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P/N: ENG-CCS-5300/5380-210145x36-20110804

BC-5300/5380Auto Hematology Analyzer

Full automatic 5-part differentiation of WBC, 27 parameters, 3

histograms and 1 scattergram

Laser scatter, Advanced flow cytometry, Chemical dye

method

Independent Basophil channel

Up to 60 samples per hour

2 Sampling modes: Autoloader and Closed tube

Large storage capacity: 40,000 results with graphs

Preface to Clinical Case Study for Mindray Hematology analyzer BC-5300/5380

Microscope and Romanowsky dyes availability have resulted in

accumulation of a vast pool of knowledge about cytological chang-

es seen in various blood disorders. This is applied prospectively to

not only suspect, but also diagnose or even differentiate haemato-

logical disorders. It is unthinkable today to practice hematology

without support from an expert morphologist. At the base of such

approach lies the process of pattern recognition i.e. first discerning

a set of test results (qualitative + quantitative) as not normal (or

abnormal) and then establishing its association with a known he-

matological condition.

CBC+DIFF or ABC (i.e. Automated Blood Count & differentiation of

white cells into 5 common subtypes) is the most ordered blood test

worldwide. While Clinical laboratories world over test millions of

blood specimens daily on automated hematology analyzers; Lab

managers also have to grapple with a decreasing pool of expert

morphologists. Consequently, the newer entrants to medical pro-

fession look for solutions that bridge the gap between newer (not

necessarily well known) technologies and known maladies. Obvi-

ously, an interested user is looking for repositories of data produced

by automated devices that establishes link between the data and

diseases.

Mindray is a global healthcare manufacturer committed to bring

healthcare within reach of wider section of people. With a wide-

spread product portfolio and an established presence in over 165

countries; Mindray takes the task of supporting current healthcare

demands seriously.

Clinical case study for BC-5300/5380 hematology analyzer is an

example of that effort. It is a compilation of BC-5300/5380 hemato-

logy analyzer results obtained on healthy individual and patients

with commonly seen hematological abnormalities. It is designed to

introduce the BC-5300/5380 user to the benefits of pattern reco-

gnition. We wish to draw user's attention to the 'screening' principle

that is fundamental to judicious & proper use of this Clinical case

study book. Currently available hematology analyzers are unable to

classify all types of morphological abnormalities, primarily due to

the limitations of technology which cannot match the accuracy of

an expert morphologist who observes visual attributes of a well

stained cell and using his past knowledge classifies the cell. How-

ever, the analyzers make up for the lower accuracy by providing far

greater reproducibility/precision because they count large number

of cells and consistency to 'flag' an abnormality.

Hence, when BC-5300/5380 analyzer 'flags' a result, an expert

morphologist is expected to review patient's blood film from before

issuing findings & opinion, of course only after correlating with

patient's medical history and clinical condition.

It is also our hope that with your feedback, suggestions and newer

observations; we will be able to bring out richer editions of Clinical

Case Study in future.

Dr. Vijay Parekh, Scientific Director in Mindray

1 2

For RBC/PLT numeration, the classical electrical impedance

method is used. When cell passing through the aperture by

vacuum, it will introduce the change on resistance. In a

constant current, the voltage change signal will be recorded

and accords with the volume of cell.

For WBC 4 parts(lymphocytes, monocytes, neutrophils and

eosinophils) differentiation, chemical dye, flow cytometry

and laser scatter are applied.

Cells are injected into a flow cell

which is located in the optical path

of a light source, usually a laser;

Surrounded with sheath flow, the

blood cell pass through the center of

flow cell in a single colume at a fast

speed.

Flow cytometry

LEO I lyse breaks down red blood

cells and imposes on effect on white

blood cells.

LEO II lyse densifies the granules of

eosinophils.

