CBC --- InterpretationsCBC --- Interpretations

AbstractAbstract

Interpretation of different parameters Interpretation of different parameters reported on modern day analyzers is bit reported on modern day analyzers is bit tricky and demand continuous monitoring tricky and demand continuous monitoring and on-going learning. In present paper and on-going learning. In present paper interpretation of different reported interpretation of different reported parameters has been discussed with parameters has been discussed with approach to diagnosis of various approach to diagnosis of various abnormalities. 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.

• 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 (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 :

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 = 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 (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%

• 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 Definition of Anaemia

► Decrease in the number of circulating Decrease in the number of circulating red blood cell mass and there by Ored blood cell mass and there by O22 carrying capacitycarrying capacity

► Most common hematological disorder by Most common hematological disorder by farfar

► Almost always a secondary disorderAlmost always a secondary disorder► As such, critical for all practitioners to As such, critical for all practitioners to

know how to evaluate / determine its know how to evaluate / determine its cause / treatcause / treat

First QuestionFirst Question

►The onset of AnaemiaThe onset of Anaemia►Acute versus chronicAcute versus chronic►CluesClues

Hemodynamic stabilityHemodynamic stability Previous CBCPrevious CBC Overt blood lossOvert blood loss

Types of AnaemiaTypes of Anaemia

Screening Tests – Anaemia Screening Tests – Anaemia

►Clinical Signs and symptoms of Clinical Signs and symptoms of AnaemiaAnaemia

►Look for bleeding – all possible sitesLook for bleeding – all possible sites►Look for the causes for anemiaLook for the causes for anemia►Routine Hemoglobin examinationRoutine Hemoglobin examination►Cut off marks for Hb – Cut off marks for Hb –

US < 13.5 g US < 13.5 g WHO < 12.5 gWHO < 12.5 g Subcontinent Subcontinent Less than 12 g%Less than 12 g%

Clinical Signs to be looked forClinical Signs to be looked for

► Skin / mucosal pallor,Skin / mucosal pallor,► Skin dryness, Skin dryness, palmar palmar

creasescreases► Bald tongue, GlossitisBald tongue, Glossitis► Mouth ulcers, Mouth ulcers, Rectal examRectal exam► Jaundice, PurpuraJaundice, Purpura► LymphLymphadenopathyadenopathy► Hepato-splenomegalyHepato-splenomegaly► BreathlessnessBreathlessness► Tachycardia, CHFTachycardia, CHF► Bleeding, Bleeding, Occult BloodOccult Blood

PCV or HematocritPCV or Hematocrit

► 57% Plasma57% Plasma

► 1% Buffy coat – WBC1% Buffy coat – WBC

► 42% Hct (PCV)42% Hct (PCV)

The Three Basic MeasuresThe Three Basic Measures

MeasurementMeasurement NormalNormal RangeRange

A.A. RBC countRBC count 5 million5 million 4 to 6 4 to 6

B.B. HemoglobinHemoglobin 15 g%15 g% 12 to 1712 to 17

C.C. HematocritHematocrit 4545 38 to 5038 to 50

A x 3 = B x 3 = C - This is the rule of thumbA x 3 = B x 3 = C - This is the rule of thumb

Check whether this holds good in given Check whether this holds good in given resultsresults

If not -indicates micro or macrocytosis or If not -indicates micro or macrocytosis or hypochromia.hypochromia.

Causes of AnaemiaCauses of Anaemia

1.1. Decreased Decreased productionproduction of Red Cells of Red Cells- Hypoproliferative, marrow failure- Hypoproliferative, marrow failure

2.2. Increased destruction of Red CellsIncreased destruction of Red Cells- Hemolysis (decreased - Hemolysis (decreased survivalsurvival of RBC) of RBC)

3.3. Loss of Red Cells due to bleedingLoss of Red Cells due to bleeding- Acute / chronic blood - Acute / chronic blood lossloss (hemorrhagic)(hemorrhagic)

Anaemia – First TestAnaemia – First Test

RETICULOCYTE COUNT %RETICULOCYTE COUNT %

NormalLess than

2%

• ‘RBC to be’ or Apprentice RBC

• Fragments of nuclear material

• RNA strands which stain blue

ReticulocytesReticulocytes

Leishman’sSupravital

AnaemiaAnaemia

Hypoproliferative Hemolytic

Retics < 2 Retics > 2

Hb% < 12, Hct < 38%

Normal CBC Normal CBC

Workup – Second TestWorkup – Second Test

► The next step is The next step is ‘What is the size of RBC’ ?‘What is the size of RBC’ ?► MCV indicates the Red cell volume (size)MCV indicates the Red cell volume (size)► Both the MCH & MCHC tell Hb content of Both the MCH & MCHC tell Hb content of

RBCRBC► If the Retic count is 2 or lessIf the Retic count is 2 or less► We are dealing with either We are dealing with either

