Making the most out of the CBC Making the most out of the CBC
and peripheral blood smear
May 2011
John D’Orazio, M.D., Ph.D.
gy
gy
Pediatric Hematology-Oncology
University of Kentucky College of Medicine
jdorazio@uky.edu
objectives
• Understand
Understand the clinical information that a complete blood 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.
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
y
• UK hospital runs about 700 hemograms a day
– 15,000‐20,000 a month
p
p
– 40% outpatient 60% inpatient
(Compared to ~1,000 chemistry panels per day)
• Directed test for blood disorders
• Screening test for systemic diseases
Advia 2120 Hematology Analyzer
What comes with a CBC?
LLots of information about cellular blood elements: fi f
i
b
ll l bl d l
 Total number
 Composition
 Absolute numbers Absolute numbers
of each type




Amount of RBC’s
Average size
Amount of hgb in each
Amount of hgb in each
Uniformity of size
 Total number
 Average size
Iron deficiency
Di
d
Diamond‐
Blackfan anemia
Pertussis
TTP
M
Mononucleosis
l i
Fanconi Anemia
Immunodeficiency
Aplastic Anemia
Hemolytic Uremia Syndrome
Hereditary Spherocytosis
Neutropenia
AML
Folate, B12 Folate
B12
deficiency
DIC
CML
Bernard‐Soulier
syndrome
Alloimmune
thrombocytopenia
Eosinophilia
Autoimmune y
hemolysis
HUS
Thrombocytopenia
Allergy
ALL
S i
Sepsis
Chronic Chronic
inflammation
Steroid use
Steroid use
ITP
Myelodysplasia
HIV infection
HIV infection
Hypoxia, polycythemia
Wiskott‐Aldrich
The CBC is one of the most commonly used screening tests in medicine
i
i
di i
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?
•
Cellll D
C
Dyn 4000 modern
d
h
hematology
t l
analyzer,
l
Abbott Laboratories, Chicago, IL
Automated CBC analyzers work by determining A
d CBC
l
kb d
i i
light scattering profiles of individual blood cells
Hemoglobin (Hgb)
g
( g )
•
The oxygen‐carrying molecule in RBC’s
•
Measured as grams per deciliter (g/dL) of whole blood. •
Tetramer comprised of 4 globin proteins d f l b
and an iron‐containing heme moiety.
Hemoglobin
Alpha globin
Beta globin
Hgb A (adult)
2
2
Hgb A2
2
δ2
H b F (fetal)
Hgb
F (f t l)
2
γ2
Almost all analyzers calculate hemoglobin by the
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”
Classic
method “Spun Hematocrit”
– determined by centrifugation of whole blood in a narrow capillary blood glass tube sealed at one end.
– Since Since "crit"
crit tubes are fragile and dangerous to use, spun tubes are fragile and dangerous to use spun
hematocrits are rarely used today.
•
The automated hematology analyzer calculates the Hct from The
automated hematology analyzer calculates the Hct from
the RBC and MCV by the following formula:
Hct (%) = RBC x MCV
Air
Plasma
Buffy coat (WBC)
Hematocrit (RBC)
Clay plug
In general, hematocrit = 3x hemoglobin
– Since the Hct is a calculated value, it is less accurate than ,
hemoglobin
Mean Corpuscular Volume (MCV)
p
(
)
• Average size of RBC’s
• “Normal” varies with age
– Elevated MCV = RBC’s larger than normal
• “macrocytosis”
– Decreased
Decreased MCV = RBC
MCV = RBC’ss smaller smaller
than normal
• “microcyosis”
microcyosis – Normal MCV = RBC’s “just right”
• “normocytosis”
– For adults = 80‐94 fL
– < 10 y/o, lower limit of normal = 70 fL + age (yrs)
l 70 fL +
( )
– Infants: much higher MCV’ss
MCV
Key
y
Concept
To make a proper
p p RBC,, there must be coordination
between proliferation of RBC precursor cells and
hemoglobinization of maturing RBC’s
- - - cell division - - - differentiation - - Hematopoeitic
Stem cell
Mature
erythrocytes
Cell division occurs relatively normally but Hgb production is defective. The cytoplasm can’t “fill up” properly with hemoglobin before the cells divide, so daughter cells are small.