Counting Principles for Hematology Analyzer BC-5300/5380

Chemical dye

DIFF Channel

EOS

Other WBC

RBC

LEO I LEO II

3 4

+ -electrode vacuum

aperture

Laser scatter

Light scattering occurs when a particle

deflects laser light. The extent to which

this occurs depends on the physical

properties of the particle:

Forward scatter (FS): cell volume

Side scatter (SS): cell granularity

FS

SS

LH Lyse breaks down red blood cell and shrinks other WBC cells except

basophils while keeps the original volume of basophils

BASO

Other WBC

RBC

WBC/BASO Channel

LH

5 6

For basophils and WBC total number count, the cells are first

treated by chemical dye, and then numerated by the classical

electrical impedance method.

LH lyse is also used for HGB quantitative analysis. With the

aid of a color reagent, the concentration of HGB is

determined by the change of absorbance in 525nm using

colorimetric method.

LH lyse breaks down red blood cells, binds to hemoglobin and converts

it to a complex that is measurable at 525nm.

LH

Flags Appendix

Abnormal Suspect

WBC

1Leucocytosis

High monocytes analysis results

Flag Meaning

High WBC analysis results

Low WBC analysis results

High neutrophils analysis results

High lymphocytes analysis results1Lymphocytosis

RBC/HGB

1Microcytosis Small MCV

RBC Abn. Distribution Abnormal RBC scattergram

Sizes of RBCs are dissimilar1Anisocytosis

Diamorphologic RBC dimorphic distribution

PLT

1Thrombocytosis

1Thrombocytopenia

PLT Abn Distribution

PLTs increase

PLTs decrease

PLT histogram distribution abnormal

WBC

Flag Meaning

RBC/HGB

PLT

WBC numbers of BASO and DIFF channels are inconsistent. The sample may be abnormal, or the analyzer may be abnormal

7 8

The criterions which trigger the flag information can be edited from the software version of V01.19.

2 For this flag, if the analyzer determines that it is resulted from fragile WBCs, or 9 9the WBC result in the predilute mode is between 0.5x10 /L and 2.0x10 /L, the

analysis result will be displayed; otherwise, the analysis result shows ”***”.

1

2WBC Abn. ?

WBC Abn. Histogram?

Abnormal WBC scattergram WBC Abn Scattergram?

RBC or HGB Abn.? 1 Results of RBC or HGB may be inaccurate

RBC Lyse Resist? RBC hemolysis may be incomplete

Immature Cell? Immature cells may exist

PLT Clump? PLT clump may exist

Left Shift?

Abnormal WBC histogram

Left shift may exist

Abn./Atypical Lym?

Abnormal lymphocytes or atypical lymphocytes may exist

1Leucopenia

1Neutrophilia

Low neutrophils analysis results1Neutropenia

Low lymphocytes analysis results1Lymphopenia

1Monocytosis

1Eosinophilia High eosinophils analysis results1Basophilia High basophils analysis results

1Macrocytosis Large MCV1Erythrocytosis Increased RBCs

1Anemia Anemia1Hypochromia Hypochromia

Normal scattergram appearance; the WBC sub-populations

are well differentiated from each other and aggregate with-

in expected areas; no flag message for abnormal cells. The

WBC/BASO, RBC and PLT histograms are normal.

Male, 27-year-old healthy volunteer.

Under microscope, the morphology of erythrocytes, platelets and all

sub-populations of leukocytes were normal, and no atypical or imma-

ture cells were observed.

Microscopic Differential

WBC DIFF Neutrophilic band granulocyte

Neutrophilic segmented granulocyteLymphocyte Monocyte Eosinophil Basophil

RBC morph

PLT morph

Screen Interpretation:

Upper part: results, reference ranges and flag information areas

Lower part: histograms and scattergram (

)

lymphocytes monocytes

neutrophils eosinophils

(n=200)

1%

54%37% 4%

3.5%0.5%

Normal Normal

Normal Sample

9 10

Lym

Neu

The dimorphic RBC population in this case indicates aniso-

cytosis and evidenced by presence of two red cell popula-

tions with different cell size distributions. Dimorphic RBC is

commonly seen in patients with sideroblastic anemia. It can

also be seen in patients recovering from iron deficiency

anemia upon receiving iron therapy or patients who have

received massive blood transfusion.

