Subtleties of The

Home , Mean corpuscular volume, Normochromic anemia

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Complete blood count (CBC)

• Usual components • WBC • RBC Subtleties of the CBC • Hemoglobin • Hematocrit Meghan East • Indices Salisbury University • Platelet count • Optional: Microscopic evaluation • Alternate name: PBC for Peripheral Blood Count

Outline Complete blood count (cont.)

• Review: what is included in a CBC • Usually performed on automated instrument • Common changes seen on the CBC and relevance • 5 part diff most common to patient care • 3 part diff on smaller instruments • “New-ish” tests in the CBC & how to use clinically • Can also be performed manually • Hemocytometer to count cells • Effects of improper collection and transportation • Manual hemoglobin on CBC results • Micro hematocrit • Case studies • Calculations for indices

Components of Blood Complete blood count (cont.)

• Specimen from correct patient • Volume • Patient identified prior to obtaining sample • 4—6 liters • Properly labeled sample and requisition • Approximately 8% of total body weight • Usual specimen is EDTA whole blood. • Plasma 55%--liquid portion • EDTA in liquid form; chelates Ca++ and prevents clotting • Water • Ideal peripheral smears made within 3 hours • Solutes: proteins, electrolytes, hormones • Within 1 hour highly preferred • Cellular elements 45%--cellular portion • > 5 hours after collection results in artifacts • Red blood cells: carry oxygen and carbon dioxide • Smear from direct finger puncture (un-anticoagulated) must be • Example diseases- anemia, polycythemia made immediately • White blood cells: immunity • Stability of specimen for counts • Example diseases- leukemia, infection • Perform on room temp blood within 6 hours • Platelets: primary hemostasis (initiate clot) • Perform on refrigerated blood within 24 hours • Example diseases- thrombosis, bleeding disorders

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Peripheral blood distribution of Complete blood count (cont.) WBC types

• Unacceptable CBC specimens • Neutrophils 40-85% • Too old • Neutrophils 40-80% Reversed In young • Macroscopic or microscopic clotting • Bands 0-5% children* • Clotting activates & consumes coagulation factors • Binds blood cells within fibrin mesh • Lymphocytes 25-35% • erroneous for all assays • Monocytes 2-10% * So-called “Reverse Diff” • clogs apparatus of automated analyzers • Non-fasting specimen • Eosinophils 0-5% • Improper collection from line with TPN • • Hemolysis Basophils 0-1%

Absolute concentrations of CBC– component detail (cont.) leukocytes • RBC • Much better value than % in evaluation of whether a • Cells per cubic millimeter (microliter), expressed in millions (106) OR particular cell type is elevated • Cells per liter, expressed in 1012 cells • Reference ranges • Examples • Neutrophils 1.8 - 7.0 x 109/L • 5.00 X 106 cells per μL OR • Bands 0 - 0.7 x 109/L • 5.00 X 1012 cells per L • Lymphocytes 1.0 – 4.8 x 109/L • Reference ranges • Monocytes 0.1 - 0.8 x 109/L 6 • Adult male = 4.50 – 5.90 X 10 cells per μL • Eosinophils 0 - 0.4 x 109/L • Adult female = 3.80 – 5.20 X 106 cells per μL • Basophils 0 – 0.2 x 109/L

CBC– component detail (cont.) Leukocyte function (cont.)

• WBC • Granulocytes = non-specific arm of the immune 3 system (along with macrophages)  phagocytosis • Cells per microliter, expressed in thousands (10 ), OR & digestion of pathogens 9 • Cells per liter, expressed in 10 units • Neutrophils – bacteria • Examples • Eosinophils – weak phagocytes; parasite toxins, allergy • 5.1 X 103 cells per μL abatement 9 • Basophils – phagocytosis irrelevant; inflammatory response • 5.1 X 10 cells per L from IgE 3 • Reference range = 4.0 – 11.0 X 10 cells per μL • Lymphocytes = specific immune system arm • Monocytes & macrophages = non-specific arm of the immune system  phagocytosis & antigen presentation to T helper cells