Problems with
Hemoglobin
Production
Hgb production is fine but there is a problem with DNA synthesis. RBC precursors divide slowly, allowing more time to accumulate Hgb which makes the cells large.
Problem with DNA
Synthesis
Marrow failure
↓ Globin
(thalassemia)
B12 deficiency
Iron
Deficiency
Hydroxyurea
Hydroxyurea,
Chemo
Folate
deficiencyy
Red cell distribution width (RDW)
Red cell distribution width (RDW)
• q
quantitative measure of variation in red blood cell size (anisocytosis)
– normal RDW range is 11.5
l RDW
i 11 5 ‐ 14.5 %
14 5 %
• Nutritional anemias → high RDW’s
– Day‐to‐day variation in diet
• Inherited anemias → low RDW’s
I h it d
i → l RDW’
– Fixed genetic lesion affecting hematopoiesis all the time
MCV and RDW
Microcytosis
Low RDW
(Thalassemia)
Normal
o a
Events (cells)
Events (cells)
Normal
RBC Size
RBC Size
Normal
Normocytosis
Events (ce
ells)
Events (ce
ells)
Normal
RBC Size
Microcytosis
High RDW
(Fe deficiency)
RBC Size
Macrocytosis
(Folate or B12)
“Mentzer
Mentzer Index
Index”
William Mentzer, M.D.
Pediatric Hematology/Oncology
Professor Emeritus, UCSF
• helps differentiate whether microcytic anemia is caused from iron deficiency or from thalassemia
caused from iron deficiency or from thalassemia.
Mentzer Index Index = MCV 
MCV  RBC count
RBC count
< 11
thalassemia
> 13
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
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’ss
in the cytoplasm of RBC
• Ribosomes persist in RBC’s for 24‐48h after leaving the marrow
g
– ongoing Hgb synthesis
• Reticulocytes are young red blood cells only are young red blood cells only
1‐2 days removed from the marrow.
• Why is the retic
y
count normally ~1%?
y
– Normal RBC life‐span ~ 120d
– Each
Each day the body must replace 1 day the body must replace 1 ÷ 120 120 = ~1%
1% of the red cell mass
Reticulocyte Index
• More informative than just the retic
M
i f
ti th j t th
ti count. t
• Corrects for abnormal hematocrit.
(Actual
(A
t l Hct)
H t)
Reticulocyte index = (Percent reticulocytes) x
(Normal Hct)
< 2%
> 2%
Production problems
•
Hypoproliferative Anemias
Destruction problems
•
Hemolysis
–
Nutritional (iron, folate, B12)
–
Immune‐mediated
–
Anemia of inflammation
–
Hemoglobinopathies
•
Erythropoeitin defect
–
Membranopathies
•
Bone marrow failure –
RBC metabolic abnormalities
•
Bone marrow infiltration
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
Microcytic
Mi
ti
(low MCV)
Underproduction
(low retic’s*)
•
•
•
Normocytic
N
ti
(MCV nl. for age)
Iron deficiency
Lead poisoning
Anemia of inflammation
•
•
TEC
Viral suppression
Thalassemia
•
•
•
•
•
•
Membrane disorders
Hemoglobinopathies
Enzymopathies
G6PD deficiency
Microangiopathy
Blood loss
Macrocytic
M
ti
(high MCV)
•
•
•
•
Bone marrow failure
MDS
Megaloblastic anemia
DBA
•
Immune-mediated
hemolysis
*for
for degree of anemia
RBC destruction
(high retic’s)
•
Automated WBC Differential
Forward sscatter (cell size)
• Histogram analysis of WBC’s
monocytes
neutrophils
• each "dot" represents data from a
single cell.
y of WBC displays
y a
• Each type
characteristic size and granularity
• In this case:
eosinophils
basophils
lymphocytes
Side scatter (cellular complexity)
• 65.6%
65 6% Neutrophils
• 26.2% Lymphocytes
y
• 5.6% Monocytes
• 2.2% Eosinophils
• 0.4% Basophils
CBC’s at UK
• Pretty much all CBC
Pretty much all CBC’ss start with analysis by an automated start with analysis by an automated
CBC analyzer.