Male, 50-year-old, outpatient.Diagnosis: Rectal cancer

Under microscope, the erythrocytes varied in size; All WBC sub-

populations were within normal limits.

Microscopic Differential

WBC DIFFNeutrophilic band granulocyteNeutrophilic segmented granulocyte LymphocyteMonocyteEosinophilBasophil

RBC morph

PLT morph

Report Analysis:

Inaccurate RDW-CV and RDW-D results displayed as “**.*”; MCV results

might be affected; related parameters including HCT, MCV and MCHC

were flagged with ”?” where microscopic examination was suggested

RBC flag messages: “Dimorphologic” and “Anisocytosis”

Histogram: dimorphic RBC histogram indicated anisocytosis; in the

PLT histogram, the right part was raised from the X axis, indicating an

abnormal PLT distribution which might be interfered by microcytic

red cells

(n=200)

1%

55%35%

4%4.5%0.5%

Vary in size, the pale area in the center of some RBC

expandedNormal

Diamorphic RBC

11 12

Large RBC

Small RBC

Microcytosis is a condition where red blood cells are reveal-

ed to be unusually small when their mean corpuscular

volume is measured. A large number of hypochromic micro-

erythrocytes appear in blood smear, indicating reduction in

hemoglobin synthesis. It is seen in case of iron deficiency

anemia and thalassemia. However the microerythrocyte in

hereditary spherocytosis is well filled with hemoglobin and

the hypochromic area in its physiological center disappears.

Under microscope, the erythrocytes decreased in size, but were in

similar sizes.

Male, 34-year-old, outpatient.

Microscopic Differential

WBC DIFFNeutrophilic bandgranulocyte Neutrophilic segmented granulocyteLymphocyteMonocyte Eosinophil Basophil

RBC morph

PLT morph

(n=200)

1%

51%42.5%

4%1%

0.5%

Decrease in size, microcytic

Normal

Microcytosis

13 14

Neu

Report Analysis:

RBC and PLT counts increased; MCV decreased significantly

RBC flag messages: “Microcytosis” and “Erythrocytosis”

Histogram: the RBC dominant peak moved to left, indicating that

there were microcytes; in the PLT histogram, the right part was raised

from the X axis, indicating an abnormal PLT distribution due to

interference by microcytes

Aplastic anemia (AA) is a hematopoietic depletion syndrome

which may be caused by exposure to chemical toxins, physi-

cal trauma, biological factors or may be idiopathic in origin.

The hematopoietic stem cell dysfunction is prominent,

which leads to the replacement of hematopoietic red pulp by

fat, resulting in decrease of healthy blood cells causing pro-

gressive anemia, hemorrhage or infection. AA is usually seen

in adults.

Under microscope, the erythrocytes and leukocytes appeared fewer

than normal. The leukocyte in the field view on this page, was a

neutrophilic segmented granulocyte.

Female, 30-year-old.Diagnosis: aplastic anemia confirmed half a year ago.

Report Analysis:

WBC, RBC, HGB and PLT counts decreased significantly; lymphocyte

and neutrophil numbers decreased, especially the neutrophil number,

which was consistent with the features of aplastic anemia histogram

WBC flag message: “WBC Abn. scattergram”

RBC flag message: “Anemia”

PLT flag messages: “PLT Abn. Distribution” and “Thrombopenia”

WBC Differential

WBC DIFFPromyelocyteMyelocyteMetamyelocyteNeutrophilic bandgranulocyte Neutrophilic segmented granulocyteLymphocyteMonocyteEosinophil

RBC morphPLT morph

(n=200)1%1%2%

12%

71.5%12%

1%0.5%

Normal

Normal

Aplastic Anemia

15 16

Neu

Monocytes and phagocytes in tissues form a defense mecha-

nism by phagocytizing or killing damaged cells and antigens

. Monocytosis is an increase in the number of circulating

monocytes in blood. Physiological monocytosis is commonly

found among children and infants, while pathological

monocytosis is usually seen in patients with subacute infec-

tious endocarditis, malaria, kala-azar, active tuberculosis. It

may also present during the convalescence of an acute infec-

tion or hematological diseases such as malignant histocyto-

sis, lymphomatosis and agranulocytosis.