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Neutrophil distribution Basophil function

• Origin in marrow, 7-8 days total: • 2-3 days in “Mitotic pool” = myeloblast  myelocyte • Can also phagocytize • 5-7 days in “Storage pool” = metamyelocyte  • Major function is mediators of inflammatory segmented stage responses • Released into PBS, stay for 7-10 hours • Have receptors for IgE • Marginal pool – adhere to vessel walls OR • When bound to IgE, histamine is released from • Circulating pool – free in plasma granules • Constant dynamic change between pools • Histamine release  immediate hypersensitivity • Circulating pool can be increased during stress via mobilization of marginal pool by epinephrine • Also recruit eosinophils and neutrophils • Diapedesis into tissues for functions • Also function in the coagulation system via heparin granules

Monocyte distribution and Neutrophil function function (cont.) • Participate in innate immune response • Participate in both immune systems • Phagocytosis by neutrophils • Innate • Ingest and digest invaders • Other functions of neutrophils • Act as “vacuum cleaners” to clean up debris and old cells • Secrete substances which activate parts of the • Adaptive coagulation system • Antigen-presentation of digested material to T helper cells • Interact with the kinin system, an ancillary pathway • Cytokines stimulate various lymphoctyes in the AIR (adaptive associated with coagulation immune response) • Secrete the pyrogen, IL-1, which induces fever

Eosinophil functions Lymphocytes

• Similar to neutrophils • Mature lymphocytes • Size VERY variable! (from 7-10 μm to as large as a monocyte) • Capable of phagocytosis • Three categories • Also secrete granular contents outside the cell  • Small mature lymphocyte better defense against parasites, especially • Larger normal lymphocyte helminths • Variant lymphocyte • Are also increased in response to allergy, asthma, • Current preferred term and generalized inflammation • Historic/other terms used • Reactive lymphocyte • Atypical lymphocyte

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T-cell functions (cellular Complete blood count – immunity) component detail (cont.) • Delayed type hypersensitivity • Platelet count • Cytotoxic reactions • Cells per microliter, expressed in thousands (103) OR 9 • Killing virus-infected cells • Cells per liter, expressed as 10 cells • Rejection of transplanted organs • Examples • 150 X 103 cells per μL OR • Regulator T-cells • 150 X 109 cells per L • CD4+ helper is central player • Reference range = 150 – 450 X 103 cells per μL • Interact with other T-cells, B-cells and macrophages • CD8+ suppressor shuts off system • Normal ratio of CD4+ to CD8+ = 2:1

B-cell functions CBC– component detail (cont.) (humoral immunity) • Hemoglobin = concentration • g/dL OR • Unstimulated, carry immunoglobulin on cell • g/L surface • Example: 13.5 g/dL = 135 g/L • Antibody release • Reference ranges • StimulusTransform into plasma cells  Antibody • Adult male = 13.5 – 17.5 g/dL secretion for current stimulus • Adult female = 12.0 – 16.0 g/dL • Stimulus Memory B-cells that can secrete antibody if stimulus encountered later

Complete blood count – Natural Killer (NK cell) functions component detail (cont.) • Part of the innate/non-specific arm of the immune • Hematocrit = percentage or proportion of system plasma that is RBC’s • Kill without any previous sensitization or immune • 45% = 0.45 L/L response • Reference ranges • Tumor cells Adult male = 42-52% • Virus-infected cells Adult female = 36-46% • Antibody coated cells

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CBC– component detail (cont.) CBC– component detail (cont.)