Hypoproliferative anaemia (lack of raw material)Hypoproliferative anaemia (lack of raw material) Maturation defect with less productionMaturation defect with less production Bone marrow suppression (primary/ secondary)Bone marrow suppression (primary/ secondary)

Mean Cell Volume (MCV)Mean Cell Volume (MCV)

► RBC volume (rather) is measured byRBC volume (rather) is measured by► The Mean Cell Volume or MCV and RDWThe Mean Cell Volume or MCV and RDW

Microcytic

< 80 fl

MCV

Normocytic Macrocytic

80 -100 fl > 100 fl

< 6.5 µ 6.5 - 9 µ > 9 µ

Anaemia Workup - MCVAnaemia Workup - MCV

Microcytic

MCV

Normocytic Macrocytic

Iron Deficiency IDA

Chronic Infections

Thalassemias

Hemoglobinopathies

Sideroblastic Anemia

Chronic disease

Early IDA

Hemoglobinopathies

Primary marrow disorders

Combined deficiencies

Increased destruction

Megaloblastic anemias

Liver disease/alcohol

Hemoglobinopathies

Metabolic disorders

Marrow disorders

Increased destruction

Red cell Distribution Width - Red cell Distribution Width - RDWRDW

Normal

Population Uniform

RDW

High

Population Double

Anaemia Workup - 4Anaemia Workup - 4thth Test TestPeripheral Smear StudyPeripheral Smear Study

► Are all RBC of the same size ?Are all RBC of the same size ?► Are all RBC of the same normal discoid shape Are all RBC of the same normal discoid shape

??► How is the colour (Hb content) saturation ?How is the colour (Hb content) saturation ?► Are all the RBC of same colour/ multi Are all the RBC of same colour/ multi

coloured ?coloured ?► Are there any RBC inclusions ?Are there any RBC inclusions ?► Are intra RBC there any hemo-parasites ?Are intra RBC there any hemo-parasites ?► Are leucocytes normal in number and D.C ?Are leucocytes normal in number and D.C ?► Is platelet distribution adequate ? Is platelet distribution adequate ?

IDA -CBC IDA -CBC

Microcytic Hypochromic - IDA Microcytic Hypochromic - IDA

IDA – Special TestsIDA – Special Tests

Iron related testsIron related tests NormalNormal IDAIDA

Serum Ferritin (pmoSerum Ferritin (pmo/L)/L) 33-27033-270 < 33< 33

TIBC (TIBC (µg/dL)µg/dL) 300-340300-340 > 400> 400

Serum Iron (Serum Iron (µg/dL)µg/dL) 50-15050-150 < 30< 30

Saturation %Saturation % 30-5030-50 < 10< 10

Bone marrow IronBone marrow Iron ++++ AbsentAbsent

IDA SummaryIDA Summary

► MicrocyticMicrocytic MCV < 80 fl, RBC < 6 MCV < 80 fl, RBC < 6 µµ► RDWRDW Widened with low MCVWidened with low MCV► HypochromicHypochromic MCH < 27 pg, MCHC < MCH < 27 pg, MCHC <

30%30%► RIRI < 2< 2► Serum ferritinSerum ferritin Very low < 30 (p mols/L)Very low < 30 (p mols/L)► TIBCTIBC Increased > 400 (Increased > 400 (µµg/dL)g/dL)► Serum IronSerum Iron Very low < 30 (µg/dL)Very low < 30 (µg/dL)► BM Fe StainBM Fe Stain Absent FeAbsent Fe► Response to Fe Rx.Response to Fe Rx. Excellent Excellent

IDA- Some NuggetsIDA- Some Nuggets► Look for occult blood loss – 2 days non veg. freeLook for occult blood loss – 2 days non veg. free► Pica and Pagophagia – Ice suckingPica and Pagophagia – Ice sucking► Absorption of Haem Iron > FeAbsorption of Haem Iron > Fe ++ ++ > Fe > Fe++++++

► Food, Phytates, Ca, Phosphate, antacids Food, Phytates, Ca, Phosphate, antacids ↓↓absorptionabsorption

► Ascorbic acid Ascorbic acid ↑↑absorptionabsorption► Oral iron Rx. always is the best, ? Carbonyl Fe Oral iron Rx. always is the best, ? Carbonyl Fe ► FeSOFeSO44 is the best. Reserve parenteral Rx. is the best. Reserve parenteral Rx.