Under microscope, the monocyte proportion increased, in the micro-

scopic field shown here, two monocytes could be observed.

Male, 20-year-old, outpatient. Diagnosis: ankylosing spondylitis.

Microscopic Differential

WBC DIFF Neutrophilic segmented granulocyte Lymphocyte Monocyte Eosinophil

RBC morph PLT morph

(n=200)

49%32.5%

16%2.5%

NormalNormal

17 18

Report Analysis:

WBC count increased and monocyte number increased significantly

RBC and HGB results were within normal range; PLT count increased

WBC flag message: Monocytosis

Scattergram: in the DIFF scattergram, the monocyte area was brighter

than normal, indicating an intense aggregation of spots and increase

of monocyte proportion

" "

Mo

no

cytosis

MonMon

Eosinophil is capable of inhibiting allergic responses,

phagocytizing and is involved in immunological reactions to

parasites. Eosinophilia, elevated eosinophil count, is

commonly seen in patients with parasitic diseases, allergic

reactions and dermatological diseases. Increased eosino-

phil count is not unusual in chronic granulocytic leukemia,

polycythemia vera, multiple myeloma. Eosinophilia may

also be seen in patients with malignant tumors, infectious

diseases, rheumatic diseases, pituitary gland anterior lobe

deterioration, adrenal cortex deterioration and allergic

interstitial nephritis.

Under microscope, the eosinophils population appeared increased. In

the microscopic field shown here, two eosinophil granulocytes could be

observed.

Report Analysis:

Eosinophil number increased significantly; MCV decreased

WBC flag message Eosinophilia

Scattergram: in the DIFF scattergram, there were a significant

increase of eosinophil spots and increase of eosinophil proportion

: " "

Microscopic Differential

WBC DIFFNeutrophilic segmented granulocyte Lymphocyte Monocyte EosinophilBasophil

RBC morph PLT morph

Female, 25-year-old, outpatient. Diagnosis: edema of unknown cause.

(n=200)

42.5%28%

4.5%24.5%

0.5%

NormalNormal

19 20

Eosin

op

hilia

Eos

Eos

Large Immature Cell (LIC) refers to the increase of stab cells

and/or the presence of metamyelocytes, myelocytes and

promyelocytes in the peripheral blood. It can be divided into

reproductive left shift and degenerative left shift. The form-

er is a kind of left shift accompanied by elevated WBC count.

Left shift has its significance in evaluating the seriousness of

illness and the patients’ ability to respond.

Male, 34-year-old, outpatient. Diagnosis: Adult Still’s disease.

Report Analysis:

WBC count increased, RBC and HGB decreased

There was no clear distinction to differentiate neutrophil spots and

monocyte spots. The abnormal cells might affect the Baso histogram;

Neu#/%, Mon and Bas were flagged with “?”, indicating these

results might have been affected by presence of abnormal cells and a

microscopic examination was indicated

WBC flag message: ”Immature cell”?

Scattergram: in the DIFF scattergram, there was an cluster of spots in

the LIC area

#/% #/%

Microscopic Differential

WBC DIFF MyelocyteMetamyelocyteNeutrophilic band granulocyte Neutrophilic segmented granulocyte Lymphocyte MonocyteEosinophilBasophil

RBC morph PLT morph

Under microscope, a trend of left shift, for neutrophils & promyelocytes,

was observed. The cell in the left of the microscope field shot shown on

this page were a myelocyte and a .metamyelocyte

(n=200)1%

2.5%

2%

66.5%22.5%

3.5%1%1%

NormalNormal

21 22

Large Im

matu

re Cell

Myelocyte

Metamyelocyte

Atypical lymphocytes (ALY), also known as reactive lympho-

cytes, are enlarged and elongated white cells with an ellip-

tical nucleus. They are usually associated with viral illnesses

when normal lymphocytes are stimulated by the viral anti-

gens. These are commonly seen in infectious mononucleosis,

infectious hepatitis, measles, viral pneumonia, pertussis-

like syndrome, influenza, epidemic hemorrhagic fever and

even common cold.