• Indices = mathematical calculations with • MCH = mean corpuscular hemoglobin erythrocyte values • Calculation: • Size and hemoglobin content of RBC’s • Each is an average (except RDW) Hgb MCH = X 10 e.g. 14.2 X 10 = 29.1 pg • MCV = mean corpuscular volume RBC* 4.88 • MCH = mean corpuscular hemoglobin • MCHC = mean corpuscular hemoglobin concentration *Expressed as 106 /uL • RDW = red cell distribution width • Indices used to help classify anemias • Reference Interval = 26.0-34.0 pg (1 picogram = 10-12 gram)

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Complete blood count – CBC– component component detail (cont.) detail (cont.) • MCV = mean corpuscular volume • Calculation: • MCH = mean corpuscular hemoglobin (cont.) Hct e.g. 42.6 • Cell “color” between 26.0-36.0 pg = normochromic MCV = X 10 X 10 = 87.3 fL RBC* 4.88 • Cell “color” < 26.0 pg = hypochromic • Cell “color” > 36.0 pg = hyperchromic *Expressed as 106 /uL • Large cells (macrocytes) have more hemoglobin but are a normal color; NOT called hyperchromic • Spherocytes abnormal cells that are darkly colored for their size • Reference Interval = 80.0-100.0 fL so could be called hyperchromic (1 femtoliter = 10-15 Liter) • Some advocate never using the term

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http://departments.weber.edu/chpweb/3e/Acute%20Lymphocytic%20Leukemia/cbcresults2%20.html http://www.dwickes.com/anemia http://www.corbisimages.com/stock-photo/rights-managed/42-23595743/severe-iron-deficiency-anemia-showing-hypochromic-pale CBC– component detail CBC– component detail (cont.) (cont.) • MCHC = mean corpuscular hemoglobin concentration • MCV (cont.) • Calculation: • Using MCV to classify RBC’s • Cell volume 80-100 fL = MCHC = Hgb e.g. 14.2 X 100 X 100 = 33.3 g/dL normocytic HCT 42.6 • Cell volume < 80 fL = microcytic • Reference Interval = 32.0-36.0 g/dL • Cell volume >100 fL = • This is the better parameter for assessing cell color macrocytic • MCH doesn’t take cell size into account • Larger cells = more hemoglobin • Hemoglobin concentration/cell better

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http://departments.weber.edu/chpweb/3e/Acute%20Lymphocytic%20Leukemia/cbcresults2%20.html http://www.dwickes.com/anemia http://www.corbisimages.com/stock-photo/rights-managed/42-23595743/severe-iron-deficiency-anemia-showing-hypochromic-pale CBC – component Quality Control for CBC’s (cont.) detail (cont.) • “Rule of three” • MCHC (cont.) • An internal “QC” check on values related to RBC’s (RBC, • Cell “color” between 32-36 g/dL = Hgb, Hct) • Normochromic • Only works for normal size and colorized • Central pallor ~1/3 of cell (hemoglobinized) RBC’s • Cell “color” < 32 g/dL= • Formulas • Hypochromic • RBC count X 3 = Hemoglobin • Enlarged central pallor • Hemoglobin X 3 = Hematocrit +3% • Cell “color” > 36 g/dL = • Often used when performing automated • Hyperchromic instrumentation, as operator “accepts” or “rejects” a • Not valid EXCEPT in spherocytes result before reporting test results • Some advocate never using the term

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CBC – component detail (cont.) Quality Control for CBC’s (cont.)

• Red cell distribution width (RDW) • “Rule of three” examples • MCV is an average of all RBC volumes in count • Patient #1 • Does not indicate what variation of size is • Values • Calculation: • RBC = 3.00 X 1012/L • Hgb = 9.2 g/dL • 1 standard deviation of MCV Hct = 26.0% X 100 • Calculations MCV • 3 X 3 = 9……checks with Hgb • 9 X 3 = 27…………………….checks with Hct

CBC – component detail (cont.) Quality Control for CBC’s (cont.)

• Red cell distribution width (RDW) (cont.) • “Rule of three” examples (cont.) • High RDW (>14.5%) indicate that the RBC is very • Patient #2 heterogeneous = anisocytosis • Values • Occurs in some diseases with abnormal RBC’s • RBC = 4.00 X 1012/L • Occurs after transfusion with two different cell populations • Hgb = 8.9 g/dL • Occurs with microcytosis (low MCV) because denominator is • HCT = 37% lower • Calculations • Low RDW • 4 X 3 = 12……………..does NOT check with Hgb • No known disease causes this • 8.9 X 3 = 26.7…………does NOT check with Hct • RDW of macrocytes may be within normal limits even if • Follow-up = check for errors in hemoglobin and population heterogeneous (bigger number in denominator) hematocrit

