approach to hematological diagnosis (with cbc alone

DR SUTHANTHIRA KANNAN MD FRCPACONSULTANT HEMATO ONCOLOGIST

WHY HEMATOLOGICAL CASES GETS MISDIAGNOSED OFTEN?

Not doing a complete blood count in analyser

Peripheral smear reports not focussing on diagnosis

HB 45 g/l

MCV 121

RDW 20.5

Wbc 3.5 Platlet 75

Rbc show gross aniospoikilocytosis with numerous microcytes, fragments, few macrocytes, basophilic stippling

Wbc show normal differential with no left shift

Platelets are reduced.

?DIAGNOSIS

Gross macrocytosis with many fragments, basophilic stippling, Wbcs show few hypersegmented and occasional large polymorphs, suggestive of megaloblastic anemia.

20 year male, presenting with facial and mild pedal edema

Hb 6 g/dlTc 30,000/cu mmDC POLY 24 LYMPH 64PLT 134

Treated as interstitial nephrits

Normocytic RBCsWbc show atypical lymphocyte.

PURPOSE OF TALKIndia has far far less number of hemato

pathologistTry to arrive at a working diagnosis based on

CBC, which is possible in ~70% of patients.

Doing a complete blood count is a basic necessity to diagnose most of the underlying haematological disorders/ANY OTHER DISORDER

MCV and RDW are the key MCV and RDW are the key parameters in diagnosing any parameters in diagnosing any anemia, before looking at the blood anemia, before looking at the blood filmfilm

MCV & RDWNormal MCV in adults is around 80-90fl.RDW (Red cell distribution width) normal

cv(16-18%)Reticulocytes are larger than RBCs and can

have MCV from 90-130fl.

RDW50% of RBCs have MCV of 80fl (60)50% of RBCs have MCV of 100 fl (120)MCV will be 90.RDW 25% (gross anisocytosis)Normochromic anemia with reticulocytosis.

RDW high in few conditionsReticulocytosis (Normal + Mild High MCV)

Transfusion (Transfused Rbcs are smaller)

Nutritional anemias (Gradual transition – microcytic + normal OR macrocytic + normal or + low)

VERY LOW MCV (<70)

LOW MCV (70-80)

NORMAL (80-95)

HIGH MCV (95 -110)

V HIGH MCV (>110)

NORMAL RDWHIGH RDW

ANEMIA ONLY

WITH CYTOPENIA OF OTHE CELL LINES

50 yr old male, came for elective surgery for hernia

Found to have HB 9G/dl

Hb 9.2gWbc 5,700Plt 2,30,000

MCV 62RBC 5.2RDW 16

Normal diff

? Iron deficiency

Any further tests?

Implications?

58 year old male presents with tiredness and palpitations on exertion

Hb 5.2g/dlWbc 6,300Plt 5,60,000

MCV 61RDW 18RBC 3.1

? Need for transfusion

Further tests

?Further evaluation

Very Low MCVIron deficiency (Low RBC, high RDW)

Thal trait (Normal RBC, Normal RDW)

Rare (Thal major, sideroblastic)

Low MCV (70-80)Same as V L MCV

Anemia of chronic disease

50 yr old male, with c/o poor appetite, altered taste came for master health check up

Hb 6.4Wbc 2300Plt 85,000

MCV 118RDW18.5RBC 3.1

Why Pancytopenia?

Can it be misdiagnosed?

Simpler tests to confirm?

26 year old lady with sudden onset breathlessness on exertion

Confirmation

Pregnant lady presents with breathlessness on exertion

Tight MS Valvotomy done few years back

Now has features of MS/MR

Not in obvious CCF

Hb 5.2Wbc 8900Plt 65,000

MCV 108RBC 3.8RDW 17.2

Smear/Reticulocyte count

Retic 23%

Diagnosis of hemolysis

Commonest hemolytic disorders in practice

AIHASICKLE (Endemic)G6PDMICROANGIOPATHY (TTP/HUS/VALVE)PNH

Very high MCV >110Hb 6.5MCV 115 RDW 19MCH 34RBC 3.6WBC 2500PLATELET 75,000

?Diagnosis? confirmation

45 yr old lady sudden onset anemia, no bleedingHb 4.2MCV 130RBC 2.5RDW 21MCH 45WBC 12,300PLT 3,50,000

? Diagnosis

AIHA with red cell clumps

AIHA with sphero/reticulocytosis

Very high MCVTrue

High LDH, Bili PancytopeniaB12/folate

Spurious

High LDH, BiliLow Hb aloneAIHA

NORMOCYTIC ANEMIAS14 yr old girl on anti epileptic, presents with

pallor, NO bleedingHb 4.2Wbc, Plat Normal

MCV 85RDW 16RBC 2.8

Further tests?

Any other D/D?

8 year old boy referred for evaluation of anemia

Hb 5.2Wbc plat Normal

MCV 86RDW 16RBC 2.9

One test picked up

Normocytic anemia (80-90)PRCA

Renal failure

Chronic hemolysis

Acute bleed

Mild macrocytic anemia (95-110)Leave it for hematologists to diagnose !!!!

Usually indicates hypoxia, marrow stress.

Aplasia, MDS, myeloma

Myeloma

Myelodysplastic syndromes

Aplastic anemia

DiabetesSmokingHypothyroid

Megaloblastic anemia - Very good prognostic pancytopenia

Other good prognostic/bi-pancytopeniaVHF

Hypersplenism

Pancytopenia what to do? Good pancytopenia

Viral Short lived (not more than a week) Hb, RBC count normal SGOT/PT often deranged

Megaloblastic (High MCV, high LDH, rapid response)

Hypersplenism (absolutely well looking patient, splenomegaly, normal diff – However, this needs evaluation.)

Lethal pancytopenia

LETHAL PANCYTOPENIA90% of the time Leukemia can be suspected/

diagnosed in the peripheral blood

THERE IS NO POINT IN DOING A MARROW FOR DIAGNOSIS OF LEUKEMIA ITSELF

Diagnostic evaluation of leukemia involves, CD marker analysis, karyotyping, FISH, molecular studies

Some times most of the tests can be done in PB (? Marrow for HP evidence )

When the blast number is lowTo check for MDS, fibrosis

Palliative chemo is the preferred option in majority of elderly AML

Prognostication markers can be done in PB in majority of patients

25 year old man with ankle joint pain and swelling comes to orthopedic clinic

56 year old lady, presents with anemia, recurrent fever, body pains for the past 3 months

Has been to various hospitals

26 Year old lady with chronic severe back acheHb 6g (transfused)TC 2200 MCV 82PLT 50000

DIFF: Poly 20 Lymph 70 Mono 10

Has been having fevers for the past 2 months

Shown in various hospitals

MARROW done twice, reported as inadequate

Diagnosis

37 year old female presented with tiredness

Hb 6g/dlMCV 106TC 5.6 PLY 12

LDH, alb/glob ratio normal

CARRY HOMEClassify MCV into low (<80), normal (80-95),

mildly high (95-110), severely high (>110)Check poly/lymph ratioDegree and number or cytopenias.

Bone marrows in periphery mostly not needed