Report Analysis:

There was no clear demarcation to differentiate clusters of lympho-

cyte and monocyte. The abnormal cells might affect the Baso

histogram; Lym#/%, Mon Eos and Bas are flagged with

“?” , indicating that these results might be affected by presence of

abnormal cells and a microscopic examination was indicated

WBC flag messages: ”Abn./Atypical Lym ? “, ” Lymphocytosis” and

“Neutropenia”

Scattergram: there was a cluster of spots in the ALY area

#/%, #/% #/%

Microscopic Differential

WBC DIFFNeutrophilic band granulocyte Neutrophilic segmented granulocyte LymphocyteAtypical lymphocyte Monocyte EosinophilBasophil

RBC morph PLT morph

Female, 2-year-old, inpatient; Virus test results: adenovirus: weak positive; respiratory syncytial virus: positive; Coxsackie virus: positive.Diagnosis: bronchopneumonia; virus infection confirmed.

Under microscope, the ALY proportion appeared increased. The micro-

scope field shot here showed two mononuclear atypical lymphocytes.

(n=200)

1%

14%75.5%

5%3%

0.5%1%

NormalNormal

23 24

Atyp

ical Lymp

ho

cyte

ALY

ALY

Acute promyelocytic leukemia (FAB M3) is a type of acute

myeloblastic leukemia. In FAB M3, there is an abnormal

accumulation of promyelocytes. The disease presents a chro-

mosomal translocation involving the retinoic acid receptor

alpha (RARα or RARA) gene and is unique from other forms of

AML in its responsiveness to all-trans retinoic acid (ATRA)

therapy.

Report Analysis:

WBC count increased, RBC and PLT counts decreased

WBC flag message: ”WBC Abn scattergram”

RBC flag message: “Anemia”

PLT flag message: “Thrombopenia”

Scattergram: there was a cluster of spots in the immature cell area;

the monocyte spots mixed with the granulocyte spots, while the

lymphocyte spots were clearly differentiated, indicating an abnormal

granulocyte morphology. Therefore, microscopic examination was

recommended

Microscopic Differential

WBC DIFFBlast PromyelocyteMyelocyte Metamyelocyte Lymphocyte

RBC morph PLT morph

Most of the cells observed under microscope were promyelocytes with

increased number of abnormal grains, and there were a few myeloblasts

and other granulocytes.

Female, 33-year-old. Chief complaints: increased menstrual blood loss and ecchymosis. Physical examination results: anemic look; petechiae all over her body; no superficial lymphadenodes could be detected during physical exam.

(n=200)6%

81%2%1%

10%

NormalNormal

25 26

AP

ML

PromyelocytePromyelocyte

Acute myelo-monocytic leukemia (FAB M4) is a form of acute

myeloid leukemia that involves a unwanted proliferation of

CFU-GM myeloblasts and monoblasts. It is a common type of

pediatric AML. The symptoms may be non-specific: weakness

, pallor, fever, dizziness and respiratory symptoms. More

specific symptoms include bruises and/or bleeding, DIC,

neurological disorders and gingival hyperplasia.

Report Analysis:

WBC count increased and RBC and PLT counts decreased

WBC flag message: “WBC Abn scattergram”

RBC flag message: “Anemia”

PLT flag messages: ”PLT Abn. Distribution” and “Thrombopenia”

Histogram: PLT number was very low and indices not reported

Scattergram: there was an cluster of spots in the immature cell area;

the monocyte spots mixed with the granulocyte spots while the

lymphocyte spots were clearly differentiated, which indicated that

the granulocyte and monocyte morphs were abnormal, so

microscopic examination was suggested

Microscopic Differential

WBC DIFF BlastPromyelocyteMyelocyteMetamyelocytePromonocyteNeutrophilic bandgranulocyte Neutrophilic segmented granulocyte Lymphocyte MonocyteNRBC

RBC morph PLT morph

Under microscope, a large number of promyelocytes and premonocytes

were observed, as well as active phagocytes. In the microscope field

shot, there were three leukocytes: promonocyte, promyelocyte and

blast.