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Counting particles/cells by electrical Histogram, “smoothed out” – impedance – The Coulter Principle single cell population

Numbers Of cells

Cell size www.cyto.purdue.edu

Isotonic diluent. ALL cells present Specrophotometer Same counting chamber. 540 nm Differentiation based ONLY on size Histograms

Additional counts possible. Example: reticulocytes Diluent lyses RBC. Contains cyanide for Cyanmethgb. Number of cells on y-axis

WBC analysis varies with model

Cell size on x-axis

Raw data (oscilloscope) histogram – Erythrocyte histogram single population of cells

Numbers Numbers Of Of cells cells

200 Cell size 50 100 150 femtoliters

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Abnormal RBC Histogram

Patient histogram – RBC’s Larger than normal

Numbers Of cells

50 100 150 200 femtoliters Constantino, B. (2010). The Red Cell Histogram and The Dimorphic Red Cell Population. LabMedicine, 42(5), 300-308.

Abnormal RBC Histogram

Dimorphic RBC population

Numbers Of cells

50 100 150 200 femtoliters Constantino, B. (2010). The Red Cell Histogram and The Dimorphic Red Cell Population. LabMedicine, 42(5), 300-308.

“Normal” Hemogram but abnormal smear • Hereditary Spherocytosis RBC • Heterozygous β thalassemia abnormalities • Lead poisoning • Multiple Myeloma • Malaria • Infectious Mononucleosis

Coulter STKS manual

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www.cyto.purdue.edu VCS = 3-dimensional Multi-population histogram histogram/scattergram Volume

Scatter (Opacity)

Patent US7235404 - Cyanide-free lytic

DF1 Screen on instrument Abnormal WBC histogram Neutrophils

Decreased lymphocytes & Monocytes with increased Monos granulocytes Eos

lymphocytes

monocytes Lymphs

Relativenumber granulocytes

200 300 400 50 100 Where are the basophils? femtoliters

www.mlo-online.com

Abnormal WBC histogram Coulter scatterplot - Normal NORMAL WBC HISTOGRAM

ABNORMAL WBC HISTOGRAM

NUCLEATED RBC’S

SLANG IS “HIGH TAKE

OFF” imagebank.hematology.org

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Abnormal Abnormalities on scattergram cells on scatterplot

Coulter STKS manual

Abnormalities on scattergram Sysmex analyzers (cont.)

www.idexxbioresearch.com • Normal WBC scatter plot • Side scatter on x- axis • Side fluorescence on y-axis

Coulter STKS manual

Abnormalities on scattergram Reticulocytes

• Absolute reticulocyte count • 25-75 x 109/L • Reticulocyte count • 0.5-2% • Corrected reticulocyte count • 2% cutoff • Reticulocyte Production Index (RPI) • 2 • Immature reticulocyte fraction (IRF) • Vary by manufacturer • Reticulocyte hemoglobin • Vary by manufacturer

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www.sysmex.com

Hgb catabolism (cont.)

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Hemoglobin catabolism Hemoglobin catabolism (cont.)

• Two ways RBC’s removed from circulation • Intravascular hemolysis • Extravascular destruction such as macrophage • Haptoglobin = circulating protein that conserves removal in the spleen free hemoglobin • Intravascular destruction due to hemolysis • Without haptoglobin, hgb could pass into urine • Hgb-Haptoglobin complexes • Too big to be filtered by kidney • Taken up by cells in the liver • Liver cells process hemoglobin similar to macrophages • Depleted haptoglobin a marker of intravascular hemolysis

smallcollation.blogspot.com Hemoglobin catabolism (cont.)

• Macrophage processing of RBC’s • Three chemical components of HGB = globins, Fe++ and heme • Amino acids from globins and Iron conserved for synthesis of new molecules • Heme changed to biliverdin which is then converted to bilirubin • Bilirubin released to blood for additional processing and excretion by liver

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Definition of anemia Adaptive mechanisms to anemia (cont.)

