laboratory diagnosis

1. Laboratory Diagnosis

2. What is laboratory diagnosis?
 Laboratory diagnosis is such a diagnostic
process in which the samples coming from
patients’ blood , body fluid , secretion ,
excretion , tissues and cells are examined
by using various laboratory methods to get
useful data which may reflects body` s
functional status , pathological changes and
etiological hints.

3. Why to study laboratory
diagnosis?
 Laboratory diagnosis is a very important
part in diagnostics. After we have finished
the study of physical diagnosis and
instrument examination , we might be able
to judge what kind of disease this patient
probably suffer from . For further diagnosis
, it is still not enough if we only master
physical examination . We have to depend
upon some laboratory data to ensure our
diagnosis .

4. How to learn laboratory
diagnosis?
 First, the methods used in laboratory
diagnosis are more automatic and
computerized.
 Second , the aim is to train for clinical
application .
 For each test, referential values and clinical
significance always should be known very
well.

5. Chapter 1 Blood Test
Blood routine test (BRT)
 1. content (items) of BRT
 red blood cell count (RBC)
 hemoglobin(HB)concentration determination
 total white blood cell count (WBC)
 leukocyte differential count (DC)
 platelet count (PC)

6. Rferential values of BRT
 Table 1. Deferential values for blood routine test
in different age and sex
 ___________________________________
 male female newborn
 ___________________________________
 RBC 4.0-5.5 3.5-5.0 6.0-7.0
 HB 120-160 110-150 170-200
 WBC 4-10 4-10 15-20
 PLT 100-300 100-300
 ___________________________________

7. Table 2 Referential values of
differential count
 ___________________________________
 type percent value(%) absolute value
 ___________________________________
 N st 1-5 0.04-0.5
 N se 50-70 2-7
 LYM 20-40 0.8-4
 Mo 3-8 0.12-0.8
 Eo 0.5-5 0.02-0.5
 Ba 0-1 0-0.1
 ___________________________________

8. Morphology of blood cells
 Red blood cell: normocyte: 6-9um,
discocyte- shape, no nucleus
 white blood cell divided in five types:
neutrophilic granulocyte : neutrophil stab
cell (Nst), neutrophil segmented cell (Nse),
lymphocyte, basophil granulocyte,
eosinophil granulocyte
 Platelet: smallest cell in peripheral blood

9. In automatic blood cell analyzer,
25 items are included together :
 WBC : 4.0~10.0x109/L
 LYM : 0.8~ 4.0 x109 /L (20~40%)
 MID( middle cells) : monocyte, eosinocyte,
basocyte , immature cells(rare be seen)
 GRAN(granulocyte):2.0~7.8x109/L(50~70%)
 RBC:4.0~5.5x1012/L(male),3.5~5.0x 1012 /L
(female)
 HGB: 120~160 g/L (male), 110~150 g /L (femal)

10. -
 HCT(hematocrit):0.4~0.5L/L(male), 0.37~ 0.48
L/L (female)
 MCV ( mean corpuscular volume): 82~95 fl
 MCH(mean corpuscular hemoglubin): 27~31 pg
 MCHC ( mean corpuscular hemoglubin
concentration): 320~360 g/L
 RDW ( red cell distribution width ): 11.5~14.5%
 PLT( platelet): 100~300x109 /L
 MPV ( mean platelet volume): 8.7~16.5 fl
 PDW ( platelet distribution width): 15.8~21.4%

11. Clinical significance
 Anomalies of RBC and HB
 1. decrease of RBC and HB
 Anemia: When RBC and HB of individual
is lower than the referential values of the
people in same age , same sex and same
area. Usually, if Hb of adult male and
female is lower than 120g/L or 110g/L
respectively, they are considered as anemia.

12. According to the level of Hb,
anemia is divided into four
degrees in clinic
 mild anemia: Hb < 120g/L(male) or <
110g/L(female)
 medium anemia : Hb <90 g/L
 severe anemia : Hb <60g/L
 extreme severe anemia: Hb <30g/L

13. Physiological anemia
 infant and children aged between 3 months
to 15 years,
 pregnant women in middle or terminal
periods of pregnancy,
 elderly people.

