cbc interpretation

1. 1

2. Complete blood count
interpretation
By Dr / Mohammed Basiony
2

3. BLOOD COMPONENTS
CELLS 45%
PLASMA 55%
WBCs PlateletsRBCs 3

4. 4
How Are Blood Cells Formed?

5. 5
Reticulocyte Count
 Reticulocytes are “young” red blood cells that
were recently released from the bone marrow.
 Normally, reticulocytes comprise 0.5 - 2% of all
red blood cells.
 Increased reticulocytes (reticulocytosis) is a
normal response to blood loss or anemia. Since
reticulocytes are larger, the MCV (and RDW)
may be elevated.
 The combination of anemia with a low or
normal reticulocyte count indicates that the
bone marrow is unable to respond normally,
either due to lack of essential ingredients (iron
deficiency, vitamin B12 or folate deficiency),
bone marrow disease, or chronic disease.

6. White Blood Cells
6
 There are several types of White Blood Cells
 They are all involved in immunity but in somewhat
different ways
Never
60
Let
30
Monkey
6
Eat
3
Banana
1

7. 7
Platelets
 Really more of a fragment of a
cell
 They are broken off from a
very large cell in the bone
marrow called a
megakaryocyte
 Primary function is to aid
in blood clotting
 Lifetime in the blood is 7-
10 days after which they are
destroyed in the spleen
 Their clotting function is
permanently inhibited by
aspirin

8. The Three Basic Measures
Measurement Normal
Range
A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. Hematocrit 45 38 to 50
A x 3 = B x 3 = C
8

9. Special Considerations in
Determining Anemia
 Acute Bleeding
 Drop in Hgb or Hct may not be shown until 36 to
48 hours after acute bleeding.
 Pregnancy
 In third trimester, RBC and plasma volume are
expanded by 25 and 50%, respectively.
 Labs will show reductions in Hgb, Hct, and RBC
count, often to anemic levels, but according to
RBC mass, they are actually polycythemic
 This affect HB - RBC count - HT ------but no
effect on MCV
 Volume Depletion
 Patient’s who are severely volume depleted may
not show anemia until after rehydrated
9

10. 10
Descriptive Terms Used on
Peripheral Smears
 Anisocytosis: marked variation in RBC sizes
(visual counterpart of increased RDW)
 Poikilocytosis: marked variation in the shape of
RBCs
 Hypochromia : RBCs are paler than normal
because they contain less hemoglobin (visual
counterpart of decreased MCH)
 Macrocytosis: increased number of large RBCs
(visual counterpart of increased MCV)
 Microcytosis: increased number of small RBCs
(visual counterpart of decreased MCV)

11. How to read
 1st look for HB
 3 possibilities:
A - normal its ok.
B - high polycythemia.
C - low anemia
11

12. HB
polycythemia
WBC
plat
Primary
polycythemia
WBC
plat
Secondary
polycythemia
12

13. HB
HB
• 11 Female
• 12 male
HB
• 13 child
• 14 infant
13

14. Red Cell Indices
Are measurements that indicate the size and
hemoglobin content of red cells:
M.C.V (Mean Corpuscular Volume)
M.C.H (Mean Corpuscular Hemoglobin)
M.C.H.C (Mean Corpuscular Hemoglobin
Concentration)
14

15. M.C.V (Mean Corpuscular Volume):
Referred to the average volume of red cells , normally = 77 - 99 fl
It can be calculated from an independently-measured red blood
cell count and hematocrit:
MCV (femtoliters) = 10 x HCT(percent) ÷ RBC (millions/µL)
MICROCYTOSIS & MACROCYTOSIS :
By definition, microcytosis is taken to mean the presence of RBCs
with a MCV less than normal, while macrocytosis means the
presence of RBCs with an MCV greater than normal.
15

16. M.C.H (Mean Corpuscular Hemoglobin):
or "mean cell hemoglobin" (MCH), is a measure of the
mass of hemoglobin contained by a red blood cell. It
is diminished in microcytic anemias, and increased in
macrocytic anemias. It is calculated by dividing the
total mass of hemoglobin by the RBC count :-
MCH=Hb/RBC
A normal value in humans is 27 to 32 picograms/cell
16

17. M.C.H.C
(Mean Corpuscular Hemoglobin Concentration):
is a measure of the concentration of hemoglobin in a given
volume of packed red blood cell .
It is diminished )"hypochromic") in microcytic anemias,
and normal "(normochromic )"saimena citycorcam ni
ro tnuoma nibolgomeh eht hguoht ,ezis llec regral ot eud(
lamron sniamer noitartnecnoc eht ,hgih si HCM.)
It is calculated by dividing the hemoglobin by the hematocrit :
M.C.H.C = Hb / Hct
A normal value is 30 to 36 g/dl .
17

18. RDW
Red cell distribution width
 It is correlates with the degree of
anisocytosis
 Normal range from 10-15%
 <21 in thalathemia.
 >21 in IDA
 elevated RDW is the first hematological
manifestation of iron deficiency anemia, and
hence a very sensitive screening test for that
particular disorder
18