• A decrease in the competence of blood to supply tissues with oxygen • Other conditions with tissue hypoxia • • Result is tissue hypoxia  Signs/symptoms Not related to defects in hematopoietic system • Body responds by increasing RBC production • Not an actual disease/pathology, but an expression • Decreased pO2 at high altitudes of underlying RBC deficit • Emphysema • Very much a relative state • Heavy smokers • Not restricted to any particular laboratory “values” • Can result in polycythemia- RBC values above reference interval • Almost always decreased RBC values • RBC, Hgb, HCT

Degrees of anemia Laboratory methods to detect anemia

• RBC count • For adults and children: • Hemoglobin • Mild 10-12 gm/dL Hgb • Hematocrit • Moderate 7-10 gm/dL Hgb • Indices • Severe < 7 gm/dL Hgb • Reticulocyte count • Different in • Peripheral smear RBC morphology • Neonates • Size • Shape • Pregnant women • Color • Residents of high altitudes • Inclusions • Smokers • WBC and plt quantitative and qualitative • Test to measure RBC destruction • Bone marrow aspiration

Laboratory methods to detect anemia Adaptive mechanisms to anemia (cont.)

• Get RBC’s to tissues faster • Others – specific anemias

• Divert oxygen from low-O2 requiring organs to vital organs • Nutrients- iron, vitamin B12, folic acid • Increase tissue efficiency in using oxygen • Hemoglobin variants • Normal bone marrow • RBC enzymes – G6PD, methemoglobin reductase, • Can increase production 6-8 times the normal rate in PK response to anemia • Inherited defects • Result is erythroid hyperplasia • Immune disorders • Anemia results when • Others………… • Marrow cannot produce enough RBC’s – production problem OR • RBC’s are destroyed or lost faster than marrow can replace them

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Classification methods for Classification methods for anemias anemias (cont.) • Two methods: • Morphology • Functional underlying cause • Morphological classification • Based on RPI • • Pathophysiology Classifications- Production vs. Destruction anemias • Functional classification Red cell mass = Production rate x Survival

Reduction of either results in low RBC mass

Classification methods for Functional underlying cause anemias (cont.) classification of anemias • Production anemias • “True” production anemias = lack of nutrients/raw • Morphologic using indices materials to make RBC’s • Based on size and color of RBC’s • RPI ≤ 2 • Classifications • Utilization anemias = nutrients/raw materials there, but • Microcytic-hypochromic anemias defective usage • Destruction anemias • Normocytic-normochromic anemias • RBC’s produced normally • Macrocytic-normochromic anemias • Usually have RPI > 3 • Have decreased survival times (destroyed or lost) • Marrow cannot compensate, even by increasing production

Morphologic anemias: Limitations Common Lab Findings in relation to RBC’s • BM RBC production • Increased RBC destruction • • Based on average size and colorization of RBC’s • Increased Anemia • Spherocytes, schistocytes, • Oversimplifies complex situations • Reticulocytosis &/or other poikilocytes • Increased IRF • Positive DAT • Can have more than one condition affecting • Leukocytosis • Decreased haptoglobin and indices- Example: • nRBC hemopexin • Decreased glycosylated HGB • Iron deficiency anemia (microcytic-hypochromic) + • Polychromasia on smear • Increased fecal & urin Vitamin B12 deficiency (macrocytic-normochromic) • Normoblastic erythroid urobilinogen • Result could be an average, normocytic normochromic hyperplasia in BM • Increased bilirubin • Decreased (unconjugated) • Anemia • Hemoglobinemia • retics/IRF • Hemoglobinuria • Hemosiderinuria • Erythroid hypoplasia in BM, increased M:E ratio • Increased serum LD • Increased expired CO

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Common Causes of Anemia Hemolytic Anemia classification

