Interpretation ofInterpretation ofCBCCBC

Dr.Dr.Iffat Misbah SiddiquaIffat Misbah SiddiquaM.D PathologyM.D Pathology

CompleteComplete Blood Count (CBC)Blood Count (CBC)Also known as:Also known as: CBP, Haemogram CBP, Haemogram

Blood consists of 55% plasma andBlood consists of 55% plasma and

45%45% formed elementsformed elements

Red Blood Cells, Platelets (purple), a T Lymphocyte (green), Monocyte (gold) as seen through a scanning electron microscope.

CBCCBCWBC(TLC)WBC(TLC)

RBCRBCHgbHgb

HctHctMCVMCVMCHMCH

MCHCMCHCRDWRDW

PltPltDLCDLC

Haematology Automated Analyser

..Isolates and counts the cells found in the blood especially red blood cells, white blood cells & platelets.

..Reflects problems blood loss &with fluid volume (dehydration)

..Shows any abnormalities in the production ,destruction & life span of blood cells.

..Reflects acute or chronic infection, allergies, and problems with clotting.

CBC CBC is a screening test, used to diagnose and manage is a screening test, used to diagnose and manage numerous diseasesnumerous diseases..

The CBC test (contd)..

..Finds the cause of symptoms such as fatigue, weakness, fever, bruising, or weight loss .

..Diagnoses diseases of the blood, such as Leukemia, Polycythemia, Thrombocytosis.

..Checks how the body is dealing with some types of drug or radiation treatment .

……The results of CBC shows how well the vital organs

are functioning.

**The scientific name for red blood cells is

Erythrocytes.

*The most numerous of all cells in the blood.(4-5 million/cmm)

* Produced at a rate of 4-5 billion every hour in an adult human!(Life span 120 days).

* Looks like a doughnut, but without a hole in the middle.

* 7-8 microns in diameter.

• *Contain hemoglobin, a protein that carries oxygen .

• *Absorbs oxygen through the little alveoli in our lungs .

• *Delivers it to all the muscles, tissues and• organs in our body .

* Picks up a waste product called carbon dioxide.

*These deoxygenated red cells, make the return trip back to the lungs through the veins

where the CO2 can finally be released .

*Then, the red blood cells start the trip all over again. It takes, on average...only 30-45 seconds!

**RBCs are removed from circulation by the spleen.

*** RBC count is determined by age, sex, altitude, exercise, diet, pollution ,

drug use, tobacco /nicotine use, kidney function, etc.

** ** High red blood cell countHigh red blood cell count** **

**** Increase in Increase in Red Cell Red Cell productionproduction ****Primary: Primary: Polycythemia vera (Neoplastic)Polycythemia vera (Neoplastic)

Secondary: Secondary: To compensate for low O2 levels To compensate for low O2 levels (( Poor heart / Poor heart / lung function, high altitude lung function, high altitude ))

~ ~Erythropoietin (EPO)- Internal / ExternalErythropoietin (EPO)- Internal / External

~ ~ Anabolic SteroidsAnabolic Steroids

~ ~Smoking, Alcohol, Carbon MonoxideSmoking, Alcohol, Carbon Monoxide

~ ~Liver diseaseLiver disease

~ ~ HaemoglobinopathiesHaemoglobinopathies

****Relative / Spurious PolycythemiaRelative / Spurious Polycythemia****

** **Dehydration - - diarrhea or vomitingdiarrhea or vomiting,,

- - excessive sweatingexcessive sweating , ,

- - severe burnssevere burns , ,

- - diureticsdiuretics . .

** **The loss of blood plasmaThe loss of blood plasma..

: :Low Red blood cell CountLow Red blood cell Count: :

: :Decreased Production (Aplastic Anemia, deficiency ofDecreased Production (Aplastic Anemia, deficiency of

Iron / VitBIron / VitB12 12 / Folic acid etc/ Folic acid etc ( (

: :Blood loss.. Internal / ExternalBlood loss.. Internal / External

: :Haemolytic AnaemiasHaemolytic Anaemias

: :TumorsTumors , ,Addison's disease

: :TThalassemia, other haemoglobinopathies, other haemoglobinopathies

: :LLead poisoning, stomach ulcers,Bowel diseases, stomach ulcers,Bowel diseases..