• ~75%
of CBC’ss have an automated differential only. have an automated differential only.
75% of CBC
– Clue to automated differential = reported % with tenths values.
Neutrophils 54.8%
54 8%
Lymphs
23.6%
Monocytes 15.2%
Eosinophils 4.3%
Basophils
2.1%
Automated Differential
Neutrophils 55%
Lymphs
24%
Monocytes 15%
Eosinophils 4%
Basophils
2%
Manual Differential
• If the automated analysis picks up certain “flags”, then the CBC is ticked for a manual assessment by the Heme techs.
CBC i i k d f
l
b h H
h
Nucleated RBC’s
Blast forms Platelet count < 30,000
High WBC
(> 50,000)
(>
50 000)
Immature neutrophils
Macrocytosis
Marked
Anisocytosis
Variant lymphocytes
Abnormal Absolute monocyte count
Low
MCV
Platelet Pl
t l t
clumps
Certain RBC Morphology Abnormalities
Abnormal Absolute lymphocyte count
Bottom line
Bottom line…
• Today’s automated hematology analyzers are very good for most routine applications, but they’re not perfect.
• A
Automated CBC’s can’t reliably describe the actual morphology of d CBC’
’ li bl d
ib h
l
h l
f
WBC’s or RBC’s
– Machines can “flag” certain RBC or WBC abnormalities (e.g. 2
g
( g + anisocytosis)
y
)
• 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)
• Lik
Likewise, if the CBC doesn’t “fit” with the clinical picture, then more i if th CBC d
’t “fit” ith th li i l i t
th
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 physically look at the peripheral blood smear.
p y
y
p p
• Remains the “gold standard” for blood interpretation
• Clinical Lab
Clinical Lab’ss Heme techs are excellent and reliable
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)
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!
Goodness that is a lot of
variation in color! This
person must have a high
retic count!!!
1.
2
2.
3.
4.
Spherocytes
Polychromasia
Sickled forms
Nucleated RBC’s
Describe those RBC’s!
Describe those RBC
s!
Just look at all
that variation in
red cell size!
1.
2
2.
3.
4.
Poikilocytosis
Polychromasia
Anisocytosis
g
Target Forms
Describe those RBC’s!
Describe those RBC
s!
I say! Have you ever
seen such differences in
red cell shape?!
1.
2
2.
3.
4.
Polychromasia
Anisocytosis
Poikilocytosis
g
Target Forms
Describe those RBC’s!
Describe those RBC
s!
Which term best describes this smear?
1.
2
2.
3.
4.
Schistocytes
Sickled
Forms
Sickled Forms
RBC Stippling
Spherocytes
p
y
The spleen: gp
y
final resting place for many a spherocyte…
Describe those RBC’s!
Describe those RBC
s!
SSchistocytes
hi
are broken red cell fragments b k
d ll f
that form with microangiopathy and abnormal shearing.
1.
2
2.
3.
4.
Sickled Forms
Schistocytes
Reticulocytosis
p
y
Spherocytes
Describe those RBC’s!
Describe those RBC
s!
Did someone mention
targets?! This patient
might have hemoglobin C!
1.
2
2.
3.
4.
Polychromasia
Anisocytosis
Poikilocytosis
Target Forms
g
Name
that Cell!
Name that Cell!
B Cells, T Cells B
C ll T C ll
and NK Cells, Oh My!
1.
2.
3.
4.
Monocyte
Lymphocyte
Neutrophil
Blast
Name that Cell!
Name that Cell!
1.
2.
3.
4.