• Decreased RBC production Source of Defect Mode of Onset Site of Hemolysis Predominant Poikilocyte • Microcytic Intrinsic Inherited Extravascular Spherocyte • Iron deficiency, sideroblastic, thalassemia's, lead poisoning, (intracorpuscular) anemia of chronic disease Extrinsic Acquired Extravascular or Schistocyte • Normocytic (extracorpuscular) Intravascular • Anemia of chronic disease, BM failure • Macrocytic • Vitamin B12, folate, alcohol

wayanadnoticeboard.com Intravascular Anemias Morphologic Flow Chart classification • Activation of Complement • PNH, paroxysmal cold hemoglobinuria, transfusion reaction (some), autoimmune hemolytic anemias (some) • Physical of Mechanical Trauma • Microangiopathic hemolytic anemia, abnormalities of the heart and great vessels, DIC • Toxic Microenvironment • Bacterial infections, venoms, arsine poisoning, Acute drug reaction in G6PD deficiency, IV administration of distilled water, thermal injury

Extravascular Anemias Functional Flow Chart classification

Micro hypo • Inherited erythrocyte defects Production MCV Low, MCH anemia Normo • Thalassemia, hemoglobinopathies, enzyme deficiencies, MCHC ≤ 2 normo membrane disorders Low Macro • Acquired erythrocyte defects Hemoglobin* RPI normo Female < 12 • Megaloblastic anemia, spur cell anemia, Vitamin E Male < 13 deficiency in newborns Micro • Immunohemolytic anemias High, Destruction MCV hypo > 3 Anemia, MCH • Autoimmune, drug induced, some transfusion reactions (hemolytic) MCHC Normo normo

* Patient is anemic

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Comparison of IDA & thalassemia Iron studies to differentiate ACD & IDA

• As IDA develops • Iron studies in ACD • Iron studies in IDA • MCV decreased proportionately as the anemia develops • Serum iron = low • • e.g. MCV of 60 would have very low Hgb Serum iron = low • TIBC = low to normal • TIBC = increased • Thalassemias • % saturation = low to • % saturation = low • Defect is low globin synthesis; Fe is fine. normal • MCV is much lower for a given concentration of Hgb and • Serum ferritin = normal • Serum ferritin = low Hct than would be seen in IDA to increased • ZnPP = increased • Body often compensates by making MORE RBC’s • ZnPP = increased • sTfR = increased • e.g. MCV of 60 would likely have a Hgb of even 12 g/dL • sTfR = normal or more

Anemia of chronic disease/inflammation Case Study 1

• Anemia that ranges from normochromic/normocytic to microcytic/hypochromic • 18 year old female • Most common anemia except IDA from blood loss • WBC = 11.4 x 109/L • Chronic diseases = continuous “strain” on bone marrow, • Routine physical • Hgb = 10.0 g/dL various types: • Overall healthy • MCV = 79 fL • Chronic infections such as: • Sub-acute bacterial endocarditis • Pale mucous • RDW = 14.8% • Tuberculosis membranes • PLT = 400 x 109 /L • Inflammatory diseases • Micro/Hypo • Autoimmune diseases such as: • Poor muscle tone • Polychromasia • SLE • Heart murmur • RA • Retic count 2.5% • Malignancies • RPI 0.95

Anemia of chronic disease (cont.) Case 1 • Various mechanisms may contribute • Categories of anemia? • Block in Fe release from macrophages to the • marrow in normal Fe recirculation Microcytic / Hypochromic • • Failure to trigger the EPO release Production • Decrease in RBC survival • Potential causes • Non-specific macrophage activation • Iron Deficiency • Hemolytic factors released by tumors • Anemia of Inflammation (Chronic Disease) • Vascular factors – mechanical damage to RBC’s • Thalassemias • Bacterial toxins  RBC lysis • Sideroblastic Anemia • Marrow suppressive effect of cytokines & • Lead Poisoning (acquired) interleukins

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Case 1 Differential Diagnosis Case 2 Peripheral Blood Smear

IDA ACD Sideroblastic Marrow Iron   to N  Marrow Sideroblasts    (ringed) Serum Ferritin   to N  Serum Iron   N to  TIBC   N to  % Saturation   to N N to  Basophilic stippling