: :Reactions to some chemicals and medicinesReactions to some chemicals and medicines..

Blood films of few anaemiasBlood films of few anaemias

*Hemoglobin is what gives the red color to the blood .

*It contains the iron, which carries the oxygen to the cells ,

haem molecules and globin chains .• *Its level indicates the amount of intracellular iron;

• hence,its value in determining anemia.

# Hemoglobin is the most abundant protein in the RBC.

# The causes of low hemoglobin may need

serum iron studies, globulin levels, uric acid , Ceruloplasmin (copper), and ferritin (iron

stores) to be determined.

# HGB is measured in gram per deciliter (g/dL) of blood

Causes of Raised HaemoglobinCauses of Raised Haemoglobin::

**** PrimaryPrimary: :

Polycythemia vera (neoplastic)Polycythemia vera (neoplastic)

** **SecondarySecondary: :

* *Associated with hypoxiaAssociated with hypoxia

----Cardiovascular diseases, pulmonary diseasesCardiovascular diseases, pulmonary diseases,,

----High altitude, hypoventilation, Hgb variantsHigh altitude, hypoventilation, Hgb variants

----Smoking, MethaemoglobinemiaSmoking, Methaemoglobinemia..

* *Increased erythropoitin productionIncreased erythropoitin production

----Kidney diseases and tumoursKidney diseases and tumours

----liver tumoursliver tumours

Contd..Increased HgbContd..Increased Hgb::**Associated with adrenocortical steroids, Associated with adrenocortical steroids,

testosterone supplementstestosterone supplements..

**Associated with chronic chemical exposure.. Associated with chronic chemical exposure.. nitrites, nitrites, cobalt, alcoholcobalt, alcohol……

****RelativeRelative::**StressStress

**Dehydration: vomiting, diarrhoeaDehydration: vomiting, diarrhoea……**Plasma loss: burns, enteropathyPlasma loss: burns, enteropathy……

Decreased haemoglobin leveDecreased haemoglobin levell::

* *Blood lossBlood loss - - Internal, ExternalInternal, External

* *Impaired red cell productionImpaired red cell production - - Deficiency of iron, Vit BDeficiency of iron, Vit B1212

- - Infection, renal failure, liver disease, chronic diseasesInfection, renal failure, liver disease, chronic diseases . . - - Aplastic, sideroblastic & dyserythroblastic anemiaAplastic, sideroblastic & dyserythroblastic anemia

- - Bone marrow infiltrations with tumour cellsBone marrow infiltrations with tumour cells

* *Increased destruction of RBC (Haemolysis)Increased destruction of RBC (Haemolysis):: - - Intrinsic abnormalityIntrinsic abnormality - - Extrinsic abnormalityExtrinsic abnormality

* *HaemodilutionHaemodilution - - Pregnancy, oedemaPregnancy, oedema

Haematocrit (HCT)Haematocrit (HCT)

< <Represents the volume of RBCs in 100ml of blood (40-50%)Represents the volume of RBCs in 100ml of blood (40-50%)

<< A low hematocrit and hemoglobin usuallyA low hematocrit and hemoglobin usually indicates decreased production, excessiveindicates decreased production, excessive

loss, or destruction of red blood cellsloss, or destruction of red blood cells . .

**** ****It is one of the most precise methods of determining It is one of the most precise methods of determining the degree of anemia or polycythemia the degree of anemia or polycythemia . .

****The conditions associated with an increased or The conditions associated with an increased or decreased hematocrit are the same as for decreased hematocrit are the same as for hemoglobinhemoglobin..

** ** In addition, it has been suggested that an elevated In addition, it has been suggested that an elevated hematocrit may be due to spleen hyperfunction, hematocrit may be due to spleen hyperfunction, while a reduced hematocrit may indicate low while a reduced hematocrit may indicate low thymus functionthymus function..

Red blood cell indicesRed blood cell indices::

There are three red blood cell indicesThere are three red blood cell indices * * Mean corpuscular volume (MCV)Mean corpuscular volume (MCV),,

* * Mean corpuscular hemoglobin (MCH)Mean corpuscular hemoglobin (MCH) , , * * Mean corpuscular hemoglobinMean corpuscular hemoglobin

concentration (MCHC)concentration (MCHC) . .