Neutrophil
Eosinophil
Granular Lymphocyte
Basophil
g basophils
p
p
Finding
in the p
peripheral
blood is fairly uncommon.
Name that Cell!
Name that Cell!
Does anyone else think that eosinophils
are beautiful? They look
like they’re filled
look like they’re filled with little rubies!
1.
2.
3.
4.
4
Neutrophil
Monocyte
Eosinophil
Basophil
hil
Name that Cell!
Name that Cell!
1.
2.
3.
4.
Band
Monocyte
Lymphocyte
Basophil
Now THAT’s a fine band!
Name that Cell!
Hey look‐ it’s a little neutrophil p
smiley face!
1.
2.
3.
4.
4
Neutrophil
Monocyte
Eosinophil
Basophil
hil
Name that Cell!
Name that Cell!
Prepare to be
phagocytized!
1.
2.
3.
4.
Neutrophil
Monocyte
Lymphocyte
Basophil
Name that Cell!
Name that Cell!
1.
2.
3.
4.
Monocyte
y
Band
Reactive
lymphocyte
Reactive lymphocyte
Blast
Ka-BOOM!!!
Ka BOOM!!!
Cases
CBC and peripheral blood smear can clinch the diagnosis. diagnosis.
d
l k
’
f
Hands on clickers… it’s time for audience participation fun!
p
p
Toddler with pallor.
6.1
58
5.8
17.9
478
MCV: 57 fL
RDW: 23 %
MCHC: 32 fL
P46,L
L38,M
M12,E
E4
Retic: 1.3%
•
•
•
•
Pallor seems to have developed gradually.
No jaundice, no dark urine, no fevers
P l b
Pale
butt well-appearing,
ll
i
playful
l f l
No organomegaly
Toddler with pallor.
5.8
6.1
17.9
478
25%
25%
25%
2
3
25%
MCV: 57 fL
RDW: 23 %
MCHC: 32 fL
P46,L38,M12,E4
Retic: 1
1.3%
3%
Which diagnosis is most likely?
1.
2.
3.
4.
Iron deficiency anemia
Thalassemia
a asse a
Vitamin B12 deficiency
Autoimmune hemolysis
1
4
4 y/o immigrant from Nigeria.
7.7
10.8
21.8
423
MCV 83 fL
MCV:
RDW: 19.1 %
P61,L28,M8,E3
Retic: 9.3%
•
Not previously known to be anemic.
•
Bloodwork on his initial “well-child” check.
•
4-5 cm firm spleen felt on examination.
•
Muddy sclerae
•
II/VI systolic murmur left sternal border
4 y/o immigrant from Nigeria.
7.7
10.8
21.8
423
MCV: 83 fL
RDW: 19.1 %
P61,L28,M8,E3
Retic: 9.3%
25%
25%
25%
2
3
25%
Which diagnosis is most likely?
1.
2.
3.
4.
Trypanosomiasis
G6PD deficiency
Thalassemia
Sickle Cell Disease
1
4
4 y/o with widespread bruising.
12.1
58
5.8
35.8
3
MCV: 87 fL
RDW: 12.3 %
MCHC: 34 fL
P60,L28,M6,E2,Atyp4
Retic: 1.3%
1.
2.
3
3.
4.
No family history of bruising/bleeding.
Normal medical history.
N iincreased
No
d bl
bleeding
di with
i h neonatall circumcision.
i
i i
Petechiae and purpura appeared suddenly overnight.
4 y/o with widespread bruising.
5.8
12.1
35.8
3
MCV: 87 fL
RDW: 12.3 %
MCHC: 34 fL
P60,L28,M6,E2,Atyp4
R ti 1
Retic:
1.3%
3%
25%
25%
25%
2
3
25%
Which diagnosis
g
is most likely?
y
1.
2.
3.
4.
Acute Leukemia
Idiopathic Aplastic Anemia
Child abuse
ITP (Primary autoimmune
thrombocytopenia)
y p
)
1
4
Teenager with Crohn’s disease and pallor.
