abc of c.b.c
TRANSCRIPT
ABCS OF CBC
Dr.abdulfattah alshenawiMBBch,Msc,Mrcs(Ireland)
Cons,general surgery(M.G.H)
OBJECTIVES
Be able to interpret (CBC) reports
Recognize common blood disorders
Know when to request hematology consultation
REMEMBER!
WHY DO WE NEED CBC?
Screening? Diagnosing clinical situations. Monitoring disease& effect of
treatment Prior to major procedure.
BLOOD COMPONENTS
57% Plasma
1% Buffy coat – WBC
42% RBCS
FROM WHERE BL.CELLS?
o All Blood Cells made in bone marrow.o Bone Marrow is the spongy centers of
bones sometimes seen in cuts of meat
oStem cells are young cellsoThey get “drafted” as RBCs, WBCs or platelets depending on the body’s needs
LOOK FOR WHAT?
CBC REPORT
RESULTS OF LAB.TESTS
• May be affected byActivity
DietStress
Geographymedications
Time of the day
CONCEPT OF NORMAL
REF.RANGE
PANIC VALUE
ERYTHROCYTES
WBCS DIFF.
ASSESS ERYTHROCYTE ABNORMALITIES HB% gm%(13-17gm%)
HCT volume of blood occupied by RBCS(35-45%)
MCV average volume of individual RBC.(80-100fl) RETIC % of immature RBCs in blood(1-2%)
RDW (10-15%)
RBCS. COUNT IS ADDITIONAL TO DIAGNOSIS
RBCSX3=HBX3=HCT (If not -indicates micro or macrocytosis or hypochromia).
PBS is additional privilge.
depend on both total red cell
mass and plasma volume
BM activity
Degree of anisocytosis
HCT
RETICULOCYTE
50 100 200 fl
RBC
%
MCV&RDW width" refers to the width of the
volume curve (distribution width), not the width of the cells.
Correlate with the degree of anisocytosis
normal RDW+ mic. Anaemia thalassemia high RDW + mic.anaemia iron deficiencyhigh RDW + mac.anaemia vit B12&folate def.high RDW + norm.anaemia hge
ANAEMIA(PATHOPHYSIOLGY)
PROCEED TO INTERPRETATION
Is the pt. anaemic? Low HB = anaemia Look to MCV Normal =normocytic anaemia?A. Acute hge= normal Hct B. explore for the site by HX&PE(shock,revealed or
concealed hge)C. Haemolysis= high retic., ( high LDH,low haptoglobin,& indirect
hyperbilirubinaemia,jaundice) Acute haemolysis, incompatible blood trans. Chronic haemolysis (Hbpathy,enzymopathy, membranopathy)
HAEMOLYSIS
Haemoglobinuria is differentiating between IV&EV haemolysis
HB
A B
AB
A
A
DELTA
DELTA
A
A
GAMMA
GAMMA
HBAA2B2
HBA2A2D2
HB FA2 G2
Normal variant of HB
QUALITATIVE VS QUANTITATIVE
HBSDef.B
Subunit
Sickle cellanaemia
B, thalassDec. B chain
A.ThalassDec,A chain
Abnormal HB
HEREDITARY SPHEROCYTOSIS
MEMBRANOPATHIESRBCS SHAPE
PROCEED MORE!! Low MCV= microcytic anaemia What THIS?1) Normal or low retic=do serum
ferritin IDA (low ferritin) ACD (high ferritin) (low TIBC) Thalas (normal ferritin) SA (high ferritin) (normal
TIBC)2) High Retic= Search for signs of haemolysis
MICROCYTIC ANAEMIA Thalasemia I.D.A S.A A.C.D
MICROCYTIC ANAEMIA
THINK OF DESTURBED HB SUBSTRATES.