Male, 30-year-old. Chief complaints: hypodynamia and pyrexia for 1 month; pain in left hip for 1 day.

(n=200)20%15%

4%4%

14%

3%

14%14%12%

5/100

NormalNormal

27 28

AM

Mo

L

Monoblast

Promonocyte

Promyelocyte

Acute Megakaryocytic Leukemia (AMKL) is a rare kind of

leukemia. Its clinical symptoms are similar to other types of

acute leukemias. Micromegakaryocytes that look like lym-

phocytes can be observed in blood smear; in marrow smear,

the abnormal proliferation of megakaryocytes can be found

with the count of megakaryocytes over 1000, among which

megakaryoblasts and promegakaryocytes are prominant.

A large number of immature cells which resembled lymphocytes (could

be megakaryoblasts or promegkaryocytes) were observed under

microscope. In the microscope field shot on this page, there were two

megakaryocytes.Report Analysis:

WBC count increased and RBC and PLT count decreased

WBC flag message: ” WBC Abn scattergram”

RBC flag messages: ”RBC Distribution Abn.” and “Anemia”

PLT flag messages: “PLT Abn. Distribution” and “ Thrombopenia”

Histogram: PLT number was low and indices reported with low

reliability

Scattergram: there was an cluster of spots in the immature cell area,

and the abnormal spots were on the top right; the monocyte spots

mixed with the granulocyte spots while the lymphocyte spots were

clearly differentiated

Female, 71-year-old. Chief complaints: hypodynamia and dazziness for half a year. Physical examination results: anemic appearance; with scattered petechiae on skin; bleeding observed on the left of oral mucosa, no superficial lymphnodes discovered by physical exam.

Microscopic Differential

29 30

WBC DIFF BlastMyelocyteMetamyelocyteImmature cell Neutrophilic bandgranulocyte Neutrophilic segmented granulocyte Lymphocyte MonocyteBasophil

RBC morph PLT morph

(n=200)10%

1%2%

30%

4%

25%24%

3%1%

NormalNormal

AM

KL

Megakayocyte

Chronic myelocytic leukemia (CML) is a clonal proliferative

disease which originates from the hematopoietic stem cells

with primary changes in myelocyte proliferation. The disea-

se is typically diagnosed in individuals aged between 20 and

50. One of the most distinctive features is enlarged or swoll-

en spleen. From the cytogenetic perspective, a positive CML

diagnosis is confirmed when the test for Philadelphia chro-

mosome is positive and the BCR/ABL fusion gene is detected.

Promyelocytes were seen under microscope. Basophil number increa-

sed significantly. In the microscope field shot on this page, there were

one neutrophilic segmented granulocyte and one

.

neutrophilic band

granulocyte

Report Analysis:

The number of basophil increased, and immature cells were observed,

which indicated a possibility of chronic myelocytic leukemia

WBC flag messages: ” Immature Cell?”, “Abnormal/Atypical Lym?” and “

Basophilia”

RBC flag messages: ”Anisocytosis” and “Macrocytosis”

Scattergram: there were a few spots scattered in the immature cell

area and the abnormal/atypical lymphocyte area which indicated an

abnormal WBC morph, so microscopic examination was suggested

Microscopic Differential

Male, 32-year-old. Chief complaint: leucocytosis for 2 years. Physical examination result: Normal. Bone marrow examina-tion result showed a possibility of chronic myelocytic leuke-mia.

31 32

WBC DIFF MyelocyteMetamyelocyteNeutrophilic bandgranulocyte Neutrophilic segmentedgranulocyte Lymphocyte Atypical lymphocyteMonocyte Basophil

RBC morph PLT morph

(n=200)1%1%

2%

46%37%

1%8%4%

Macrocytes presentNormal

CM

L

Neu

Band