6.7
28
2.8
19.8
110
MCV: 107 fL
RDW: 19.1 %
P41,L48,M9,E2
Retic: 2.3%
2 3%
•
Diagnosed 4 years prior with IBD
•
Hospitalized a few times with Crohn’s exacerbations.
•
Pallor seems to have come on gradually.
•
Symptoms include some weakness and dizziness.
Teenager with Crohn’s disease and pallor.
2.8
8.1
23.8
110
MCV: 107 fL
RDW: 19.1 %
25%
25%
25%
2
3
25%
Retic: 2.3%
Which diagnosis is most likely?
1.
1
2.
3
3.
4.
Myelogenous
M
l
l k i
leukemia
Steroid effect
L
Lupus
erythematosus
h
Vitamin B12 deficiency
1
4
Child in ICU with thrombocytopenia
85
8.5
10.1
29.4
48
Retic: 3.2%
MCV: 87 fL
P64,L26,M8,E2
• Admitted yesterday with high fevers and obtundation.
• Blood
Bl d culture
lt
positive
iti ffor gram-negative
ti rods.
d
Child in ICU with thrombocytopenia
8.5
10.1
29 4
29.4
48
25%
25%
25%
2
3
25%
Retic: 3.2%
MCV: 87 fL
P64,L26,M8,E2
Which diagnosis is most likely?
1.
2.
3.
4.
Endocarditis
Disseminated intravascular
coagulation (DIC)
Sickle cell anemia
Dehydrated red cells
1
4
5 y/o with fever, pallor and bruising
8.1
133.8
23.9
47
25%
25%
25%
2
3
25%
MCV: 79fL
RDW: 13 %
MCHC 33
MCHC:
33.4
4 fL
Retic: 0.4%
1.
2.
3.
4
4.
Sepsis
Viral infection
Acute leukemia
I fl
Inflammatory
t
response
1
4
9 y/o with abdominal cramping.
25%
1.
2.
3.
4.
25%
25%
2
3
25%
Helminth infection
Lactose intolerance
Clostridium difficile colitis
Irritable bowel syndrome
1
4
Another toddler with pallor
7.1
68
6.8
21.9
348
MCV: 57 fL
RDW: 11 %
MCHC: 32 fL
P54,L
L28,M
M17,E
E1
Retic: 10.3%
•
•
•
Family recently immigrated from Turkey
Firm spleen 5 cm below costal margin
Mildly icteric sclerae
Another toddler with pallor
6.8
7.1
21.9
348
MCV: 57 fL
RDW: 11 %
MCHC: 32 fL
P54,L28,M17,E1
Retic: 10.3%
%
25%
25%
25%
2
3
25%
Which diagnosis is most likely?
1.
2.
3.
4.
Iron deficiency anemia
Thalassemia
Chronic renal failure (EpO
deficiency)
Anemia of inflammation
1
4
2 y/o with pneumococcal sepsis
12.1
68
6.8
36.9
498
MCV: 81 fL
RDW: 12 %
MCHC: 34 fL
P65,L
L23,M
M11,E
E1
Retic: 1.8%
• Normal full‐term baby
• Normal growth/development
• 1 prior hospitalization for pneumonia
2 y/o with pneumococcal sepsis
6.8
12.1
36.9
498
MCV: 81 fL
RDW: 12 %
MCHC: 34 fL
P65,L
L23,M
M11,E
E1
25%
25%
25%
2
3
25%
Which diagnosis is most likely?
1.
2.
3.
4.
Common variable immunodeficiency
HIV infection - AIDS
Asplenia
Congenital neutropenia
1
4
7 y/o with pallor.
5.1
83
8.3
15.4
401
MCV: 103 fL
RDW: 26 %
MCHC: 34.3 fL
P32,L
L48,M
M14,E
E2,nRBC
nRBC4
Retic: 34.5%
•
•
•
•
Fatigue and pallor seem to have “come out of nowhere” over the past day or two.
Patient is sallow, ill-appearing and has mild scleral icterus.