14. Pathological anemia.
 decrease in synthesis of red blood cell in
bone marrow
 increased destroy of red blood cell in
peripheral blood
 blood loss

15. Decrease in synthesis of red
blood cell in bone marrow
 disorder of hemopoiesis in bone marrow:
aplastic anemia
 infiltration of bone marrow by
tumorous cell: leukemia, multiple myeloma
, lymphoma , metastatic tumor
 deficiency of hemopoietic materials or
factors: iron deficiency anemia(IDA),
megaloblastic anemia (folic acid deficiency)

16. Destroy of RBC in peripheral
blood -- hemolytic anemia
 Hereditory disease : hereditory
sphrocytosis (HS) , G6PD deficiency,
thalassmia , Hb disease
 Acquired anomalies : hemolysis by
immunological , physical, chemical ,
biological and mechanical factors

17. Blood loss --
hemorrhagic anemia
 acute blood loss : acute upper digestive tract
bleeding , splenic rupture
 chronic blood loss : hemorrhoid, hookworm
disease, hypermenorrhea, GI tumor

18. 2. Increase of RBC and Hb
• Comparative increase of RBC and Hb:
due to the decrease of volume of plasma-
-severe dehydration: severe vomoting,
diarrhea, severe burn
• Absolute increase of RBC and Hb—ery-
throcytosis: polycythemia vera(PV),
chronic cardiopulmonary diseases: cor
pulmonale, obstructive emphysema,
scarcity of oxygen.

19. Anomalies of WBC and DC
•In most cases, increase and decrease of
WBC is chiefly depend on the numbers of
neutrophil granuiocyte in the blood.
•Leukocytosis: WBC is high than 10 x109 /L
•Leukopenia: WBC is lower than 4 x109 /L

20. 1. Neutrophil granulocyte
A. granulocytosis: 5 causes leading to
granulocytosis ‫صابه‬
‫حاده‬
‫الوز‬
‫هيمابيسس‬
‫انسجه‬ ‫تلف‬
‫امراض‬
‫الدم‬ ‫وفقد‬ ‫التسمم‬
‫الخبيثه‬
• acute infection or inflammation: acute pyogenic
tonsilitis, acute appendicitis, hematosepsis
• damage of tissue: severe burn, acute myocardiac
infarction

21. •acute blood loss: digestive tract bleeding,
splenic rupture
•Acute poisoning: uremia, ketoacidosis
•Malignant blood diseases and tumor:
leukemia, metastatic tumor

22. B. Granulocytopenia:
• leukopenia: WBC < 4 x109 /L
• granulocytopenia:
neutrophil granulocyte < 1.5 x109 /L
• agranulocytopenia:
neutrophil granulocyte < 0.5 x109 /L

23. 5 causes for granulocytopenia: ‫صابه‬
‫بكتريا‬
‫انفلوزن‬
‫امراض‬
‫حبيثه‬
‫كليوكما‬
• Infection of bacteria and virus: typhoid, influenza,
measles
• some physical and chemical factors: drug
• autoimmune diseases: systemic lupus
erythematosis (SLE),
• malignant blood diseases: aplastic
anemia,leukemia
•hypersplenism

24. Changes of nucleus
nucleus shift to left:
• mild shift to left: Nst > 6% only
• medium shift to left: Nst > 10% with meta-
myelocyte
• severe shift to left : Nst > 25% with more
immuture cell (leukemiod reaction )
nucleus shift to left cab be seen in acute infection,
acute poisoning, acute hemolysis

25. Nucleus shift to right: multi-segmented Nse >3%
3-lobed Nse is normal segmented neutrophil in BP
nucleus shift to right can be seen
• megaloblastic anemia
• administration of anti-metabolic drugs

26. 2. Lymphocyte ‫اصابه‬
‫فيرس‬
‫ميكوميا‬
‫ليمفوك‬
‫ليمفوما‬
A . Lymphocytosis: DC: Lym > 40%
•Virus infection: infectious mononucleosis,
chickenpox,
•Lymphocytic leukemia: ALL, AA, lymphoma
•GVHD or GVHR after BMT

