CBC Interpretition

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<ul><li> 1. CBC --- Interpretations</li></ul> <p> 2. Abstract </p> <ul><li>Interpretation of different parameters reported on modern day analyzers is bit tricky and demand continuous monitoring and on-going learning. In present paper interpretation of different reported parameters has been discussed with approach to diagnosis of various abnormalities.</li></ul> <p> 3. objectives 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. 4. </p> <ul><li>Component of the CBC: </li></ul> <ul><li>Red Blood Cells (RBCs) Hematocrit (Hct) Hemoglobin (Hgb) Mean Corpuscular Volume (MCV) Mean Corpuscular HemoglobinConcentration (MCHC) </li></ul> <ul><li>- Red cell distribution width (RDW) </li></ul> <ul><li>White Blood Cells (WBCs) Platelet</li></ul> <p>CBC- complete blood count 5. RBC </p> <ul><li>RBC (varies with altitude):</li></ul> <ul><li><ul><li>M: 4.7 to 6.1 x10^12 /L</li></ul></li></ul> <ul><li><ul><li>F: 4.2 to 5.4 x10^12 /L </li></ul></li></ul> <ul><li>Biconcave disc shape with diameter</li></ul> <ul><li>of about 8m </li></ul> <ul><li>Function : - transport hemoglobin which carries oxygen from the lung to the tissues</li></ul> <ul><li>-acid base buffer. </li></ul> <ul><li>Life span 100-120 days.</li></ul> <p> 6. </p> <ul><li>Hemoglobin : </li></ul> <ul><li><ul><li>M: 13.8 to 17.2 gm/dL</li></ul></li></ul> <ul><li><ul><li>F: 12.1 to 15.1 gm/dL </li></ul></li></ul> <ul><li>Hematocrit: ( packed cell volume ) </li></ul> <ul><li>It is ratio of the volume of red cell to the volume of whole blood.</li></ul> <ul><li><ul><li>M: 40.7 to 50.3 %</li></ul></li></ul> <ul><li><ul><li>F: 36.1 to 44.3 %</li></ul></li></ul> <p>Hemoglobin &amp; Hematocrit 7. </p> <ul><li><ul><li>MCV =mean corpuscular volumeHCT/RBC count= 80-100fL </li></ul></li></ul> <ul><li><ul><li><ul><li>small = microcytic </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>normal = normocytic </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>large = macrocytic </li></ul></li></ul></li></ul> <ul><li><ul><li>MCHC=mean corpuscular hemoglobin concentration HB/RBC count= 26-34% </li></ul></li></ul> <ul><li><ul><li><ul><li>decreased = hypochromic </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>normal = normochromic </li></ul></li></ul></li></ul> <p>MCV&amp;MCHC 8. </p> <ul><li>MCH (mean corpuscular hemoglobin) </li></ul> <ul><li>HB/HCT = 27-32 pg </li></ul> <ul><li>RDW (red cell distribution width) </li></ul> <ul><li>It is correlates with the degree of anisocytosis </li></ul> <ul><li>_ Normal range from 10-15% </li></ul> <p>MCH &amp; RDW 9. </p> <ul><li>This important value is needed in the evaluation of any anemia.</li></ul> <ul><li>Normal range 1-2%</li></ul> <ul><li>Retic count goes up with</li></ul> <ul><li><ul><li>Hemolytic anemia</li></ul></li></ul> <ul><li>Retic goes down with</li></ul> <ul><li><ul><li>Nutritional deficiencies</li></ul></li></ul> <ul><li>_ Diseases of the bone marrow itself </li></ul> <p>The Reticulocyte Count 10. Definition of Anaemia</p> <ul><li>Decrease in the number of circulating red blood cell mass and there by O 2carrying capacity </li></ul> <ul><li>Most common hematological disorder by far </li></ul> <ul><li>Almost always a secondary disorder </li></ul> <ul><li>As such, critical for all practitioners to knowhow to evaluate / determine its cause / treat </li></ul> <p> 11. First Question </p> <ul><li>The onset of Anaemia </li></ul> <ul><li>Acute versus chronic </li></ul> <ul><li>Clues </li></ul> <ul><li><ul><li>Hemodynamic stability </li></ul></li></ul> <ul><li><ul><li>Previous CBC </li></ul></li></ul> <ul><li><ul><li>Overt blood loss </li></ul></li></ul> <p> 12. Types of Anaemia 13. Screening Tests