Hyperdynamic precordium with III-IV/VI systolic murmur
murmur.
No organomegaly.
7 y/o with pallor.
8.3
5.1
401
15.4
MCV: 103 fL
RDW: 26 %
MCHC: 34.3 fL
P32,,L48,,M14,,E2,,nRBC4
Retic: 34.5%
25%
25%
25%
2
3
25%
Which diagnosis
g
is most likely?
y
1.
2.
3.
4.
Autoimmune hemolytic
anemia
Disseminated intravascular
coagulation (DIC)
Acute Leukemia
Folic acid deficiency
1
4
6 y/o with splenomegaly.
5.5
81
8.1
24.4
288
Retic: 8.2%
MCV: 87 fL
MCHC: 36
P44,L
L46,M
M8,E
E2
Direct Coomb’s: negative
•
•
•
•
Child is asymptomatic
Splenomegaly appreciated on routine exam by an apt clinic resident
Ph t th
Phototherapy
as a newborn
b
Mother with history of cholecystectomy as a teenager
6 y/o with splenomegaly.
5.5
8.1
288
24.4
24
4
Retic: 8.2%
MCV: 87 fL
MCHC: 36
P44,L
L46,M
M8,E
E2
Coomb’s neg
25%
25%
25%
2
3
25%
Whichh diagnosis
Wh
g o is most
o likely?
ke y
1.
2
2.
3.
4.
B‐thal trait
G6PD deficiency
G6PD deficiency
Hereditary spherocytosis
Storage disease (Gaucher’s)
1
4
18 month old well child with anemia
76
7.6
5.3
14.4
248
25%
25%
25%
2
3
25%
Retic: 0.2%
MCV: 89 fL
RDW: 13.3
P49,L41,M9,E1
ESR: 6 sec
1.
1
2.
3.
4.
Iron deficiency
Folate deficiency
Transient erythroblastopenia of
childhood
hildh d (TEC)
Aplastic Anemia
1
4
Teenager with low-grade fevers, malaise and
splenomegaly
25%
1.
1
2.
3.
4
4.
25%
25%
2
3
25%
Acute myelogenous leukemia
Infectious mononucleosis (EBV)
Systemic lupus erythematosus
Histiocytosis
1
4
Teenager with fevers, recently back from a
mission trip.
10.7
11.2
32.9
448
MCV: 83 fL
RDW: 15 %
MCHC: 34 fL
25%
25%
25%
2
3
25%
Retic: 2.3%
1.
2.
3.
4.
Sleeping sickness
Liver fluke infection
Malaria
Chagas disease
1
4
School-age child with bruising and lowgrade fever
8.3
28 4
28.4
24.7
52
25%
25%
25%
2
3
25%
MCV: 91 fL
RDW: 13 %
MCHC: 33.4 fL
Retic: 1.7%
1.
2.
3.
4
4.
Acute myelogenous
y g
leukemia
Reactive left shift
ITP
Listeria infection
1
4
8 y/o girl with swollen cervical lymph node
25%
1.
2.
3.
4.
25%
25%
2
3
25%
Lymphoma
Atypical bacterial infection
Mumps infection
An amazing shot of all the major
normal WBC’s in the same field
1
4
Take home
• The CBC and peripheral blood smear offer a wealth of information regarding g
g
pathophysiology.
– Heme/onc diagnoses
– Atopy, Rheumatology
– Infectious disease
– Others
“John
always review the
John, always review the primary data yourself…”
• Th
There is benefit to reviewing blood i b
fit t
i i bl d
smears yourself, especially in difficult or challenging cases
or challenging cases.
Or ask your friendly hematologist for help!
Howard Weinstein, MD
Chief, Pediatric Hematology/Oncology, MGH
jdorazio@uky.edu; 323‐6238
What the !@#$ are they talking about?