Case Study 2 Case 2 • Categories of anemia? • 36 month old male - Sicilian • Microcytic / Hypochromic • Irritable, “colic-like pain”, diarrhea • Production • Normal pregnancy and development to date • Probable cause? • Pale mucous membranes • Lead Poisoning • Thin dark line around gums • Additional testing? • Decreased ability to concentrate • Blood lead level • FEP/ZnPP • Porphyrins

Case Study 2 Case Study 3 9 • 72 year old female • WBC = 14.5 x 10 /L • Dimorphic population • Hgb = 9.7 g/dL • Microcytic / • Rectal bleeding • MCV = 77 fL Hypochromic • 40 year history of rheumatoid arthritis • RDW = 15.5% • Normocytic / • Drugs: high dose ibuprofen Normochromic • Basophilic stippling • Rare nRBC

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Case Study 3 Case Study 4 • WBC = 13.0 x 109/L • Mild neutrophilia • 50 year old woman • RBC = 2.98 x 1012/L • Slight thrombocytosis • Weakness, fatigue, shortness of breath • Hgb = 9.7 g/dL • Microcytic /Hypochromic RBCs • Skin has yellow cast • Hct = 32% • Marked poikilocytosis • RDW = 16% • Occasional basophilic stippling • Smooth red tongue • MCV = 74 fL • Occasional Pappenheimer • Loss of vibratory sense and problems • MCH = 19.4 pg bodies with gait coordination • MCHC = 30.3% • PLT = 490 x 109/L

Case 3 Peripheral blood smear Case Study 4 • WBC = 4.4 x 109/L • Differential: • RBC = 2.2 x 1012/L 67% PMNs- (5% • Hgb = 8.5 g/dL hypersegmented) 25% Lymphs • Hct = 25% 5% Monos • MCV = 114 fL 3% Eos • MCHC = 34% • Macrocytic • RDW = 15.2% • Macro-ovalocytes- mod 9 • PLT = 100 x 10 /L • Schistocytes - few • Pappenheimer bodies Retic = 0.2% • H.J. bodies - few

Case Study 3 Case Study 4 Peripheral Blood Smear • Probable cause of this anemia? Hypersegmented neutrophil • Sideroblastic anemia • Categories of anemia for the cause you named? • Hypochromic/microcytic • Production Oval macrocyte • Additional testing? • Prussian blue staining blood and marrow • Serum iron/ferritin analysis • Cause of bleeding? • Ibuprofen interferes with platelet function • On high-dose ibuprofen for prolonged period • Thrombocytosis indicates attempt at compensation

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Case Study 4 Peripheral Blood Smear Case Study 4 • Total bilirubin = 2.5 mg/dL (0.2 - 1.0) • Indirect bilirubin = 1.9 mg/dL (0.2 - 0.8) Schistocyte • Serum LDH = 320 U/L (100 - 190) • Serum ferritin 315 ng/mL (10-300)

• Serum B12 = 50 pg/dL (100 - 700) • Red Cell Folate = 200 ng/ml (130 - 628)

What is the most likely condition based on the above? Howell-Jolly Pernicious Anemia bodies How would you prove it?

Case 4 Confirming Megaloblastic Anemia • Categories of anemia? • Macrocytic/normochromic • Serum vitamin B12 • Production • Serum & RBC Folate • Possible causes? • Anti – intrinsic factor or parietal cell antibodies • • Vitamin B12 deficiency Schillings Test • Folic acid deficiency • Decreased excretion of B12 when administered alone • • Myelodysplastic syndrome Normal excretion of B12 when administered with IF • Early detection • Additional testing? • Methylmalonic acid (MMA) • Vitamin B12/Folic acid levels • Homocysteine • Bone marrow for MDS

