Evaluation of Peripheral blood

Huang Jinwen

Sir Run Run Shaw Hospital

Automated hematology instrumentation

WBC differential Advia 2120

peroxidase

cell

size Neutrophils (pink) and eosinophils

(yellow) containing the most perox activity are found to the right. Cells with little or no perox cluster to the left, such as lymphocytes/basophils (blue) and large unstained cells (blasts, variant and atypical lymphocytes, light blue). Monocytes (green) contain a small amount of perox and are located between the neutrophils and large unstained cells. Noise is indicated in the lower left hand corner (white).

Neutrophils

eosinophils

Monocytes

Lymphocytes

blasts

Red cell size distribution curves in hereditary

sideroblastic anemia

Presence of two populations of red cells A broad population of red cells, varying markedly in size, with the majority of the cells being microcytic.

Comparison between automated optical

and immunologic platelet counts

The majority of the data points well outside of the 95 percent confidence limits are above the best-fit line, suggesting that the optical method is more prone to overestimate platelet counts than the immunologic method in this range.

Optimal area for review

Suboptimal blood smear

Normal peripheral blood smear Rouleaux in myeloma

Definition and mechanisms of leukocytosis and neutrophilia

WBC Count

• The normal limit in adults: 4.400 to 11.0. (4.0 to 10.0) x109/L

• Leukocytosis: NL + 2SD, or> 11.0 x109/L

• Hyperleukocytosis or leukemoid reaction: > 50.0 x109/L

• Neutrophilic leukocytosis: >11.0 x109/L, + ANC>7,700 x109/L

• ANC = WBC x percent (PMNs + bands) ÷ 100

Neutrophilic leukocytosis

• It commonly seen in

• It can also occur in

• Neutrophilia

Infection,

Stress,

Smoking,

Pregnancy,

Following exercise.

Chronic myeloproliferative disorders,

Chronic myeloid leukemia

Lymphocytic leukocytosis

• WBC 11.0 X109/L, an absolute lymphocyte count > 4.8 X109/L .

• Infectious mononucleosis and pertussis

• Lymphoproliferative disorders, such as the acute and chronic lymphocytic leukemias

Monocytic leukocytosis

• WBC> 11.0 x109/L, an absolute monocyte > 0.8 x109/L.

• Acute and chronic monocytic variants of leukemia

• Acute bacterial infection or tuberculosis

• Monophilia.

Eosinophilic and basophilic leukocytosis • WBC>11.0 x109/L, an absolute eosinophil > 0.45 x109/L

or basophil >0.2 x109/L

• Eosinophilic leukocytosis can be seen in

• Basophilic leukocytosis is a distinctly unusual condition,

Chronic leukemia,

Solid tumors,

Infection with parasites, Allergic reactions,

Following treatment with IL-2

Basophilic or Mast cell variants of acute or chronic leukemia

Regulation of neutrophil counts

PMN development

Detection of infection or inflammation

band count ≥20

left-shift

cytoplasmic vacuoles

Dohle bodies, Toxic granulation

The leukocyte alkaline phosphatase score

• LAP is high in

• LAP is low in

Infection

InflammationPolycythemia vera

Chronic myeloid leukemia Paroxysmal nocturnal hemoglobinuria

Definitions of neutropenia

• Mild neutropenia: ANC 1.0 ~1.5 X109/L

• Moderate neutropenia: ANC 0.500 ~1.0 X109/L

• Severe neutropenia: ANC < 0.5 X109/L

Neutropenia and hospitalization for infection

Etiology of isolated neutropenia

• Acquired neutropenias• Postinfectious neutropenia• Drug-induced neutropenia and agranulocytosis• Primary immune disorders• Hypersplenism• Bone marrow disorders• Congenital neutropenias• Myeloperoxidase deficiency

NIH grading of hematologic toxicity

of chemotherapy

Fever in the neutropenic adult patient with cancer

Risk Factors of Fever

■ A rapid decline in ANC or ANC <0.1 X109/L

■ Prolonged duration of neutropenia (>7 to 10 days)

■ Leukemic induction

■ Cancer not under control

■ Comorbid illnesses requiring hospitalization

■ Use of central venous catheters

■ Disruption of mucosal barriers

■ Use of monoclonal antibodies

INFECTIONS IN FEBRILE NEUTROPENIA

■ A majority of patients had occult bacterial infections

■ An infectious source identified in ~ 30 %

■ Bacteremia documented ~25%

■ ~80% of identified infections arised from patients‘

own endogenous flora.

Symptoms and a physical examination daily

Laboratory studies • CBC with differential, transaminases, bilirubin, amylase an

d electrolytes, a chest radiograph, and cultures.

• Two or more blood cultures, sputum Gram stain and culture, and urine Gram stain and culture.

• Pulmonary infiltrates frequently can not produce sputum; a more invasive approach including bronchoscopy or open lung biopsy.

• Lumbar puncture is not usually recommended.

Blood cultures

• One set /day for a stable fever pattern.

• Two or three sets initially and to wait 48 to 72 hours to repeat blood cultures.

Chest radiographs

■ Findings are often minimal or absent even in patients with pneumonia. ■ Findings may develop along with an increase in symptoms as the neutropenia begins to resolve.

Chest CT scanning

CT should be ordered for the patients with pulmonary symptoms.

Colony stimulating factors

■ CSF reported to decrease the duration of neutropenia, fever, and hospitalization.

■ CSF have not been shown to decrease mortality.

■ These agents should not be used routinely for patients with fever and neutropenia.

■ It may be appropriate to consider their use in critically ill patients.

THANKS