterozygous HbS and either thallasemia or another Hb like Hb C
- 52. Nucleated red cells Cells have dense dark nucleus in the center of the cell Results from marked stimulation of the bone marrow Seen in New born (first 3-4 days) Acute bleeding severe haemolytic anemia Megaloblastic anemia Congenital infections (syphilis, CMV, rubella) Postspleenectomy Leukoerythroblastic reaction Fungal and mycobacterial infections Dyselectropoeitic anemia
- 53. Basophilic stippling Numeroussmall, purplish inclusions, which results from RNA and mitochrondrial remenants Seen in Lead toxicity Thalessemia Haemoglobinopathies Macrocytic anemia
- 54. Cabot ring Theseare delicate thread like inclusions, remenants of the nuclear membranes, in the RBC They can take any shape like purplish ring, figure of eight, incomplete ring Seen in Pernicious anemia Lead poisoning Alcoholic jaundice Severe anemia Leukamia
- 55. Roulex formation Astack like arrengment of red blood cells where the biconcave surdface of RBCs are next to each other. Seen in Increase in cathodal protien, such as immunoglobins and fibronegen Multiple myleoma Macroglobulimias Acute and cronic infections Connective tissue disease Diabetes mellitus Malignancies
- 56. Grading ofinclusions Rare 0-1/hpf Few 1-2/hpf Mod 2-4/hpf Many >5/hpf Qualitative grading of abnormal RBC morphology Grade degree of abnormalities 1-5 cells /10fields slight 6-15cells /10fields moderate >15cells /10fields marked