Clinical Features of Megaloblastic Case Study 5 Anemia • Bone Marrow • Chemistry- due to RBC • 3 year old • WBC = 18 x 109/L • Hypercellular destruction • African American • RBC = 2.59 x 1012/L • Megaloblastic changes • Elevated LDH female • Hgb = 7.1 g/dL • Possibly elevated indirect bilirubin • Giant bands and • metamyelocytes • Possibly elevated ferritin Hct = 23.2% • MCV = 89.4 fL • • MCH = 27.6 pg Peripheral blood • Physical exam • Pancytopenia • MCHC = 30.8% • Signs of anemia- BOTH B12 and • Macro-ovalocytes folate deficiency • RDW = 19.8% • Hypersegmented PMNs 9 • Neurologic impairment = B12 • PLT = 276 x 10 /L deficiency only

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Case Study 5 Case Study 6 Sickle cells

Target cells http://www.healcentral.org/healapp/showMetadata?metadataId=5954, USED WITH PERMISSION (http://www.wadsworth.org/chemheme http://www.mayoclinicproceedings.com/images/7906/7906mi-fig1.jpg

Case Study 5 Case Study 6

• Category of anemia? • Category of Anemia? • Destruction • Destruction • Probable cause? • Hemolytic • Sickle cell anemia • Differential Diagnosis? • Why are WBC increased? • DIC • Often increased in Sickle cell disease • HUS • Shift from marginating to circulating pools • Additional Testing? • Nidus may be infection • Chemistry and coagulation • Shiga toxin producing E. Coli O157:H7

Case Study 6 Case Study 7

• Previously healthy • WBC = 33.6 x 109/L • 58 year old female • WBC = 14.4 x 109/L • • • Shift to the left • C/O lightheadedness and 91% segs 14 year old admitted to heart pounding • 12 the hospital • RBC = 2.04 x 1012/L RBC = 2.9 x 10 /L • H/O Vit. B12 deficiency & • Hgb = 8.8 g/dL • Fever/chills • Hgb = 6.2 g/dL hypothyroidism • Hct = 26.5% • Abdominal pain and • Hct = 17.1% • MCV = 91.4 fL vomiting • MCV = 83.7 fL • MCH = 30.3 pg • Bloody diarrhea • MCH = 30.4 pg • MCHC = 33.2% • Hematuria • MCHC = 36.3% • RDW = 19.3 % 9 • RDW = 16.9% • PLT = 148 x 10 /L • Retic = 1.5% (corrected 0.8) • PLT = 146 x 109/L

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Case Study 7 Case Study 8

• 40 year old • WBC = 70.0 x 109/L • Male • 91% segs • Routine physical exam • Segs 50% • RBC = 4.75 x 1012/L • Bands 15% • Hgb = 13.2 g/dL • Metamyelocytes 3% • Hct = 39.4% • Myelocytes 5% • MCV = 83.0 fL • Promyelocytes 9% • MCH = 28.0 pg • Blasts 2% • MCHC = 33.5% • Eos 1% • PLT = 490 x 109/L • Basos 9% • Lymphs 6%

http;//www.wadsworth.org/chemhem

Case Study 7 Case Study 8

• Category of Anemia? • Production • ? Normo-normo • Differential Diagnosis? • Megaloblastic anemia? • Iron related anemia? • Refractory anemia? • MDS? • Additional Testing? • Iron studies, vitamin B12/folate levels • Chemistry • Bone Marrow

119 The Crookston Collection, used with permission http://biomed.brown.edu/Courses/BI279/Lec12/Lec12-rD.htm

Myelodysplastic syndromes Case Study 8

• Laboratory findings: • What is most probable diagnosis? • Think: cytopenia’s and dysplasia’s • CML • Normocytic normochromic anemia • Inadequate reticulocyte response • What additional tests should be done? • RBC early forms show • LAP, BM eval, cytogenetics, molecular • Megaloblastic changes • Multinuclearity • What is the classic cytogenetic marker associated • Other bizarre forms with this condition? • Neutropenia &/or thrombocytopenia (even in presence of giant platelets) • BCR-ABL fusion gene: Philadelphia chromosome • Pseudo-Pelger-Huet cells and other general abnormalities of granulocytes • Hypogranular cytoplasm • Hyperclumped chromatin

117 http://wiki.clinicalflow.com/myelodysplastic-syndromes-mds

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Thank you, Questions? Comments?