ACD
MICROCYTIC ANAEMIA
MICROCYTIC ANAEMIA CHECK RBCs• thalassemia
• ACD,SA,IDA S.ferritin
Low in IDA
High in SA,ACD
WHAT IF? High MCV= macrocytic anemia Think of neutritional deficiency1) Vit B12 2) Folic acid Do what???????
PBSPBS
1) non megaloblastic macroreticulocyte,rounded macrocytes (alcohol liver dis.) RFT,LFT(GGT)TFT
MACROCYTIC ANAEMIA2)MEGALOPLASTIC• 85% pernicious anaemia.(+ve AB for
IF)• Macroovalocyte&
hypersegm.neutrophil
Rule out medic
Check vit B12&FOLI
C
DEC.folate
Norm.B12
CONSIDER folate def.
Dec.B12Norm folate
Check MMA
Increase MMA
Confirm def.
Both normal
Consider alcohol.liver,medhypothyroidism
MCV#
Microcytic
MCV
Normocytic Macrocytic
Iron Deficiency IDAThalassemiasHemoglobinopathiesSideroblastic Anemia
Hemolysis
Hemorhage
Vit B12
Folic acid
Alcohol liver dis.
drugs
POLYCYTHEMIA
POLYCYTHEMIA VERA
COMPLICATIONS OF POLYCYTH.
CBC REPORT
CBC REPORT
CBC REPORT
CBC REPORT
WBCS
WBCS
Different typesDifferent life spanDifferent functions
Different sizes
NORMS OF LEUKOCYTES TLC 4-11000/cmm DLC neutrophil(60%) lymphocyte(30%) eosinophil(6%) monocyte(3%) basophil(1%)
WBCS DISORDERS PROLIFERATIVE OR LEUKOPENIA PROLIFERATIVE MAY BE REACTIVE OR
NEOPLASTIC DIFFERENTIATION BENIGN FROM
MALIGNANT DISORDERS IS OF UTMOST IMPORTANCE.
DEFINITIONS Leukocytosis increase
WBCs.>11000 Leukopenia decrease
WBCs.<4000 Granulocytosis neutrophilia Granulocytopenia
neutropenia<2000/cmm Agranulocytosis
neutropenia<500/cmm
EVALUATION OF TLC&DLC Leukocytosis
(neoplastic &prolifrative)
Identify infection,inflammation,&tissue damage
More than100000/cmm. seen in leukaemia.
Stress & steroids are reversible soon
NEUTROPHILIA Morphology. Granulocytosis. Early in acute infection x
agranulocytes!! Shift to left indicate overwhelming
infections.(bands or stabs) Shift to right indicate tissue
damage or necrosis.(segs.)
NEUTROPHILIA
Red flagsperson particularly unwellseverityrate of change of neutrophiliapresence of left shift
EOSINOPHILIA. Elevated in parasitic infestations&
allergy. Intestinal parasite,and
toxoplasmosis. Asthma &hay fever.
BASOPHILIA. Most uncommon. Seen in systemic hypersensitivity. Thorough allergy history should be
obtained before any surgical procedures.
MONOCYTOSIS. Late in acute infections Chronic infections as TB&SBE. Hodgkin,s lymphoma,fungal Monocytopenia(aplastic
anaemia,glucocorticoid ,&hairy cell leuk).
LYMPHOCYTOSIS. Origin& maturation Types . Acute viral infections CMV,INF.MONONUCLEOSIS,MMR EARLY H.I.V CLL. Lymphopenia in HIV& AIDS.(CD4
count <200)
LEUKOPENIA. Decrease production(CT,RT.). Neutropenia (aka,granulocytopenia) Neutrophil<2000/ul. Bone marrow exhaustion(prolonged
severe inf Increased
destruction(hyperspleenism) Antithyroid,antidepressant,NSAID. Protect pt.,avoid surgery if
possible.