► Packed cell transfusion in emergencyPacked cell transfusion in emergency► Continue Fe Rx at least 2 months after normal HbContinue Fe Rx at least 2 months after normal Hb► 1 gram 1 gram ↑↑in Hb every week can be expectedin Hb every week can be expected► Always supplement protein for the Globin Always supplement protein for the Globin

componentcomponent

Microcytic AnaemiasMicrocytic Anaemias

MCV < 80 flMCV < 80 fl Serum Serum IronIron TIBCTIBC BM Perls BM Perls

stainstain

Iron Def. Iron Def. AnemiaAnemia ↓↓↓↓ ↑↑↑↑ 00

Chronic Chronic InfectionInfection ↓↓↓↓ ↓↓↓↓ + ++ +

ThalassemiaThalassemia ↑↑↑↑ NN + + + ++ + + +HemoglobinopathHemoglobinopathyy NN NN + ++ +

Lead poisoningLead poisoning NN NN + ++ +SideroblasticSideroblastic ↑↑↑↑ NN + + + ++ + + +

Macrocytic AnaemiasMacrocytic Anaemias

A. Megaloblastic Macrocytic A. Megaloblastic Macrocytic –– B12 and Folate B12 and Folate↓↓

B. Non Megaloblastic Macrocytic AnaemiasB. Non Megaloblastic Macrocytic Anaemias

1.1. Liver disease/alcoholLiver disease/alcohol

2.2. HemoglobinopathiesHemoglobinopathies

3.3. Metabolic disorders, HypothyroidismMetabolic disorders, Hypothyroidism

4.4. Myelodystrophy, BM infiltrationMyelodystrophy, BM infiltration

5.5. Accelerated Erythropoesis -Accelerated Erythropoesis - ↑↑destruction destruction

6.6. Drugs (cytotoxics, immunosuppressants, Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants)AZT, anticonvulsants)

Anemia - Macrocytic (MCV > Anemia - Macrocytic (MCV > 100)100)

Premature gray hair – consider MBAPremature gray hair – consider MBA

Macrocytic anemias may be asymptomatic Macrocytic anemias may be asymptomatic untiluntil

the Hb is as low as 6 gramsthe Hb is as low as 6 grams

MCV 100-110 flMCV 100-110 fl

must look for other causes of macrocytosismust look for other causes of macrocytosis

MCV > 110 fl MCV > 110 fl

almost always folate or Balmost always folate or B1212 deficiency deficiency

MBA MBA

Macrocytosis -MBA Macrocytosis -MBA

HSN - MBA HSN - MBA

Basophilic Stippling - MBABasophilic Stippling - MBA

BS occurs in Lead poisoning also

MBA - BMMBA - BM

Pernicious Anaemia - Tongue Pernicious Anaemia - Tongue

Bald, smooth, lemon yellowish red tongue

Normocytic AnaemiasNormocytic Anaemias

1.1. Chronic diseaseChronic disease

2.2. Early IDAEarly IDA

3.3. HemoglobinopathiesHemoglobinopathies

4.4. Primary marrow disordersPrimary marrow disorders

5.5. Combined deficienciesCombined deficiencies

6.6. Increased destructionIncreased destruction

7.7. Anaemia of investigations Anaemia of investigations -ICU-ICU

Anaemia of Chronic DiseaseAnaemia of Chronic Disease

► Thyroid diseasesThyroid diseases► MalignancyMalignancy► Collagen Vascular Collagen Vascular

DiseaseDisease Rheumatoid ArthritisRheumatoid Arthritis SLESLE PolymyositisPolymyositis Polyarteritis NodosaPolyarteritis Nodosa

• IBD

– Ulcerative Colitis

– Crohn’s Disease• Chronic Infections

– HIV, Osteomyelitis

– Tuberculosis• Renal Failure

‘‘Dimorphic’ AnaemiaDimorphic’ Anaemia

► Folate & Fe deficiency (pregnancy, alcoholism)Folate & Fe deficiency (pregnancy, alcoholism)

► BB1212 & Fe deficiency (PA with atrophic gastritis) & Fe deficiency (PA with atrophic gastritis)

► Thalassemia minor & BThalassemia minor & B1212 or folate deficiency or folate deficiency

► Fe deficiency & hemolysis (prosthetic valve)Fe deficiency & hemolysis (prosthetic valve)

► Folate deficiency & hemolysis (Hb SS disease)Folate deficiency & hemolysis (Hb SS disease)

► Peripheral smear exam is critical to assess thesePeripheral smear exam is critical to assess these

► RDW is increased very muchRDW is increased very much

RBC Size – AnisocytosisRBC Size – AnisocytosisDifferent sizes of RBCDifferent sizes of RBC

PoikilocytosisPoikilocytosisDifferent Shapes of RBC Different Shapes of RBC

Polychromasia - Spherocytosis Polychromasia - Spherocytosis

Target CellsTarget Cells

1. Liver Disease

2. Thalassemia

3. Hb D Disease

4. Post splenectomy

• 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%

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.

• 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 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

– 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.

• 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

– Eosinophilia may be found in• Parasitic infections• Allergic conditions and

hypersensitivity reaction

• 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

• Lymphocytosis – may indicate_ Viral infection

e.g. Infectious mononucleosis, CMV or pertussis.

_ Bacterial infection

e.g. TB

• Lymphopenia – caused by

_Stress.

_Steroid therapy

_ Irradiation

• (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.

• 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.

• Infection of the mouth and throat.

• Painful skin ulceration.

• Recurrent infection.

• Septicemia.

•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

  • 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.

• Petechial hemorhage.

• Easy bruising.

• Mucosal bleeding

e.g. _ epistaxes.

_ gum bleeding