Anaemia</p> <ul><li>Clinical Signs and symptoms of Anaemia </li></ul> <ul><li>Look for bleeding all possible sites </li></ul> <ul><li>Look for the causes for anemia </li></ul> <ul><li>Routine Hemoglobin examination </li></ul> <ul><li>Cut offmarks for Hb </li></ul> <ul><li><ul><li>US&lt; 13.5 gWHO&lt; 12.5 g </li></ul></li></ul> <ul><li><ul><li>SubcontinentLess than 12 g% </li></ul></li></ul> <p> 14. Clinical Signs to be looked for </p> <ul><li>Skin / mucosal pallor, </li></ul> <ul><li>Skin dryness,palmar creases </li></ul> <ul><li>Bald tongue, Glossitis </li></ul> <ul><li>Mouth ulcers,Rectal exam </li></ul> <ul><li>Jaundice, Purpura </li></ul> <ul><li>Lymph adenopathy </li></ul> <ul><li>Hepato-splenomegaly </li></ul> <ul><li>Breathlessness </li></ul> <ul><li>Tachycardia, CHF </li></ul> <ul><li>Bleeding,Occult Blood </li></ul> <p> 15. PCV or Hematocrit </p> <ul><li>57% Plasma </li></ul> <ul><li>1% Buffy coat WBC </li></ul> <ul><li>42% Hct (PCV) </li></ul> <p> 16. The Three Basic Measures </p> <ul><li>Measurement Normal Range </li></ul> <ul><li>RBC count 5 million 4 to 6</li></ul> <ul><li>Hemoglobin 15 g% 12 to 17 </li></ul> <ul><li>Hematocrit 45 38 to 50 </li></ul> <ul><li>A x 3 = B x 3 = C - This is the rule of thumb </li></ul> <ul><li>Check whether this holds good in given results </li></ul> <ul><li>If not -indicates micro or macrocytosis or hypochromia. </li></ul> <p> 17. Causes of Anaemia </p> <ul><li>Decreasedproductionof Red Cells </li></ul> <ul><li><ul><li>- Hypoproliferative, marrow failure </li></ul></li></ul> <ul><li>Increased destruction of Red Cells </li></ul> <ul><li><ul><li>- Hemolysis (decreasedsurvivalof RBC) </li></ul></li></ul> <ul><li>Loss of Red Cells due to bleeding </li></ul> <ul><li><ul><li>- Acute / chronic bloodloss(hemorrhagic) </li></ul></li></ul> <p> 18. Anaemia First Test </p> <ul><li>RETICULOCYTE COUNT % </li></ul> <p>Normal Less than 2% </p> <ul><li> RBC to be or Apprentice RBC </li></ul> <ul><li>Fragments of nuclear material </li></ul> <ul><li>RNA strands which stain blue</li></ul> <p> 19. Reticulocytes Leishmans Supravital 20. Anaemia Hypoproliferative Hemolytic Retics &lt; 2 Retics &gt; 2 Hb% &lt; 12, Hct &lt; 38% 21. Normal CBC 22. Workup Second Test </p> <ul><li>The next step isWhat is the size of RBC ? </li></ul> <ul><li>MCV indicates the Red cell volume (size) </li></ul> <ul><li>Both the MCH &amp; MCHC tell Hb content of RBC </li></ul> <ul><li>If the Retic count is 2 or less </li></ul> <ul><li>We are dealing with either</li></ul> <ul><li><ul><li>Hypoproliferative anaemia (lack of raw material) </li></ul></li></ul> <ul><li><ul><li>Maturation defect with less production </li></ul></li></ul> <ul><li><ul><li>Bone marrow suppression (primary/ secondary) </li></ul></li></ul> <p> 23. Mean Cell Volume (MCV) </p> <ul><li>RBC volume (rather) is measured by </li></ul> <ul><li>The Mean Cell Volume or MCV and RDW </li></ul> <p>Microcytic &lt; 80 fl MCV Normocytic Macrocytic 80 -100 fl &gt; 100 fl &lt; 6.5 6.5 - 9 &gt; 9 24. Anaemia 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 25. Red cell Distribution Width - RDW NormalPopulation Uniform RDW High Population Double 26. Anaemia Workup - 4 thTest Peripheral Smear Study </p> <ul><li>Are all RBC of the same size ? </li></ul> <ul><li>Are all RBC of the same normal discoid shape ? </li></ul> <ul><li>How is the colour(Hb content) saturation ? </li></ul> <ul><li>Are all the RBC of same colour/ multi coloured ? </li></ul> <ul><li>Are there any RBC inclusions ? </li></ul> <ul><li>Are intra RBC there any hemo-parasites ? </li></ul> <ul><li>Are leucocytes normal in number and D.C ? </li></ul> <ul><li>Is platelet distribution adequate ?