LEUKOPENIA(CONT.) Severe
neutropenia(aka.agranulocytosis) Neutrophil,< 500/ul. Pt.is predisposed to serious,G-
ve,G+ve,& fungal infections. Red flags
person particularly unwell lymphadenopathy,
hepatosplenomegaly
CLINICAL IMPLICATIONS Leukocytosis signals infections. Leukopenia signals BM depression. Neutropenic precautions Care of invasive maneuvres. Avoid crowding& recent
vacc.children Avoid steroids&antipyretics. Avoid raw &uncooked foods. Reporting high temp.
PLATLETS Outpt . VS inpt. Norms:150-400.000/ml TPO is the primary regulatory protein in the
production of platelets
STRATIFYING LEVELS OF THROMBOCYTOPENIA
The primary reason for evaluating thrombocytopenia is to assess the risk of bleeding and assess the presence of underlying disorders (TTP, HIT etc.)< 20 000 increased risk of bleeding20 to 50000 rarely have increase risk of
spontaneous bleeding but increase risk of bleeding from procedures
50 to 100000 no increased risk of spontaneous bleeding and can undergo most procedures
DEFINITION Thrombocytopenia
is defined as a platelet count less than 150,000
2.5 percent of the normal population will have a platelet count lower than this
DIFFERENTIAL Pseudothrombocytopenia Decreased Production- suggested by:
other cytopenias normal sized/small platelets suggest a reduced
bone marrow response to need Increased Destruction- suggested by:
Microangiopathic blood picture (fragmented RBCs, high LDH)
Large platelets on smear Associated autoimmune disease
APPROACH History, FH,MED H, PBS TTP+lymphocytosis,neutrophilia
( infection) Isolated TTP(DIC,ITP,HIT,DITP) Giant plat.(hereditary TTP) Blasts& nucleated RBCS(BM disorder) Schistocytes(HUS,DIC)
PHYSICAL EXAM Petechiae Purpura — Ecchymoses The most common
cause of thrombocytopenia developing for the first time in an ICU patient is sepsis, accounting for one-half of the cases
Bone marrow suppression from infection
Platelet microaggregation
Production of toxins
Consumption of coagulation factors (DIC)
PSEUDOTHROMBOCYTOPENIA
If blood sample is inadequately anticoagulated, platelet clumps can be counted as WBC’s
0.1% of patients have EDTA dependent agglutinins
DECREASED PRODUCTION
Viral infections Direct megakaryocyte damage-HIV Post CT,RT Acquired bone marrow hypoplasia- Fanconi
anemia. alcohol toxicity B12 or folate deficiency
INCREASED DESTRUCTION
autoimmune destruction anti-platelet Abs(ITP,SLE)
Alloimmune destruction( posttransfusion)
Destination destruction(hypersplenism) Consumption (DIC ,TTP- HUS) HELLP in pregnant women Medications- heparin, valproic acid Infections- EBV, CMV, sepsis
y
PS.PENIA TRUE.PENIA Giant plt
Isolated TP
ITPHITDIC
Neutrophillymphocyt
Consider infection
Blast cellsNucleated
RBCS
1ry BM DISORDER
schistocyte
TTP/HUS/DIC
THROMBOCYTOPENIA
Hereditarythrombocy
tPBSPLT
clumbing
CBC IN ACUTE LEUKAEMIA AML Anaemia Leukocytosis Thrombocytopeni
a >20% blast in
PBS >80% blast in
BMA PUO+splenomeg
ally Auer rodes
ALL Anaemia Leukocytosis Throbocytopenia >20% blast in
PBS >80% blast in
BMA PUO,LN swelling
CBC IN CH.LEUKAEMIA CML Anaemia Leukocytosis+lt.shif
t Lymphocytosis Thrombocytopenia Basophilia splenomegally Philadelphia ch.
CLL Anaemia Leukocytosis+lt
shift Lymphocytosis Thrombocytosis Basophilia Splenomegally B cell CD19,,CD5
flow cytometry
QUIZ 1?
QUIZ 2 ?
QUIZ 3?