CBC 101 Faculty Disclosure “Cracking the Code” • My spouse or I have not had any relevant financial relationships during the past 12 months.

Sherry L. Bayliff, MD, MPH Assistant Professor of Pediatrics Kentucky Children’s Hospital

Family Medicine Review/Contemporary Pediatrics Conference November 10th, 2016

Objectives Educational Need/Practice Gap 1) Clarify a systematic approach to the • Interpreting the complete blood count interpretation of pediatric CBCs that identifies abnormalities of concern. report can often be the source of great confusion 2) Distinguish abnormalities on the CBC that indicate further evaluation is warranted and • Misinterpretation of the reported results the appropriate timeline for initiation of that may lead to great anxiety for both the workup. provider and the patient/family 3) Identify those CBC abnormalities that warrant referral for further evaluation to establish an appropriate plan of care.

Expected Outcome Active Learning • Our goal today is to “crack the code” of • Please try and incorporate some activity the CBC report and increase the ability participation into your presentation to identify when to be concerned and either through case study discussions or how/where/when to act on that concern audience response questions. • By empowering you to read beyond the “H”s and “L”s, you can return to your calm and cool demeanor (and so will your patients/families!)

1 What am I working with? What is the CBC? • a.k.a. Complete Blood Count •3 parts: – red blood cells – white blood cells – platelets • 10 tests: RBC, Hgb, HCT, MCV, MCH, MCHC, RDW, WBC, Platelets, MPV • the differential (just do it!)

Definitions x 10 • RBC – number of RBCs per microL of blood (or number of RBCs x 1012/L • HGB – Hemoglobin is the concentration of hemoglobin in whole blood, in grams/deciliter (g/dL). • HCT- The Hematocrit is the packed spun volume of blood made up of RBC, expressed as a percentage of total blood volume. It can be measured or calculated as Hct = (RBC x MCV)/10. • MCV – Mean corpuscular volume is the average volume (size) of the patient's RBCs. It can be measured or calculated as above . • MCH – Mean corpuscular hemoglobin is the average hemoglobin content in a RBC. It is calculated as MCH (pg/red cell) = Hgb (g/dL) x 10 ÷ RBC (millions/microL). • MCHC – Mean corpuscular hemoglobin concentration is the average hemoglobin concentration per RBC, in grams/dL. It is calculated as MCHC (g/dL) = Hgb (g/dL) X 100 ÷ Hct (percent). • RDW – Red cell distribution width is a measure of the variation in RBC size, which is reflected in the degree of anisocytosis on the peripheral blood smear. • WBC –The white blood cell count is the number of WBC per microL of blood (or number of WBC x 109/L). • PLT –The platelet count is the number of platelets per microL of blood (or number of platelets x 109/L). • MPV – Mean platelet volume is the average volume (size) of the patient's platelets as measured in femtoliters (fL).

Where we were . . . Automated Coulter Counters • Manual techniques • electric impedance aperture – Hemocytometer • multi-chamber coulters – Cyanomethemoglobin method • modern day “channelizers” – Wintrobe tube – plot of frequency vs channel size=RBC • Imprecise and laborious distribution curve •calculations

2 Getting the Test: When? Why? The Peripheral Blood Smear • concerns aplenty: • Gold (non-invasive) Standard – Infections (qualified) • automated processes are imperfect –Anemia • extreme importance: – Bruising/Bleeding – Hemolytic anemia – Just Cause – Thrombocytopenia • med monitoring – WBC disorders • BEFORE corticosteroids • complicated process

NORMAL Peripheral Blood Smears

Courtesy of Carola von Kapff, SH (ASCP). Mayo Clinic Laboratories

Size

Shape Color

CBC Inclusions Number Abnormalities

3 RBC “Inclusion” Etiology Conditions Special Staining?

Reticulocytes Polyribosomes Increased RBC *supravital stains production RBC Abnormalities: Shape Nucleated RBC Nuclear Remnants Severe hemolysis, *NOT NORMAL on Profound stress, peripheral smear MDS/MPS • Normal: biconcave disc

Howell Jolly Bodies Nuclear remnants Post-splenectomy Asplenism • Poikilocytosis Heinz Body Denatured Hgb G6PD, oxidant *supravital stains aggregates exposure, unstable Hgb • MCH/MCHC