****Their values come from other (RBC, Hct, Hgb)Their values come from other (RBC, Hct, Hgb)

measurements in CBCmeasurements in CBC..

****The values help in the diagnosis ofThe values help in the diagnosis of different different typestypes of anemia of anemia..

Mean Corpuscular Volume (MCV)Mean Corpuscular Volume (MCV)

The MCV relates to the average size of the red blood The MCV relates to the average size of the red blood cell.cell.

Abnormal MCV associated with changes in MCH is a Abnormal MCV associated with changes in MCH is a significant finding for folic acid and/or Bsignificant finding for folic acid and/or B1212 need need (increase) or iron, copper or vitamin B(increase) or iron, copper or vitamin B66 need need (decrease). (decrease).

MCV and MCH should always be viewed together.MCV and MCH should always be viewed together.

Optimum range is 87.0 to 92.0 femtolitresOptimum range is 87.0 to 92.0 femtolitres..

The MCV is increased inThe MCV is increased in:: ----

- -Hereditary anemia(s)Hereditary anemia(s) . .

- -Megaloblastic AnemiasMegaloblastic Anemias

- -ReticulocytosisReticulocytosis

- -Artifact – cold agglutinins ,hyperglycemiaArtifact – cold agglutinins ,hyperglycemia . .

- -Liver diseaseLiver disease. .

- -HypothyroidismHypothyroidism. .

- -Drugs (anti-convulsants)Drugs (anti-convulsants) . .

- -Zidovidune treatment (AIDS)Zidovidune treatment (AIDS)..

The MCV is decreased inThe MCV is decreased in=:=:

= =Copper and iron deficiencyCopper and iron deficiency

= =Low stomach acid (Hypochlorhydria)Low stomach acid (Hypochlorhydria) . .

= =Vitamin C and Vit B6 insufficiencyVitamin C and Vit B6 insufficiency . .

= =Rheumatoid arthritisRheumatoid arthritis . .

= =Lead poisoningLead poisoning . .

= =Hereditary (thalassemias, sideroblastic)Hereditary (thalassemias, sideroblastic)

= =After a splenectomyAfter a splenectomy

= =Hemolytic anemiaHemolytic anemia

Mean Corpuscular Hemoglobin (MCH)Mean Corpuscular Hemoglobin (MCH)

~~ ~~The amount of hemoglobin in a single RBCThe amount of hemoglobin in a single RBC

~~ ~~It is a variation of the MCV measurementIt is a variation of the MCV measurement..

~~ ~~It is the ratio of Hgb and the RBC countIt is the ratio of Hgb and the RBC count..

~~ ~~Optimum values: 28.0 to 32.0 picogramsOptimum values: 28.0 to 32.0 picograms..

~~ ~~Increased & decreased in the same conditions as theIncreased & decreased in the same conditions as the

MCVMCV . .

Mean Corpuscular Hemoglobin ConcentrationMean Corpuscular Hemoglobin Concentration

))MCHCMCHC((

** **The average hemoglobin concentration per unit volumeThe average hemoglobin concentration per unit volume

) ) 100100 mlml ( (of packed red cellsof packed red cells..

** **Optimum values: 32 to 35Optimum values: 32 to 35.% .%

** **MCHC is increased in and decreased in the same conditionsMCHC is increased in and decreased in the same conditions

as the MCVas the MCV . .

**** Two exceptions – Spherocytosis-- ^ MCHC,<MCVTwo exceptions – Spherocytosis-- ^ MCHC,<MCV

- - Pernicious anemia--<MCHC,^MCVPernicious anemia--<MCHC,^MCV..

* * Consistency in the size of the red blood cells .i.eConsistency in the size of the red blood cells .i.e

variationvariation in the RBC size (Anisocytosis) in the RBC size (Anisocytosis)..

* * * * This is an electronic index that may help clarify if anThis is an electronic index that may help clarify if an

anemia has multiple componentsanemia has multiple components..