</li></ul> <p> 27. IDA -CBC 28. Microcytic Hypochromic - IDA 29. IDA Special Tests Iron related tests Normal IDA Serum Ferritin (pmo /L) 33-270 &lt; 33 TIBC ( g/dL) 300-340 &gt; 400 Serum Iron ( g/dL) 50-150 &lt; 30 Saturation % 30-50 &lt; 10 Bone marrow Iron ++ Absent 30. IDA Summary </p> <ul><li>Microcytic MCV &lt; 80 fl, RBC &lt; 6 </li></ul> <ul><li>RDW Widened with low MCV </li></ul> <ul><li>Hypochromic MCH &lt; 27 pg, MCHC &lt; 30% </li></ul> <ul><li>RI &lt; 2 </li></ul> <ul><li>Serum ferritin Very low &lt; 30 (p mols/L) </li></ul> <ul><li>TIBC Increased &gt; 400 (g/dL) </li></ul> <ul><li>Serum Iron Very low &lt; 30 (g/dL) </li></ul> <ul><li>BM Fe Stain Absent Fe </li></ul> <ul><li>Response to Fe Rx. Excellent</li></ul> <p> 31. IDA- Some Nuggets </p> <ul><li>Look for occult blood loss 2 days non veg. free </li></ul> <ul><li>Pica and Pagophagia Ice sucking </li></ul> <ul><li>Absorption ofHaem Iron&gt; Fe++&gt; Fe +++ </li></ul> <ul><li>Food, Phytates, Ca, Phosphate, antacids absorption </li></ul> <ul><li>Ascorbic acid absorption </li></ul> <ul><li>Oral iron Rx. always is the best,? Carbonyl Fe</li></ul> <ul><li>FeSO 4is the best. Reserve parenteral Rx. </li></ul> <ul><li>Packed cell transfusion in emergency </li></ul> <ul><li>Continue Fe Rx at least 2 months after normal Hb </li></ul> <ul><li>1 gram in Hb every week can be expected </li></ul> <ul><li>Always supplement protein for the Globin component </li></ul> <p> 32. Microcytic Anaemias MCV &lt; 80 fl Serum Iron TIBC BM Perls stain Iron Def. Anemia 0 Chronic Infection + + Thalassemia N + + + + Hemoglobinopathy N N + + Lead poisoning N N + + Sideroblastic N + + + + 33. Macrocytic Anaemias </p> <ul><li>A.Megaloblastic MacrocyticB12 and Folate </li></ul> <ul><li>B.Non Megaloblastic Macrocytic Anaemias </li></ul> <ul><li><ul><li>Liver disease/alcohol </li></ul></li></ul> <ul><li><ul><li>Hemoglobinopathies </li></ul></li></ul> <ul><li><ul><li>Metabolic disorders, Hypothyroidism </li></ul></li></ul> <ul><li><ul><li>Myelodystrophy, BM infiltration </li></ul></li></ul> <ul><li><ul><li>Accelerated Erythropoesis - destruction</li></ul></li></ul> <ul><li><ul><li>Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants) </li></ul></li></ul> <p> 34. Anemia - Macrocytic (MCV &gt; 100) </p> <ul><li><ul><li>Premature gray hair consider MBA </li></ul></li></ul> <ul><li><ul><li>Macrocytic anemias may be asymptomatic until </li></ul></li></ul> <ul><li><ul><li>the Hb is as low as 6 grams </li></ul></li></ul> <ul><li>MCV 100-110 fl </li></ul> <ul><li><ul><li>must look for other causes of macrocytosis </li></ul></li></ul> <ul><li>MCV &gt; 110 fl</li></ul> <ul><li><ul><li>almost always folate or B 12deficiency </li></ul></li></ul> <p> 35. MBA 36. Macrocytosis -MBA 37. HSN - MBA 38. Basophilic Stippling - MBA BS occurs in Lead poisoning also 39. MBA - BM 40. Pernicious Anaemia - TongueBald, smooth, lemon yellowish red tongue 41. Normocytic Anaemias </p> <ul><li>Chronic disease </li></ul> <ul><li>Early IDA </li></ul> <ul><li>Hemoglobinopathies </li></ul> <ul><li>Primary marrow disorders </li></ul> <ul><li>Combined deficiencies </li></ul> <ul><li>Increased destruction </li></ul> <ul><li>Anaemia of investigations -ICU </li></ul> <p> 42. Anaemia of Chronic Disease </p> <ul><li>Thyroid diseases </li></ul> <ul><li>Malignancy </li></ul> <ul><li>Collagen Vascular Disease </li></ul> <ul><li><ul><li>Rheumatoid Arthritis </li></ul></li></ul> <ul><li><ul><li>SLE </li></ul></li></ul> <ul><li><ul><li>Polymyositis </li></ul></li></ul> <ul><li><ul><li>Polyarteritis Nodosa </li></ul></li></ul> <ul><li>IBD </li></ul> <ul><li><ul><li>Ulcerative Colitis </li></ul></li></ul> <ul><li><ul><li>Crohns Disease </li></ul></li></ul> <ul><li>Chronic Infections </li></ul> <ul><li> HIV, Osteomyelitis </li></ul> <ul><li> Tuberculosis </li></ul> <ul><li>Renal Failure </li></ul> <p> 43. Dimorphic Anaemia </p> <ul><li>Folate &amp; Fe deficiency (pregnancy, alcoholism) </li></ul> <ul><li>B 12&amp; Fe deficiency (PA with atrophic gastritis) </li></ul> <ul><li>Thalassemia minor &amp; B 12or folate deficiency </li></ul> <ul><li>Fe deficiency &amp; hemolysis (prosthetic valve) </li></ul> <ul><li>Folate deficiency &amp; hemolysis (Hb SS disease) </li></ul> <ul><li>Peripheral smear exam is critical to assess these </li></ul> <ul><li>RDW is increased very much </li></ul> <p> 44. RBC Size Anisocytosis Different sizes of RBC 45. Poikilocytosis Different Shapes of RBC 46. Polychromasia - Spherocytosis 47. Target Cells </p> <ul><li>Liver Disease </li></ul> <ul><li>Thalassemia </li></ul> <ul><li>Hb D Disease </li></ul> <ul><li>Post splenectomy </li></ul> <p> 48. </p> <ul><li>WBCs are involved in the immune response. </li></ul> <ul><li>The normal range: 4 11x10^9 /L </li></ul> <ul><li>Two types of WBC: </li></ul> <ul><li>1)Granulocytes consist of: </li></ul> <ul><li><ul><li>Neutrophils: 50 - 70%</li></ul></li></ul> <ul><li><ul><li>Eosinophils: 1 - 5%</li></ul></li></ul> <ul><li><ul><li>Basophils: up to 1%</li></ul></li></ul> <ul><li><ul><li>2)Agranulocytes consist of: </li></ul></li></ul> <ul><li>-Lymphocytes: 20 - 40%</li></ul> <ul><li><ul><li>Monocytes : 1 - 6%</li></ul></li></ul> <p>WBC 49. WBC </p> <ul><li>The type of cell affected depends upon its primary function: </li></ul> <ul><li><ul><li>In bacterial infections, neutrophils are most commonly affected </li></ul></li></ul> <ul><li><ul><li>In viral infections, lymphocytes are most commonly affected </li></ul></li></ul> <ul><li><ul><li>In parasitic infections, eosinophils are most commonly affected. </li></ul></li></ul> <p> 50. </p> <ul><li>polymorphneuclear leukocytes(PMN,s) </li></ul> <ul><li>Nucleus 3-5 lobes. </li></ul> <ul><li>Diameter 10-14m </li></ul> <ul><li>50-70% WBC </li></ul> <ul><li>=2.5-7.5x10^9/ L </li></ul> <ul><li>Function: Phagocytosis of bacteria and cell debris </li></ul> <ul><li>Numbers rise with all manner of stress, especially bacterial infections</li></ul> <p>Neutrophil 51. </p> <ul><li>Neutrophil disorders </li></ul> <ul><li><ul><li>Neutrophilia an increase in neutrophils </li></ul></li></ul> <ul><li><ul><li>Conditions associated withneutrophiliaare: </li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>1-Bacterial infections (most common cause) </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>2-Tissue destruction </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>e.g. tissue infarctions, burns. </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>3-leukemoid reaction </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>4-Leukemia </li></ul></li></ul></li></ul></li></ul> <p>Neutrophil 52. </p> <ul><li><ul><li>Neutropenia this may result from </li></ul></li></ul> <ul><li><ul><li><ul><li>1-Decreased bone marrow production </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>e.g. BM hypoplasia. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>2-Ineffective bone marrow production</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>E.g. megaloblastic anemias and myelodysplastic syndromes. </li></ul></li></ul></li></ul></li></ul> <ul><li>3- post acute infection </li></ul> <ul><li>_ e.g. typhoid fever, brucellosis. </li></ul> <p>Neutrophil 53. Eosinophil </p> <ul><li>Bilobed nucleus </li></ul> <ul><li>1-5% of WBC </li></ul> <ul><li>=0.04-0.4x10^9/L </li></ul> <ul><li>Diameter about 10-14 m </li></ul> <ul><li>Function: Involved in allergy, parasitic infections </li></ul> <ul><li>Contains: eosinophilic granules</li></ul> <p> 54. </p> <ul><li><ul><li>Eosinophilia may be found in </li></ul></li></ul> <ul><li><ul><li><ul><li>Parasitic infections </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Allergic conditions and hypersensitivity reaction </li></ul></li></ul></li></ul> <p>Eosinophil 55. </p> <ul><li>No specific granules</li></ul> <ul><li>20-40% of WBC </li></ul> <ul><li>=1.55-3.5x10^9/ L </li></ul> <ul><li>Diameter 8-10m </li></ul> <ul><li>T cells: cellular</li></ul> <ul><li>(for viral infections) </li></ul> <ul><li>B cells: humoral (antibody) </li></ul> <ul><li>Natural Killer Cells </li></ul> <p>Lymphocyte 56. </p> <ul><li>Lymphocytosis may indicate </li></ul> <ul><li><ul><li><ul><li><ul><li>_ Viral infection </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>e.g. Infectious mononucleosis, CMV or pertussis.</li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>_ Bacterial infection </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li><ul><li>e.g. TB </li></ul></li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Lymphopenia caused by</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>_Stress. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>_Steroid therapy</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>_ Irradiation </li></ul></li></ul></li></ul> <p>Lymphocyte 57. Abnormal result of WBC </p> <ul><li>(Leukocytosis) may indicate: </li></ul> <ul><li>_ Infectious diseases</li></ul> <ul><li>_Inflammatory disease (such as rheumatoid arthritis or allergy)</li></ul> <ul><li>_Leukemia</li></ul> <ul><li>_Severe emotional or physical stress</li></ul> <ul><li>_Tissue damage (e.g. necrosis,or burns) </li></ul> <ul><li>(Leukopenia) may result from: </li></ul> <ul><li>_ Decreased WBC production from BM. </li></ul> <ul><li>_ Irradiation. </li></ul> <ul><li>_ Exposure to chemical or drugs. </li></ul> <p> 58. </p> <ul><li>Fever </li></ul> <ul><li>Malaise</li></ul> <ul><li>Weakness </li></ul> <ul><li>Others depend on each system which is involved </li></ul> <ul><li>e.g. chest: cough, SOB and chest pain </li></ul> <ul><li> abdomen: diarrhea, vomiting,dehydration. </li></ul> <ul><li>CNS: headache, visual disturbance,</li></ul> <ul><li>Neck stiffness </li></ul> <ul><li>and so 0n. </li></ul> <p>Manifestation of leukocytosis 59. </p> <ul><li>Infection of the mouth and throat. </li></ul> <ul><li>Painful skin ulceration. </li></ul> <ul><li>Recurrent infection. </li></ul> <ul><li>Septicemia.</li></ul> <p>Manifestation of leukopenia 60. Platelets </p> <ul><li>Small granular non-nucleated discs. </li></ul> <ul><li>Diameter about 2-4m </li></ul> <ul><li>Nor mal range; 150-300x10^9 /L </li></ul> <ul><li>Destroyed by macrophage cells in the spleen. </li></ul> <ul><li>Function; involved in coagulation and blood haemostasis. </li></ul> <ul><li>Life span 7-10 days </li></ul> <p> 61. </p> <ul><li>Numbers of platelets </li></ul> <ul><li><ul><li>Increased (Thrombocythemia) </li></ul></li></ul> <ul><li><ul><li><ul><li>Pregnancy. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Exercise. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>High attitudes. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>splenectomy </li></ul></li></ul></li></ul> <ul><li><ul><li>Decreased (Thrombocytopenia) </li></ul></li></ul> <ul><li><ul><li><ul><li>Menstruation. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Haemorrhage. </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Bone marrow destruction or suppression e.g. leukemia</li></ul></li></ul></li></ul> <ul><li>The values have to fit the clinical situation.</li></ul> <p>Platelets 62. </p> <ul><li>Petechial hemorhage. </li></ul> <ul><li>Easy bruising. </li></ul> <ul><li>Mucosal bleeding </li></ul> <ul><li>e.g. _ epistaxes. </li></ul> <ul><li>_ gum bleeding </li></ul> <p>Manifestaton of thrombocytopenia</p>