27. B. lymphocytopenia: ‫عقاقيرضد‬
‫الورم‬
•administration of anti-tumor drugs, prednision
•radiation: x-ray, r-ray , isotope
3. monocytosis: ‫ماالريا‬
‫سوده‬ ‫حمى‬
‫ليكوكيا‬
‫مونسيت‬
• malaria, black fever, TB, subacute bacterial
endocarditis(SBE)
• monocytic leukemia, malignant histocytosis,

28. 4. eosinophilia ‫الحساسيه‬ ‫والدم‬ ‫الجلد‬ ‫امراض‬ ‫حساسيه‬
‫الشديده‬
•allergic diseases, hypersensitive diseases
•parasites infection:
•Skin diseases: psoriasis
•blood diseases: CML, eosinophilic leukemia,
lymphoma
•Infectious diseas: scarlatina
•Hypereosinophilic syndrome

29. 5. Basophil granulocyte
bosophilia: CML, basophilic leukemia,
myelofibrosis

30. Other tests for red blood cell
1. Reticulocyte count (RC)
0.05-0.015 (0.5-1.5%)
24-84 x109 /L
 Reticulocytosis: hemolytic anemia
acute hemorrhagic anemia
index of therapeutic effect:
IDA, megaloblastic anemia

31. •Reticulocytopenia:
Aplastic anemia
leukemia

32. 2. Hematocrit(Hct)
0.4-0.5L/L(male), 0.37-0.48L/L(female)
• increase of Hct:
blood concentration
water loss
polycythemia(PV)
• decreas of Hct: anemia

33. 3. Mean values of RBC
Mean corpuscular volume (MCV):
MCV=Hct/RBC 82-95fl
Mean corpuscular hemoglubin(MCH):
MCH=Hb/RBC 27-31pg
Mean corpuscular hemoglubin concentration
MCHC=Hb/Hct 320-360g/L

34. Morphological classification of anemia
Classification MCV MCH MCHC diseases
Normocytic 82-95 27-31 320-360 AA, HA, leukemia
Macrocytic >100 > 31 320-360 MA, pernicious
anemia
Microcytic < 80 < 27 320-260 infection, tumor,
uremia
Microcytic < 80 < 27 < 320 IDA, thalassemia
Hypochromic sideroblastic
anemia

35. 4. Erythrocyte sedimentation rate(ESR)
0-15mm/h (male), 0-20mm/h (female)
higher ESR:
• infection and inflammation: rheumatic
diseases,tuberculosis
• malignant tumor
• anemia
• damage or necrosis of tissue
• globulinemia, cholesterolemia

36. Chapter 2. Bone Marrow
Examination
1. Clinical application of marrow examination
 Diagnosis for hematopoietic system diseases:
leukemia, myeloma, aplastic anemia, etc
 parasite infectious diseases: malaria, black
fever
 metabolic diseases: Gaucher disease.
Niemann-Pick disease

37. Indications:
•Fever origin unknown (FOU)
•Cachexia
•Hepatomegaly, splenomegaly, lymphoadenovarix
•Abnormal in quantity and quality in peripheral
blood cell

38. Contraindication:
• Hemophilia
• Pyogenic infection in local skin
Methods:
• bone marrow aspiration
• bone marrow biopsy

39. 2. Development of blood cells
myeloblast promyelocyte myelocyte
metamyelocyte Nst Seg
normoblast basophilic normoblast
polychromatic normoblast orthochromatic
normoblast erythrocyte

40. Monoblast promonocyte monocyte
macrophage histiocyte
Megakaryoblast promega granular Meg
thrombocytogenous Meg platelet
B-lymphoblast B-prolymphoblast B-
lymphocyte plasmablast proplasmacyte
plasmacyte

41. 3. Regulation of blood cell
development
 Cytobody: from large to small,
Mega is an exception
 Cytoplasma: from less to more,
color from blue to pink or orange red,
granules from invisible to visible,
granules from non-specific to specific

42. Nucleus:
from large to small, Mega is an exception,
shape of nucleus from round to irregular,
chromatin patten of nucleus from fine to
coarse.
nucleolus from existance to nonexistance
Ration of nucleus to cytoplasma:
from bigger to smaller