19. Is the patient Anemic or not ?
Anemic means single or total
decrease in :
- Hb
- Hct
- RBCs count in millions
But…?
What Type of Anemia..?
This depends on the RBCs indices
19

20. Red Cell Indices
According to MCV & MCH
Normal
77-99
Normocytic
Normochromic
Anemia
Decreased
>77
Microcytic
Hypochromic
AnemiaIncreased
<99
Macrocytic
Anemia
20

21. Normocytic Normochromic Anemia
It may be due to :
- Acute Blood Loss
- Aplastic Anemia
- Hemolytic Anemia ( Except Thalasemia)
- A.O.C.D (Anemia Of Chronic Diseases)
Normal
A.O.C.D e.g.:
TB, SLE, Malignancy,
Rh. Arthritis
Note:
- Evidence of the cause
- Anemia May be Micro-
cytic Hypochromic
Low or Absent
B.M.F
“Aplastic Anemia”
BM biopsy or BM
aspiration show :
Acellular or Hypo-
cellular BM
High
- Acute Blood Loss
( search for evidence
of the cause)
- Hemolytic
Anemia
Which of Which ….?
Do Reticulocytic Count
21

22. Hemolytic Anemia
- low Hb &/or Hct & /or RBCs count
- Normal RBCs indices
- Reticulocytosis
Do Indirect Serum Billirubin
Unconjugated Hyper-billirubinemia
“ jaundice”
Other Evidences of Hemolysis e.g.:-
- Hemoglobinuria - Hemoglobinemia (increased free Hb)
- Decreased Haptoglobin.
What is the Further Step………..?
Coombs Test
22

23. Coombs Test
Positive
Immune
Hemolytic Anemia:
- Iso immune
- Auto immune
Negative
Non-immune
Hemolytic Anemia:
May be due to :
- Membrane Defect e.g. Spherocytosis
(lab show increased O.F.) & P.N.H
- Enzyme Defect
e.g. G6PD (lab : Enz. assay)
- Hb Defect (Hemoglobinopathy)
e.g. Sickle Cell Anemia (lab: Hb
Electrophoresis).
- Others : Malaria (lab: Bl. Film)
23

24. NN anemia
NN anemia
look for WBC& plat
markedly decrased pancytopenia
Look for retic count
If decreased aplastic anemia
If increased hypersplenism
24

25. Red Cell Indices
According to MCV & MCH
Decreased
Microcytic
Hypochromic
AnemiaIncreased
Macrocytic
Anemia
25

26. Microcytic Hypochromic Anemia
- The Commonest Cause is:
Iron Deficiency Anemia
-Other Causes: - Thalasemias
- Sedroplastic Anemia
- Lead Poisoning
- A.O.C.D
- Serum Iron
- Serum Ferritin
- T.I.B.C (Total Iron Binding Capacity)
- Transferrin Saturation
Which of Which ….?
Do Iron Studies:
26

27. According to Iron Studies
A.C.O.DSideroplastic
Anemia
ThalassemiaIron
Deficiency
Anemia
Serum Fe
N orNormalSerum
Ferritin
NormalT.I.B.C
Transferrin
Saturation
27

28. Iron Deficiency Anemia
Notes:
- Search For The Cause:
e.g.:
Chronic Blood Loss
Ankylostoma
Cancer Colon
Nutritional causes
- Severe Aniso-cytosis and
Poikilo-cytosis:
Increased R.D.W(N ≤ 13%(
Iron
Studies
Serum Fe
Serum
Ferritin
T.I.B.C
Transferrin
Saturation
28

29. Thalassemia
Notes:
- Hb Electrophoresis will
show:
Persistence of
hb f major type
hb a2 minor type
-Rdw <21
-HPLC = high performance
chromatography
A more accurate substitute for
HB electropheresis
Iron
Studies
Serum Fe
Serum
Ferritin
T.I.B.C
Transferrin
Saturation
29

30. Sideroplastic Anemia
Notes:
Sedroplastic Anemia is due
to:
- B6 Deficiency
- Drugs e.g.: INH
- Inherited
Blood film show:
RBCs contain Iron Granules
Treated by:
B6 supply
Iron
Studies
Serum Fe
NormalSerum
Ferritin
NormalT.I.B.C
Transferrin
Saturation
30

31. Red Cell Indices
According to MCV & MCH
Increased
Macrocytic
Anemia
31

32. Macrocytic Anemia
 - In Which :
- low Hb &/or Hct & /or RBCs count
- Increased RBCs indices
 -TYPES :
A. Megaloblastic Macrocytic – B12 and Folate↓
B. Non Megaloblastic Macrocytic Anaemias
1. Liver disease/alcohol
2. Hypothyroidism
3. Myelodystrophy, BM infiltration
4. Accelerated Erythropoesis –as in ↑destruction
5. Drugs (cytotoxics, immunosuppressants, AZT,
anticonvulsants)
32

