CBC --- Interpretations

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CBC --- InterpretationsAbstractInterpretation of different parameters reported on modern day analyzers is bit tricky and demand continuous monitoring and on-going…
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CBC --- InterpretationsAbstractInterpretation of different parameters reported on modern day analyzers is bit tricky and demand continuous monitoring and on-going learning. In present paper interpretation of different reported parameters has been discussed with approach to diagnosis of various abnormalities. The CBC interpretation are useful in the diagnosis of various types of anemias.It can reflect acute or chronic infection, allergies, and problems with clotting.objectivesCBC- complete blood count
  • Component of the CBC:
  • • Red Blood Cells (RBCs)• Hematocrit (Hct)• Hemoglobin (Hgb)• Mean Corpuscular Volume (MCV)• Mean Corpuscular Hemoglobin Concentration (MCHC)
  • - Red cell distribution width (RDW)
  • • White Blood Cells (WBCs)• Platelet
  • RBC
  • RBC (varies with altitude):
  • M: 4.7 to 6.1 x10^12 /L
  • F: 4.2 to 5.4 x10^12 /L
  • Biconcave disc shape with diameter
  • of about 8 µm
  • Function: - transport hemoglobin which carries oxygen from the lung to the tissues
  • -acid –base buffer.
  • Life span 100-120 days.
  • Hemoglobin & Hematocrit
  • Hemoglobin :
  • M: 13.8 to 17.2 gm/dL
  • F: 12.1 to 15.1 gm/dL
  • Hematocrit : (packed cell volume)
  • It is ratio of the volume of red cell to the volume of whole blood.
  • M: 40.7 to 50.3 %
  • F: 36.1 to 44.3 %
  • MCV&MCHC
  • MCV = mean corpuscular volume HCT/RBC count= 80-100fL
  • small = microcytic
  • normal = normocytic
  • large = macrocytic
  • MCHC= mean corpuscular hemoglobin concentration HB/RBC count= 26-34%
  • decreased = hypochromic
  • normal = normochromic
  • MCH & RDW
  • MCH (mean corpuscular hemoglobin)
  • HB/HCT = 27-32 pg
  • RDW (red cell distribution width)
  • It is correlates with the degree of anisocytosis
  • _ Normal range from 10-15%
  • The Reticulocyte Count
  • This important value is needed in the evaluation of any anemia.
  • Normal range 1-2% 
  • Retic count goes up with
  • Hemolytic anemia
  • Retic goes down with 
  • Nutritional deficiencies
  • _ Diseases of the bone marrow itself
  • Definition of Anaemia Decrease in the number of circulating red blood cell mass and there by O2 carrying capacityMost common hematological disorder by farAlmost always a secondary disorderAs such, critical for all practitioners to know how to evaluate / determine its cause / treatFirst QuestionThe onset of AnaemiaAcute versus chronicCluesHemodynamic stabilityPrevious CBCOvert blood lossTypes of AnaemiaScreening Tests – Anaemia Clinical Signs and symptoms of AnaemiaLook for bleeding – all possible sitesLook for the causes for anemiaRoutine Hemoglobin examinationCut off marks for Hb – US < 13.5 g WHO < 12.5 gSubcontinent Less than 12 g%Clinical Signs to be looked forSkin / mucosal pallor,Skin dryness, palmar creasesBald tongue, GlossitisMouth ulcers, Rectal examJaundice, PurpuraLymphadenopathyHepato-splenomegalyBreathlessnessTachycardia, CHFBleeding, Occult BloodPCV or Hematocrit57% Plasma1% Buffy coat – WBC42% Hct (PCV)The Three Basic MeasuresMeasurement Normal RangeRBC count 5 million 4 to 6 Hemoglobin 15 g% 12 to 17Hematocrit 45 38 to 50A x 3 = B x 3 = C - This is the rule of thumbCheck whether this holds good in given resultsIf not -indicates micro or macrocytosis or hypochromia.Causes of AnaemiaDecreased production of Red Cells - Hypoproliferative, marrow failureIncreased destruction of Red Cells - Hemolysis (decreased survival of RBC)Loss of Red Cells due to bleeding - Acute / chronic blood loss (hemorrhagic)Anaemia – First TestRETICULOCYTE COUNT %
  • ‘RBC to be’ or Apprentice RBC
  • Fragments of nuclear material
  • RNA strands which stain blue