45. 5.Contene and step of marrow
examination
 Myelogram:
 Low power(LP):
Wright stain of marrow film
plastic degree: 5 classification
Meg count : 7-35/1.5x3cm2
ousspecial cell: metastatic tumorous cell

46. •Oil immersion:
Nucleated cell count (%): 200-500
Ratio of myeloid to erythroid (M:E): 2-4:1
Morpholigical description of every series
Special cells and parasite
•Diagnosis

47. •Hemogram:
Low power(LP):
Oil immersion len: differential count 100
leukocyte (DC)
Immature cell (nucleated cell)
parasites

48. 6. Normal myelogram and
hemogram
1. Myelogram
 Normal cellularity: erythrocyte: nucleated cell
 M:E=2-4:1
 Granulocytic series is 40-60% in all nucleated cells
 Erythrocytic series is 20% in all nucleated cells
 Lymphocyte is 20% , monocyte is <4% in all nucleated cells
 Meg count is 7-35, platelet is normal
 Other cell: plasmacyte and histiocyte are rare
 No specific cells and parasite

49. Plastic degree of marrow
Plastic degree erythrocyte: nucleated diseases
Extreme hypercellularity 1:1 leukemia
Significant hyper- 10:1 leukemia, ITP,
Cellularity plastic anemia
Normal cellularity 20:1 anemia, normal
myelogram
Hypocellularity 50:1 AA,agranulocy-
topenia
Extreme hypocellularity 300:1 aplastic anemia

50. 2. Hemogram:
•DC is normal
•No nucleated red blood cell
•No immature white cell
•Platelet is normal

53. 7. Characters of common
blood diseases in microscope
 Iron deficiency anemia(IDA)
 Aplastic anemia(AA)
 Acute leukemia(AL)
 Chronic myelocytic leukemia(CML)
 Idiopathic thrombocytopenia purpura(ITP)

54. 1. Iron Deficiency Anemia(IDA)
 Hemogram:
Hb , RBC , normal RC,
RBC hypochromia, exaggeration of central
pallor to from rings, anisocytosis
normal WBC and platelet

55. •Myelogram:
Significant hypercellularity
M:E
Erythroid hyperplasia with small normoblast
Pycnotic nuclei and scanty cytoplasma
irregular margin

57. 2. Aplastic Anemia(AA)
 Hemogram:
pancytopenia: Hb ,RBC , WBC ,PLT
RC <0.005 or absolute value < 15 x109 /L
RBC is normocytic

58. •Myelogram:
Hypocellularity or extreme hypocellularity,
Hematopoietic cell decrease: erythroid, myeloid
cells , meg or absent, platelet rarely be
seen
Non-hematoietic cell increase: lymphocyte
Reticular cell , plasmacyte

60. 3. Acute Leukemia(AL)
 FAB classification:
acute lymphocytic leukemia: L1-L3
acute non-lymphocytic leukemia: M0-M7
 Hemogram:
Hb, RBC
WBC uncertain: normal, increase, decreas
platelet:

61. •Myelogram:
Extreme or significant hypercellularity
M:E
Hyperplasia of certain line :
Myeliod(M0,M1-3), monocyte(M4-5),
meg(M7), lymphocyte(L1-3) , erythroid(M6)
Depressed erythroid and meg line

74. 4. Chronic Myelocytic
Leukemia(CML)
 Hemogram:
WBC increase rxtremly
DC: E0, Ba increas, myelocyte,
metamyelocyte, band cell increase
normal Hb, RBC or mild decrease
normal plt

75. •Myelogram:
Extreme hypercellularity
M:E increase
Extreme hyperplasia of granulocyte with
increas of myelocyte, metamyelocyte, band
cell, E0, Ba
Normal erythroid and Megakaryocyte

79. 5. Idiopathic Thrombocytopenic
Purpura(ITP)
 Hemogram:
normal Hb, RBC
normal WBC and DC
PC decreas with abnormal morphology

80. •Myelogram:
Significant hypercellulerity or normal cellularity
Normal myeloid, erythroid line
Significant hyperplasia of Meg.
Impaired maturation of Meg:
Granular Meg or promeg increase
Platelet producting Meg absent
Platelet rarely be seen