Basophilic Stippling Cytoplasmic Thalassemias, ETOH, Ribosomes lead/heavy metals, •Other: Pyrimidine 5’ Nucleotidase deficiency – sickle cells, target cell

Pappenheimer Bodies Iron Sideroblastic anemia – fragmented red cells, bite cells, helmet cells

Hgb crystals Artifacts Hgb C disease *dehydrated sample – teardrop Hgb SC disease – Spiculated (echinocytes, acanthocytes) Red cell GHOSTS Lysed Red Cells Fulminant bacteremia *NEVER NORMAL

RBC organisms Parasites, Bacteria Malaria, Trypansomes

C. perfringens Pictures by Carola von Kapff, SH (ASCP)

RBC Abnormalities: Size RBC Abnormalities: Color • Normal: central pallor 1/3 dm of width • Normal: 7-8 microns/MCV 90 fL • Hypochromia/Hyperchromia • Anisocytosis RDW > 20% •MCHC •MCV / • Absence of pallor: spherocytes •RDW • Bluish tint: reticulocytes

RDW is normal

Classification of Anemia

Blood Loss Impaired Increased Destruction Production (Hemolytic) (Hypoproliferative) Acute/Chronic Iron deficiency Extrinsic:

Perinatal Megaloblastic -auto-immune or iso-immune (placental/umbilical) (Vitamin B12 or -infections Folate) -chemical or physical agents Postnatal Myelophthistic -hypersplenism (gut, lung, nose, (infiltrative or GU, trauma) myelodysplastic) Intrinsic: Chronic Disease -membrane defects -enzyme deficiencies Aplastic (congenital or acquired)

4 Nathan & Oski, 8th ed., 2015

MCHC

Courtesy of Carola von Kapff, SH (ASP)

History & Physical

Targeted History Physical Exam • Onset/Severity of symptoms • General Appearance • Symptoms related to hemolysis •Skin • Prior history of events •Eyes • Possible blood loss •Mouth • Underlying medical conditions • Cardiac • Drug/toxin exposure • Abdomen •Diet • Musculoskeletal • Birth/developmental history • Family history

5 Reticulocyte response Physiologic classification • Absolute reticulocyte count (ARC) – ARC= % reticulocytes x RBC/L  Reticulocytosis  Reticulocytosis –  ARC: active erythropoiesis response • Hemorrhage • Hypoplastic anemias • hemolysis, acute blood loss • Membranopathies – Congenital –Acquired –  ARC: suboptimal response • Enzymopathies •TEC • marrow aplasia, marrow infiltration, toxic insult • Hemoglobinopathies •AIHA •Systemic disease • Microangiopathic HA • Marrow infiltration • Medications •Infections

Courtesy of Stanley L. Schrier, MD Carola von Kapff, SH (ASCP)

Poikilocytosis Iron Deficiency Anemia Anisocytosis Hypochromia Microcytosis

2.31 7.8 Supportive Labs 20.4 67  iron,  TIBC Latent •  serum 23 Prelatent •  stores Frank Iron •  MCV 26  transferrin sat Iron Iron iron, TIBC Deficiency •NL HCT, NL •  MCHC 17.3 ferritin  Deficiency serum Fe Deficiency •NL HCT Anemia NORMAL retic thrombocytosis stool guaiac +/- *most common nutritional deficiency worldwide

*Gold Standard Test: RESPONSE to Iron

Management of IDA Dietary factors that increase risk . . . Dietary Counseling Implemented Changes • Insufficient Intake • Review good choices: • Breast feed 6 mos – Normal Infants: 1 mg/kg/day* – liver, other meats, seafood minimum – LBW Infants: double* (*max=15mg/kg/d) – dried fruits, nuts, beans • Iron-fortified formula –1 kg  in body wt requires  35-45 mg body iron – green leafy vegetables • < 1 pint/day whole milk – whole grains • Poor Dietary Practices •WEAN! • iron-fortified products – early cow’s milk, early solid food intake, tea,  Vit C • Iron-fortified cereals intake,  meat intake • Supplemental iron • Breast feeding > 6 mos w/o supplements – Facilitators: citrus juice, fruits, Vit C pills, tomatoes, potatoes, meat, • Low socioeconomic status fish, poultry – Inhibitors: coffee, tea, egg yolks, > 1 quart/day of Cow’s Milk milk, fiber, soy protein, antacids, H2-blockers, PPIs