  • NormalLess than 2%ReticulocytesSupravitalLeishman’sAnaemiaHb% < 12, Hct < 38%HemolyticHypoproliferativeRetics < 2Retics > 2Normal CBC Workup – Second TestThe next step is ‘What is the size of RBC’ ?MCV indicates the Red cell volume (size)Both the MCH & MCHC tell Hb content of RBCIf the Retic count is 2 or lessWe are dealing with either Hypoproliferative anaemia (lack of raw material)Maturation defect with less productionBone marrow suppression (primary/ secondary)Mean Cell Volume (MCV)RBC volume (rather) is measured byThe Mean Cell Volume or MCV and RDWMCVMicrocyticNormocyticMacrocytic< 80 fl 80 -100 fl> 100 fl< 6.5 µ6.5 - 9 µ> 9 µAnaemia Workup - MCVMCVMicrocyticNormocyticMacrocyticIron Deficiency IDAChronic InfectionsThalassemiasHemoglobinopathiesSideroblastic AnemiaChronic diseaseEarly IDAHemoglobinopathiesPrimary marrow disordersCombined deficienciesIncreased destructionMegaloblastic anemiasLiver disease/alcoholHemoglobinopathiesMetabolic disordersMarrow disordersIncreased destructionRed cell Distribution Width - RDWRDWNormal HighPopulation UniformPopulation DoubleAnaemia Workup - 4th TestPeripheral Smear StudyAre all RBC of the same size ?Are all RBC of the same normal discoid shape ?How is the colour (Hb content) saturation ?Are all the RBC of same colour/ multi coloured ?Are there any RBC inclusions ?Are intra RBC there any hemo-parasites ?Are leucocytes normal in number and D.C ?Is platelet distribution adequate ? IDA -CBC Microcytic Hypochromic - IDA IDA – Special TestsIDA SummaryMicrocytic MCV < 80 fl, RBC < 6 µRDW Widened with low MCVHypochromic MCH < 27 pg, MCHC < 30%RI < 2Serum ferritin Very low < 30 (p mols/L)TIBC Increased > 400 (µg/dL)Serum Iron Very low < 30 (µg/dL)BM Fe Stain Absent FeResponse to Fe Rx. Excellent IDA- Some NuggetsLook for occult blood loss – 2 days non veg. freePica and Pagophagia – Ice suckingAbsorption of Haem Iron > Fe ++ > Fe+++Food, Phytates, Ca, Phosphate, antacids ↓absorptionAscorbic acid ↑absorptionOral iron Rx. always is the best, ? Carbonyl Fe FeSO4 is the best. Reserve parenteral Rx.Packed cell transfusion in emergencyContinue Fe Rx at least 2 months after normal Hb1 gram ↑in Hb every week can be expectedAlways supplement protein for the Globin componentMicrocytic AnaemiasMacrocytic AnaemiasA. Megaloblastic Macrocytic – B12 and Folate↓B. Non Megaloblastic Macrocytic AnaemiasLiver disease/alcoholHemoglobinopathiesMetabolic disorders, HypothyroidismMyelodystrophy, BM infiltrationAccelerated Erythropoesis -↑destruction Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants)Anemia - Macrocytic (MCV > 100)Premature gray hair – consider MBAMacrocytic anemias may be asymptomatic untilthe Hb is as low as 6 gramsMCV 100-110 flmust look for other causes of macrocytosisMCV > 110 fl almost always folate or B12 deficiencyMBA Macrocytosis -MBA HSN - MBA Basophilic Stippling - MBABS occurs in Lead poisoning alsoMBA - BMPernicious Anaemia - Tongue Bald, smooth, lemon yellowish red tongueNormocytic AnaemiasChronic diseaseEarly IDAHemoglobinopathiesPrimary marrow disordersCombined deficienciesIncreased destructionAnaemia of investigations -ICUAnaemia of Chronic DiseaseThyroid diseasesMalignancyCollagen Vascular DiseaseRheumatoid ArthritisSLEPolymyositisPolyarteritis Nodosa
  • IBD
  • – Ulcerative Colitis
  • – Crohn’s Disease
  • Chronic Infections
  • – HIV, Osteomyelitis
  • – Tuberculosis
  • Renal Failure
  • ‘Dimorphic’ AnaemiaFolate & Fe deficiency (pregnancy, alcoholism)B12 & Fe deficiency (PA with atrophic gastritis)Thalassemia minor & B12 or folate deficiencyFe deficiency & hemolysis (prosthetic valve)Folate deficiency & hemolysis (Hb SS disease)Peripheral smear exam is critical to assess theseRDW is increased very muchRBC Size – AnisocytosisDifferent sizes of RBCPoikilocytosisDifferent Shapes of RBC Polychromasia - Spherocytosis Target Cells
  • Liver Disease
  • Thalassemia
  • Hb D Disease
  • Post splenectomy
  • WBC
  • WBCs are involved in the immune response.