* *Ratio of Standard Deviation (SD)of red cell volume & mean Ratio of Standard Deviation (SD)of red cell volume & mean of MCV of MCV

** **Normal RDW is from 11.5 to 14.5%Normal RDW is from 11.5 to 14.5%

Red cell Distribution Width (RDW)Red cell Distribution Width (RDW)

The RDW is often The RDW is often increasedincreased in in::

^ ^ BB1212 and Pernicious anemia and Pernicious anemia

^ ^ Folic acid anemiaFolic acid anemia

^ ^ Iron deficiency anemia combined with other anemiaIron deficiency anemia combined with other anemia

^ ^ Hemolytic anemiaHemolytic anemia

^ ^ TransfusionsTransfusions

^ ^ Sideroblastic anemiaSideroblastic anemia

^ ^ Alcohol abuseAlcohol abuse

^ ^ Maturation defect anemiasMaturation defect anemias

The RDW is often The RDW is often decreaseddecreased in in::

<< Iron deficiency anemia (blood lossIron deficiency anemia (blood loss,,

parasites, poor iron absorption, etcparasites, poor iron absorption, etc (. (.

< <Vitamin BVitamin B66 anemia anemia . .

< <Rheumatoid arthritisRheumatoid arthritis . .

White Blood Cells (WBC, leukocyte)White Blood Cells (WBC, leukocyte)

* * * * Important part of our immune systemImportant part of our immune system

* * TThe mobile units of the body’s infection-fighting systemhe mobile units of the body’s infection-fighting system..

** Involved in combating allergic reactions, and immune responses .

** ** Family of many (5) different cell types that mediateFamily of many (5) different cell types that mediate many functions..(DLC.)many functions..(DLC.)

WBC(Contd)WBC(Contd)

** ** Bigger than RBCs (8-20 microns) but fewer in numberBigger than RBCs (8-20 microns) but fewer in number..

*** ***Measured in thousands per cubic millimeterMeasured in thousands per cubic millimeter ) ) TLC=TLC=4 - 11 thousand per mm3 ( (of bloodof blood..

High WBC Count (Leukocytosis)High WBC Count (Leukocytosis)::

• Infection, inflammation, splenectomyInfection, inflammation, splenectomy

• Damage to body tissues,Damage to body tissues,

• Severe physical or emotional stress (fever, injury, or Severe physical or emotional stress (fever, injury, or

surgery), surgery),

• Burns, malnutrition, SteroidsBurns, malnutrition, Steroids

• LLupus, , tuberculosis, , rheumatoid arthritis,,

• Leukemia, Cancers.Leukemia, Cancers.

Low White blood cell count(Leukocytopenia)

0 Chemotherapy, Drugs

0 Aplastic anemia, viral infections, malaria,

o Alcoholism, AIDS,

o Cushing's syndrome.

o Splenomegaly

DLC (Differential Leucocyte Count): N,L,M,E,BDLC (Differential Leucocyte Count): N,L,M,E,B..

Neutrophils) polys and bands) (NE(Lymphocytes) LY (

Monocytes (MO) Eosinophils) EO (

Basophils) BA(

White blood cell types (WBC differential)White blood cell types (WBC differential)..

- -Each type of cell plays a different role in protecting theEach type of cell plays a different role in protecting the

bodybody . .

- -Too many or too few of the different types of white bloodToo many or too few of the different types of white blood

cells can help find an infection, an cells can help find an infection, an allergic or toxic or toxic

reaction to medicines or chemicals, immune status andreaction to medicines or chemicals, immune status and

other conditions asother conditions as leukemia ..

Neutrophils (Granulocytes)Neutrophils (Granulocytes)

----most numerousmost numerous

--The normal count is 2,500-6,000/cmm (40-75%) .

--The “soldiers” that fight infections. They eat or gobble up the

infectious particles in the body.

--Polys are mature neutrophils. Bands are young polys, which

also fight infections.

High count is known as “High count is known as “Neutrophilia”:Neutrophilia”:

-- Acute infections-- Acute infections --Metabolic disorders-uremia, gout, acidosis--Metabolic disorders-uremia, gout, acidosis --Drugs-Digitalis, lead, mercury--Drugs-Digitalis, lead, mercury --Trauma, Haemorrhage--Trauma, Haemorrhage --Neoplasms --Neoplasms

Low count is “Neutropenia :”

…Aplastic anaemia …SLE …Hypersplenism …Steroid & Chemotherapy…(Immunodeficiency)