33. Anemia - Macrocytic (MCV > 100)
 Macrocytic anemias may be asymptomatic until
the Hb is as low as 6 grams
 MCV 100-110 fl
must look for other causes of macrocytosis
 MCV > 110 fl
almost always folate or B12 deficiency
33

34. White blood cells
34

35.  Leukocytosis increase WBCs.>11000
 Leukopenia decrease WBCs.<4000
 Granulocytosis neutrophilia <8000/cmm
 Granulocytopenia neutropenia<2000/cmm
 Agranulocytosis neutropenia<500/cmm
 ( pseudoleukopenia?)
35

36. What to Do if WBC Abnormal
 Take a Good History
 Physical Examination
Look at Old CBC’s!!!!
36

37. History and clinical
examination
 Important features of history and clinical
examination:
 fever, lymphadenopathy
hepatomegaly, splenomegaly
frequency and severity of infections, mouth
ulcers, recent viral illness
exposure to drugs and toxins
fatigue/weight loss
pallor, jaundice
bleeding/bruising 37

38. Total WBC may be misleading
 The absolute count of each of the cell
types is more useful than the total.
 The total count may be misleading, eg:
low neutrophils with an elevated
lymphocyte count may produce a total
white count that falls within the
reference range.
38

39. Norms of leukocytes(WBC)
30000<WBC<2500
Emergency
39

40. WBC
IF decreased it is leukocytopenia
look for lymphocyte
‫عاليه‬ ‫لقيتها‬ ‫لو‬ ‫قليله‬ ‫او‬ ‫طبيعيه‬ ‫المفروض‬
relative lymphocytosis
→ Thyphoid
40

41. WBC
Neutrophils →↑bacterial infection
Lymphocyte →↑Viral infection
Monocyte →↑fungal , bacterial
Esinophil →↑allergy , parasite
Basophil →↑↑↑↑↑autoimmune disease
41

42. WBC
shift
left
staff
Acute infection
right
segmented
Chronic infection
42

43. Neutrophils
 Neutropenia
Mild ANC 1000-1500
Moderate 500-1000
Severe >500
 Neutrophilia
Absolute Neutrophil Count > 8000
 Leukemoid Reaction
Elevation in WBC
 Typically 30000-50000
 LAP score can differentiate from leukemia 43

44. Neutrophilia
– Conditions associated with :
1-Bacterial infections (most common
cause)
2-Tissue destruction
e.g. tissue infarctions, burns.
3- leukemoid reaction
4-Leukemia
44

45. Neutrophillia
 Other causes
any stressor/heavy exercise
drugs
pregnancy
 Red flags
person particularly unwell
severity
rate of change of neutrophilia
presence of left shift
45

46. Neutropenia
 Most common causes
viral infection
Chronic bacterial infection
Chemotherapy - radiotherapy
Drugs……
Red flags
person particularly unwell
severity
rate of change of neutropenia
lymphadenopathy, hepatosplenomegaly46

47. Drugs associated with
neutropenia
 Anticonvulsants ---- phenytoin
 Antithyropid ------- carbimazole
 Phenothiazines ------ carbamazepine
 Anti-inflammatory ------- phenylbutazone
 antibacterial ------ co trimoxazole
 Cytotoxic
 Others ----- gold, penicillamine,
imipramine 47

48. • T cells: cellular
immunity
• B cells: humoral
(antibody)
• Natural Killer Cells
48

49. lymphocyte
↑lymphocyte → viral infection(EBV-CMV)
chronic bact.infection(tb)
Post splenectomy
↓ lymphocyte → RadioTherapy ,
chemotherapy
+ 2S
(Sepsis,Steroid therapy)
Hiv
lupus 49

50. esinophil
 Highest Levels in am
 Contain histamin enzyme so increased in conditiond
with increased histamin release from mast cells as
Allergic conditions
1-asthma
2-allergic dermatitis
3-allergic rhinitis
4-parasitic infections except ??
Rarer causes:
 Hodgkins disease
 myeloproliferative disorders
 Churg-Strauss syndrome
↓↓↓↓↓↓with increased circulating steroids
(ex or en ) - typhoid 50

51. monocyte
 Monocyte in blood = macrophage in tissue
 Increased in the 3 most common conditions
1-typhoid
2-brucella
3-tb
+
4- Chronic inflammatory diseases
5- Viral infections common with measles &
mumps
Decreased with steroid therapy 51

52. Basophils
 Contain two substances in vesicles
Histamin ___ vasodilatation
Heparin_____prevent coagulation
 Increased in immune diseases and
tumors (most uncommon)
52

53. Basophils
Increased in 2a 2c
1- after splenectomy
2-allergic conditions
3- collagen vascular diseases
4-cancer blood( CML )
+ hypothyroidism
Decreased in CASH
1- cancer
2-acute infection
3- severe injury
4-hyperthyroidism 53

54. Thanks
4
your
attention
Be
happy