  • The normal range: 4 – 11x10^9 /L
  • Two types of WBC:
  • 1) Granulocytes consist of:
  • Neutrophils: 50 - 70%
  • Eosinophils: 1 - 5%
  • Basophils: up to 1%
  • 2) Agranulocytes consist of:
  • - Lymphocytes: 20 - 40%
  • Monocytes: 1 - 6%
  • WBC
  • The type of cell affected depends upon its primary function:
  • In bacterial infections, neutrophils are most commonly affected
  • In viral infections, lymphocytes are most commonly affected
  • In parasitic infections, eosinophils are most commonly affected.
  • Neutrophil
  • polymorphneuclear leukocytes (PMN,s)
  • Nucleus 3-5 lobes.
  • Diameter 10-14 µm
  • 50-70% WBC
  • =2.5-7.5x10^9/ L
  • Function: Phagocytosis of bacteria and cell debris
  • Numbers rise with all manner of stress, especially bacterial infections
  • Neutrophil
  • Neutrophil disorders
  • Neutrophilia – an increase in neutrophils
  • Conditions associated with neutrophilia are:
  • 1-Bacterial infections(most common cause)
  • 2-Tissue destruction
  • e.g. tissue infarctions, burns.
  • 3- leukemoid reaction
  • 4-Leukemia
  • Neutrophil
  • Neutropenia – this may result from
  • 1-Decreased bone marrow production
  • e.g. BM hypoplasia.
  • 2-Ineffective bone marrow production
  • E.g. megaloblastic anemias and myelodysplastic syndromes.
  • 3- post acute infection
  • _ e.g. typhoid fever, brucellosis.
  • Eosinophil
  • Bilobed nucleus
  • 1-5% of WBC
  • =0.04-0.4x10^9/L
  • Diameter about 10-14 µm
  • Function: Involved in allergy, parasitic infections
  • Contains: eosinophilic granules
  • Eosinophil
  • Eosinophilia may be found in
  • Parasitic infections
  • Allergic conditions and hypersensitivity reaction
  • Lymphocyte
  • No specific granules
  • 20-40% of WBC
  • =1.55-3.5x10^9/ L
  • Diameter 8-10 µm
  • T cells: cellular
  • (for viral infections)
  • B cells: humoral (antibody)
  • Natural Killer Cells
  • Lymphocyte
  • Lymphocytosis – may indicate
  • _ Viral infection
  • e.g. Infectious mononucleosis, CMV or pertussis.
  • _ Bacterial infection
  • e.g. TB
  • Lymphopenia – caused by
  • _Stress.
  • _Steroid therapy
  • _ Irradiation
  • Abnormal result of WBC
  • (Leukocytosis) may indicate:
  • _ Infectious diseases
  • _Inflammatory disease (such as rheumatoid arthritis or allergy)
  • _Leukemia
  • _Severe emotional or physical stress
  • _Tissue damage (e.g. necrosis,or burns)
  • (Leukopenia) may result from:
  • _ Decreased WBC production from BM.
  • _ Irradiation.
  • _ Exposure to chemical or drugs.
  • Manifestation of leukocytosis
  • Fever
  • Malaise
  • Weakness
  • Others depend on each system which is involved
  • e.g. » chest: cough, SOB and chest pain
  • » abdomen: diarrhea, vomiting, dehydration.
  • »CNS: headache, visual disturbance,
  • Neck stiffness
  • and so 0n.
  • Manifestation of leukopenia
  • Infection of the mouth and throat.
  • Painful skin ulceration.
  • Recurrent infection.
  • Septicemia.
  • Platelets
  • Small granular non-nucleated discs.
  • Diameter about 2-4 µm
  • Normal range; 150-300x10^9 /L
  • Destroyed by macrophage cells in the spleen.
  • Function; involved in coagulation and blood haemostasis.
  • Life span 7-10 days
  • Platelets
  • Numbers of platelets
  • Increased (Thrombocythemia)
  • Pregnancy.
  • Exercise.
  • High attitudes.
  • splenectomy
  • Decreased (Thrombocytopenia)
  • Menstruation.
  • Haemorrhage.
  • Bone marrow destruction or suppression e.g. leukemia
  • The values have to fit the clinical situation.
  • Manifestaton of thrombocytopenia
  • Petechial hemorhage.
  • Easy bruising.
  • Mucosal bleeding
  • e.g. _ epistaxes.
  • _ gum bleeding
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