LymphocytesLymphocytes

***Lymphocytes are of large and small types.

*** Normal range is 20-45%.

***Protects the body against tumors and infections.

LymphocytosisLymphocytosis

Acute infections-IM, IL, Hepatitis, Rubella, PertussisAcute infections-IM, IL, Hepatitis, Rubella, Pertussis Chronic infections-TB, Brucellosis, Syphilis.Chronic infections-TB, Brucellosis, Syphilis. Endocrine disorders- thyrotoxicosis, hypopituitirismEndocrine disorders- thyrotoxicosis, hypopituitirism NeoplasmsNeoplasms

LmphocytopeniaLmphocytopenia PancytopeniaPancytopenia Congestive Heart failureCongestive Heart failure Adrenocorticosteroid therapyAdrenocorticosteroid therapy AIDSAIDS

MonocytesMonocytes

## Monocytes share the 'vacuum cleaner' function of neutrophils.(2-9%).

## Present pieces of pathogens to T cells so the pathogens may be recognized again and killed, so that an antibody

response may be mounted .

## Also known as macrophage after they leave the bloodstream

and enter tissues.

MonocytosisMonocytosis

Infections- IM, brucellosis,Typhus,TyphoidInfections- IM, brucellosis,Typhus,Typhoid Neoplasms- Leukemia,Lymphoma,Multiple MyelomaNeoplasms- Leukemia,Lymphoma,Multiple Myeloma Rheumatoid Arthritis, SLERheumatoid Arthritis, SLE SarcoidosisSarcoidosis Ulcerative colitisUlcerative colitis

MonocytopeniaMonocytopenia

** SteroidsSteroids

** Low immunity Low immunity

ss

EosinophilsEosinophils

^ A type of leukocyte with coarse orange red round granules of uniform size and bilobed nucleus.

^^ Eosinophils are so named because their cytoplasmic granules stain red with the dye eosin.

^^^Eosinophils constitute 1 to 3 % (350 to 650 /cmm)

EosinophiliaEosinophiliao AllergyAllergyo Parasitic infectionsParasitic infectionso Skin disorders- pemphigus, psoriasis, pruritisSkin disorders- pemphigus, psoriasis, pruritiso Drugs- streptomycin, penicillin, chlorpromazine..Drugs- streptomycin, penicillin, chlorpromazine..o NeoplasmsNeoplasms

EosinopeniaEosinopenia

o Endocrine diseases-cushing’s disease, acromegalyEndocrine diseases-cushing’s disease, acromegalyo Drugs-steroids, Adrenaline, insulin..Drugs-steroids, Adrenaline, insulin..o Stress-shock, burns, cold, severe exercise..Stress-shock, burns, cold, severe exercise..o Aplastic anaemiaAplastic anaemia

BasophilBasophil::

^^^^ CCoarse bluish-black granules of uniform size andoarse bluish-black granules of uniform size and

typically a bilobate) nucleustypically a bilobate) nucleus..

^^^^ Basophils are so named because their cytoplasmicBasophils are so named because their cytoplasmic

granules stain with basic dyesgranules stain with basic dyes..

^^^^ Constitute 0.5 to 1% of the peripheral blood leukocytesConstitute 0.5 to 1% of the peripheral blood leukocytes..

^^^^ Contain (and can release) histamine and serotoninContain (and can release) histamine and serotonin..

BasophiliaBasophilia

Chronic Myeloid LeukemiaChronic Myeloid Leukemia Hypersensitivity stateHypersensitivity state MyelosclerosisMyelosclerosis Polycythemia veraPolycythemia vera Hodgkin’s LymphomaHodgkin’s Lymphoma

BasopeniaBasopenia

UrticariaUrticaria HyperthyroidismHyperthyroidism CorticosteroidsCorticosteroids

PLATELETSPLATELETS(Thrombocytes)(Thrombocytes)

Fragments of cells that participate in clotting. Fragments of cells that participate in clotting.

Initiate repair of blood vessel walls.Initiate repair of blood vessel walls.

When bleeding occurs, the platelets swell, clump When bleeding occurs, the platelets swell, clump together, and form a sticky plug that helps stop the together, and form a sticky plug that helps stop the bleeding. bleeding.

Optimum values: 150,000 to 400,000/ mm3 of blood.Optimum values: 150,000 to 400,000/ mm3 of blood.

