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Making the Most out of the CBC Making the Most out Of Making the most out of the CBC and peripheral blood smear May 2011 John D’Orazio, M.D., Ph.D. Pediatric Hematology-Oncology University of Kentucky College of Medicine [email protected] objectives • Understand the clinical information that a complete blood count (CBC) contains and how to get the most information out of it. • Appreciate the importance of the peripheral blood smear in the interpretation of hematologic conditions. • Reinforce concepts through cases via audience participation. I have no relevant financial admissions or conflicts of interest to disclose . Complete Blood Count (CBC) “hemogram” • One of the most commonly ordered tests • UK hospital runs about 700 hemograms a day – 15,000‐20,000 a month (Compared to ~1,000 chemistry panels per day) – 40% outpatient 60% inpatient • Directed test for blood disorders • Screening test for systemic diseases Advia 2120 Hematology Analyzer What comes with a CBC? Lots of ifinformat ion about cellu lar bloo d elements: Total number Amount of RBC’s Total number Composition Average size Average size Absolute numbers Amount of hgb in each of each type Uniformity of size Diamond ‐ Iron deficiency Pertussis Blackfan anemia TTP ALL MliMononucleosis SiSepsis Eosinophilia Fanconi Anemia Autoimmune HUS hemolysis Thrombocytopenia Neutropenia Hereditary Spherocytosis Immunodeficiency AML Folate, B12 Chronic DIC deficiency inflammation Aplastic Anemia CML Steroid use HIV infection Hemolytic Uremia Bernard‐Soulier Hypoxia, Syndrome ITP syndrome polycythemia Allergy Alloimmune Myelodysplasia Wiskott‐Aldrich thrombocytopenia The CBC is one of the most commonly used screening tests in medic ine Procedure • Blood is collected, usually venous – capillary, arterial blood are o.k. • Purple (lavender)‐topped tube – Contains EDTA, an anticoagulant that works by chelating calcium – Clotting is Ca‐dependent What happens when the lab gets the sample? • AdAutomated CBC analyzers work by diidetermining light scattering profiles of individual blood cells Ce ll Dyn 4000 mo dern hema to logy ana lyzer, Abbott Laboratories, Chicago, IL Hemoglobin ((g)Hgb) • The oxygen‐carrying molecule in RBC’s • Measured as grams per deciliter (g/dL) of whole blood. • Tetramer comprised of 4 glblobin proteins and an iron‐containing heme moiety. Hemoglobin Alpha globin Beta globin Hgb A (adult) 2 2 Hgb A2 2 δ2 HbHgb F (fe ta l) 2 γ2 Almost all analyzers calculate hemoglobin by the cyanomethemoglobin method. Drabkin’s reagent Hgb Cyanmet‐Hgb Hematocrit (Hct) • Reflects the volume percentage of RBC’s in whole blood • Classic method: “Spun Hematocrit” – determined by centrifugation of whole blood in a narrow Air capillary blood glass tube sealed at one end. – Since "crit" tubes are fragile and dangerous to use, spun hematocrits are rarely used today. Plasma • The automated hematology analyzer calculates the Hct from the RBC and MCV by the following formula: Buffy coat (WBC) Hct (%) = RBC x MCV In general, hematocrit = 3x hemoglobin Hematocrit (RBC) – Since the Hct is a calculated value, it is less accurate than hemoglobin Clay plug Mean Corpuscular Volume (()MCV) • Average size of RBC’s • “Normal” varies with age – For adults = 80‐94 fL – Elevated MCV = RBC’s larger than normal – < 10 y/o, lower limit of normal = 70 fL + age ()(yrs) • “macrocytosis” – Infants: much higher – Decreased MCV = RBC’s smaller MCV’ s than normal • “microcyosis” – Normal MCV = RBC’s “just right” • “normocytosis” Key Concept To make a ppproper RBC, there must be coordination between proliferation of RBC precursor cells and hemoglobinization of maturing RBC’s - - - cell division - - - differentiation - - - Hematopoeitic Mature Stem cell erythrocytes Cell division occurs relatively normally but Hgb Hgb production is fine but there is a problem production is defective. The cytoplasm can’t with DNA synthesis. RBC precursors divide “fill up” properly with hemoglobin before the slowly, allowing more time to accumulate Hgb cells divide, so daughter cells are small. which makes the cells large. Problem with DNA Problems with Synthesis Hemoglobin Production B deficiency Marrow failure 12 Iron Deficiency ↓ Globin (thalassemia) Folate Hydroxyurea, deficiency Chemo Red cell distribution width (RDW) • quantitative measure of variation in red blood cell size (anisocytosis) – normal RDW range is 11.5 ‐ 14.5 % • Nutritional anemias → high RDW’s – Day‐to‐day variation in diet • IhInher itdited anemias → low RDW’s – Fixed genetic lesion affecting hematopoiesis all the time MCV and RDW Normal Microcytosis Nooarmal Microcytosis Low RDW High RDW (Thalassemia) (Fe deficiency) (cells) (cells) Events Events RBC Size RBC Size Normal Normocytosis Normal Macrocytosis (Folate or B12) lls) lls) ee ee Events (c Events (c RBC Size RBC Size “Mentzer Index” William Mentzer, M.D. Pediatric Hematology/Oncology Professor Emeritus, UCSF • helps differentiate whether microcytic anemia is caused from iron deficiency or from thalassemia. Mentzer Index = MCV RBC count < 11 > 13 thalassemia Fe deficiency Mentzer WC, 1973, "Differentiation of iron deficiency from thalassaemia trait". Lancet 1 (7808): 882. production destruction Circulating red cell mass represents a balance between cellular production and destruction. To determine whether there is impaired RBC production or premature RBC destruction… always order a reticulocyte count in your anemia work‐up! Low retic count = RBC production problem High retic count = RBC destruction The reticulocyte count is not part of the CBC. • Supravital staining that identifies ribosomes in the cytoplasm of RBC’s • Ribosomes persist in RBC’s for 24‐48h after leaving the marrow – ongoing Hgb synthesis • Reticulocytes are young red blood cells only 1‐2 days removed from the marrow. • Why is the retic count normally ~1%? – Normal RBC life‐span ~ 120d – Each day the body must replace 1 ÷ 120 =~1% of the red cell mass Reticulocyte Index • More ifinforma tive than jtjust the reticcount. •Corrects for abnormal hematocrit. (Ac tua l Hc t) Reticulocyte index= (Percent reticulocytes) x (Normal Hct) <2%< 2% > 2% Production problems Destruction problems • Hypoproliferative Anemias • Hemolysis – Nutritional (iron, folate, B12) – Immune‐mediated – Anemia of inflammation – Hemoglobinopathies • Erythropoeitin defect – Membranopathies • Bone marrow failure – RBC metabolic abnormalities • Bone marrow infiltration • Blood loss • RBC maturation abnormality • Mechanical RBC destruction Clues to reticulocytosis on a CBC Anemias, deconstructed… Picasso: Girl Before a Mirror, 1932 Microcy tic NtiNormocytic MtiMacrocytic (low MCV) (MCV nl. for age) (high MCV) • Bone marrow failure • Iron deficiency Underproduction •TEC •MDS • Lead poisoning • Viral suppression • Megaloblastic anemia (low retic’s*) • Anemia of inflammation •DBA *for degree of anemia • Membrane disorders • Hemoglobinopathies RBC destruction • Enzymopathies • Immune-mediated • Thalassemia (high retic’s) • G6PD deficiency hemolysis • Microangiopathy • Blood loss Automated WBC Differential • Histogram analysis of WBC’s • each "dot" represents data from a monocytes neutrophils single cell. ll size) • Each tyyype of WBC displays a characteristic size and granularity • In this case: catter (ce ss • 65. 6% Neutrophils eosinophils basophils • 26.2% Lymphocytes Forward lymphocytes • 5.6% Monocytes • 2.2% Eosinophils Side scatter (cellular complexity) • 0.4% Basophils CBC’s at UK • Pretty much all CBC’ s start with analysis by an automated CBC analyzer. • ~75% of CBC’s have an automated differential only. – Clue to automated differential = reported % with tenths values. Neutrophils 54. 8% Neutrophils 55% Lymphs 23.6% Lymphs 24% Monocytes 15.2% Monocytes 15% Eosinophils 4.3% Eosinophils 4% Basophils 2.1% Basophils 2% Automated Differential Manual Differential • If the automated analysis picks up certain “flags”, then the CBC is tiikdcked for a manual assessment by the Heme techs. Nucleated Blast forms High WBC RBC’s (> 50, 000) Platelet count < 30,000 Immature neutrophils Macrocytosis Abnormal Absolute Marked Abnormal lymphocyte Anisocytosis Absolute count Variant monocyte count lymphocytes Low MCV Certain RBC Pla te let Morphology clumps Abnormalities Bottom line… • Today’s automated hematology analyzers are very good for most routine applications, but they’re not perfect. • AdAutomated CBC’s can’t relia bly dibdescribe the actual morphlhology of WBC’s or RBC’s – Machines can “flag” certain RBC or WBC abnormalities ((ge.g. 2+ anisocyy)tosis) • If the diagnosis that you are considering correlates with a specific WBC or RBC morphology, then order a manual slide review. – Leukemia (blasts) – RBC membrane disorder (spherocytes) • Likew ise, if the CBC d’tdoesn’t “fit” with the clin ica l piticture, then more information might be obtained by examining a peripheral blood smear. CBC’s and Manual Diff’s • Only when a manual differential is performed will anyone from the lab ppyhysically look at the ppperipheral blood smear. • Remains the “gold standard” for blood interpretation • Clinical Lab’ s Heme techs are excellent and reliable • Exceptional smears are also reviewed by hematopathologists • The practitioner has the option of requesting a manual differential right from the start (on the general lab order form). • For now, but the lab may evaluate this policy (labor‐intensive) Keys to success with blood smears • The smear must be artifact‐free and have an adequate region of cell dispersal Too thick! Too thin! Just right • Take your time, and ask the hematology tech his/her impression Warm-up slides Describe those RBC’s!
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