6 Supplemental Iron White Blood Cells • Oral •Parenteral – Ferrous iron – failure of oral tx – 3-6 mg Elemental –IV iron/kg/day divided –Iron sucrose BID – reduced SE – between meals – continue for 2-3 months AFTER correction of the Hgb – side effects: GI*

Size

Shape Color

CBC Inclusions Number Abnormalities

WBC Numbers Leukocytosis Leukocytopenias • INFECTION • NEUTROPENIA –viral • Lymphocytopenia – bacterial •reactive • malignant

7 Neutrophilia • Eosinophilia – allergic state, parasitic infections • Basophilia – very unusual • Monocytosis – EBV, reactive processes, post-chemotherapy Toxic granulations and Döhle bodies

Courtesy of Carola von Kapff, SH (ASCP)

Lymphocyte—abnormal shape/size

Stanley Schrier, MD

cancer.gov

Bone Marrow Examination

cancerjournal.net

8 WBC Abnormality Condition Pictures Auer rods (cytoplasmic Acute Myeloid Platelets granules) Leukemia Dohle bodies (cytoplasmic Infection or granules) Inflammation

GIANT cytoplasmic granules Chediak-Higashi

Other: Small Cleaved Lymphocytes Follicular Lymphoma Bipolar Villous Projections Splenic marginal zone lymphoma Ragged “Hairy” Cytoplasm Hairy Cell Leukemia “Cloverleaf” Nuclei Adult T Cell Leukemia

Parasites

Size

Shape Color

CBC Inclusions Number Abnormalities

N=91 (plts>600K) Platelet Numbers RT70% AT22% Thrombocytopenia Thrombocytosis (>450K) Combo8% •Pseudo- •Reactive •Confirmed – cytokine driven – Destruction ( platelets) – 3 primary qualities 31% infection • ITP, DIC, TTP, HUS • not MPD/MDD 27% infection + post op • has a likely cause 16% post surgical – Decreased Production 9% malignancy •Viral • expected normalization 9% post splenectomy •Congenital (TAR) • Autonomous 8% acute blood loss or iron deficiency •Replacement – clonal overproduction •PV, PMF, CML, myelodysplasia • Essential Thrombocytosis

Tefferi et al. Am J Med 1994;96: 247

9 Extreme Thrombocytopenia (>1,000,000/microL) Symptoms of Thrombocytosis • N=280 • Vasomotor – HA, visual, lightheadedness, atypical chest • RT 82% 31% infection pain, acral dysesthesias, erythromelalgia • AT 14% 19% post splenectomy/hyposplenism 14% malignancy •Thrombotic • Unknown 4% 14% trauma 9% inflammation • Bleeding 6% blood loss ET 24% (each) 3% rebound thrombocytosis RT 1% thrombosis 4% uncertain 3% bleeding

Buss DH, et al. Am J Med 1994; 96:247 Buss DH, et al. Am J Med 1994; 96:247

Evaluation of Thrombocytosis Essential Thrombocytosis •Confirm – repeat testing – peripheral blood smear •H & P – establish the duration of the thrombocytosis •Labs – CBCd, smear, ferritin

– CRP, ESR, fibrinogen, ferritin • *rate of cytogenetic abnormalities < 5% – Gene expression (platelet RNA) • JAK2 V617F in ~50%

Management of Thrombocytosis Reviewing the basics. . . Bleeding Thrombosis • a CBC is meant to HELP . . . NOT hinder • stop anti-platelet meds • Platelet apheresis(>800K) • always get a DIFFERENTIAL • FFP/Platelets • Platelet lowering agent – Acquired Factor V • Anticoagulant therapy • a SMEAR gains you exponential info • Platelet apheresis • Phone-a-Friend – Acquired Factor II vWd • treat the underlying dz • BUT—if it feels wrong – Iron therapy, direct endoscopy/imaging, myelosuppressive agent or REFER plt-lowering agent

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