Platelets are increased inPlatelets are increased in::

Infection Infection Acute blood loss Acute blood loss Disseminated carcinoma Disseminated carcinoma Splenectomy Splenectomy ThrombocythemiaThrombocythemia Polycythemia Vera Polycythemia Vera Myeloproliferative Disorders Myeloproliferative Disorders Chronic Granulocytic Leukemia Chronic Granulocytic Leukemia Hemolytic anemia(s) Hemolytic anemia(s) Myelosclerosis Myelosclerosis Essential (without known cause) Essential (without known cause)

Platelets are decreased inPlatelets are decreased in::

Decreased ProductionDecreased Production Marrow depression/ infiltrationMarrow depression/ infiltration Megaloblastic anemia Megaloblastic anemia CongenitalCongenital

Increased DestructionIncreased Destruction• Immunologic (ITP,SLE)Immunologic (ITP,SLE)• Infectious mononucleosis ,Rubella, CMV,EBVInfectious mononucleosis ,Rubella, CMV,EBV• Lymphoma, CLL Lymphoma, CLL • Drugs-Drugs-chemotherapy,Quinine,Sulphonamides,Rifampicin,heparinchemotherapy,Quinine,Sulphonamides,Rifampicin,heparin

Hypersplenism ,Liver dysfunction (cirrhosis)Hypersplenism ,Liver dysfunction (cirrhosis)..Dilution due to overhydrationDilution due to overhydrationPlatelet aggregation or large plateletsPlatelet aggregation or large platelets

Mean platelet volume (MPV)Mean platelet volume (MPV)..

**** MPV measures the average amount (volume) ofMPV measures the average amount (volume) of

platelets.(7.5-11 fl)platelets.(7.5-11 fl)

** **MPV is used along with platelet count to diagnose some MPV is used along with platelet count to diagnose some diseases & find about its production in bone marrow diseases & find about its production in bone marrow..

**** Even if platelet count is normal, MPV can still be too high Even if platelet count is normal, MPV can still be too high or too low or too low . .

Sources of Error

• Inadequate mixing of specimen.• Hemolyzed specimens.• Lipemic specimens.• Clotted specimens.• Platelet clumps or platelet satellitosis.• Diluted specimens.

Variations in results not associated with disease of the Variations in results not associated with disease of the patientpatient : :

Haemolysed:~Haemolysed:~ ^Hb, ^MCHC; <RBC ,<Hct.^Hb, ^MCHC; <RBC ,<Hct.

Clotted:~Clotted:~ <All parameters.<All parameters.

Hyperlipemic / hyperglycemic:~ Hyperlipemic / hyperglycemic:~ ^RBC,^Hb,^Hct,^MCV.^RBC,^Hb,^Hct,^MCV.

Paraprotiens,cold agglutinins:Paraprotiens,cold agglutinins:<RBC<Hct,^MCHC,^MCH,^MCV<RBC<Hct,^MCHC,^MCH,^MCV

Dehydration:~ Dehydration:~ ^RBC, ^Hb^RBC, ^Hb

Diurnal variation, Posture, Drugs ,Diluted samples.Diurnal variation, Posture, Drugs ,Diluted samples.

Insufficient sample, improper blood collection & Insufficient sample, improper blood collection & storage; Improper mixing.storage; Improper mixing.

Correlate with Clinical Features !!! Correlate with Clinical Features !!!

Normal CBC valuesNormal CBC values

Normal CBC values…contdNormal CBC values…contd

– Mean corpuscular volume (MCV)– N: 80-100 fl

– RDW(Red cell Distrubution Width)

- N: 11.5-14.5 – Mean corpuscular hemoglobin (MCH)

– N: 27-34 pg– Mean corpuscular hemoglobin concentration (MCHC)

– N: (31-37 g/dl)

Laboratory findings:•Red cell indices:

Low Hb conc.MCV, MCH, MCHC*

•Blood film:Hypochromic microcytic Picture.Occasional Target cells.Pencil shaped poikilocytes.Normal reticulocyte count.

•Bone marrow iron:Normal to hypercellular.RBC precursors are increased in number.Iron stain negative.

•Chemical testing on serum:Serum iron Decreased Transferrin/TIBC Normal to HighSerum ferritin Decreased (Very low)