• Polychromasia, Polychromatophilia
y
p
RBC’s of different staining color,
implies reticulocytosis
• Poikilocytosis
RBC’s of different shape, mixed
population (old + transfused cells)
• Anisocytosis
RBC s of different size;
RBC’s
reticulocytosis, high RDW
• Schistocytosis
RBC fragments, microangiopathic
processes (DIC), shearing
• Elliptocytes, Ovalocytosis
RBC’s look elliptical,
membranopathy
• Drepanocytosis
Sickle cell forms
forms, Hgb S disease
• Spherocytosis
No central pallor in rbc’s; HS or AIHA
• Howell‐Jolly bodies
Functional asplenia
Spherocytes
p
y
Schistocytes
y
Acanthocytes
y
Elliptocytes
Drepanocytes
Echinocytes
Poikilocytes
Target cells
Stomatocytes
Decreased
Increased
Neutrophils
•
•
•
•
•
•
•
•
•
Kostmann’s syndrome
Cyclic
y
neutropenia
p
Bone marrow failure
Leukemia
Autoimmune neutropenia
Benign neutropenia of childhood
g
p
Infection/sepsis
Drug‐induced (Bactrim, chemotherapy)
Myelodysplasia
•
•
•
•
•
Infections
Tissue destruction
Corticosteroids
Leukemoid reaction
GCSF administration
Lymphocytes
•
•
•
•
•
Congenital immunodeficiency
Severe infection
Drugs (Corticosteroids alkylating)
Drugs (Corticosteroids, alkylating)
GI disease
Acquired Immunodeficiency
•
•
•
•
•
Viral infection (e.g. EBV)
Some fungal, parasitic infections
Rare bacterial infection (Pertussis)
Rare bacterial infection (Pertussis)
Allergic reactions/drug sensitivities
Immunologic disease
Monocytes
• Corticosteroids
• Inflammatory responses
• Recovery phase of neutropenia
• Myeloproliferative disorders
Eosinophils
• Bacterial infection
ACTH administration
• ACTH administration
• Parasitic infections
• Allergic conditions
• Drug therapy
Basophils
• Corticosteroids
• Bone marrow failure
• Myeloproliferative syndromes
Normal blood cells
monocyte
band
platelet
l t l t
lymphocyte
neutrophil
basophil
eosinophil
Anemia‐ a suggested approach
• Does the child look anemic?
• Does the child act anemic?
• Key physical exam parameters:
– Look at the conjunctiva under the lower eye lid
– Splenomegaly? Tachycardia? Petechiae/purpurae?
• The lab tests to order will be dictated by:
– The degree of pallor, presence of symptoms
The degree of pallor presence of symptoms
– Physical findings (jaundice, HSM, adenopathy, etc)
– Apparent pace of the anemia
pp
p
– What diagnoses are being considered
• Start out with a CBC, but always order a reticulocyte count too!
– The retic count distinguishes between RBC destruction and underproduction
Red blood cells
Mean corpuscular hemoglobin (MCH)
Mean corpuscular hemoglobin (MCH) • Average amount
g
of Hgb inside each RBC
g
• High MCH’s go along with large (macrocytic) RBC’s
• Low MCH’s correlate with microcytosis and anemias caused by impaired Hgb synthesis. th i
Mean corpuscular hemoglobin concentration (MCHC) i (MCHC)
• Average concentration of hemoglobin inside a red cell. • Takes red cell volume into account
• Decreased MCHC values (hypochromia) seen in conditions where Hgb is abnormally diluted inside RBC’s
• Iron deficiency anemia • Thalassemia
• Increased MCHC values (hyperchromia) seen when Hgb is abnormally concentrated
inside RBC’ss
concentrated inside RBC
• Spherocytosis
g ((S, C)
, )
• Abnormal Hgb
• Severe burns If MCHC 35 fL thi k h
If MCHC > 35 fL, think spherocytes!
t !
hematoccrit (%)
Normal hematologic values depend on age and gender.
Therefore, there is no absolute value for “anemia” for all kids.
Always check the age-appropriate cut-offs.
But in general, suspect anemia for hgb < 10 g/dl or hct < 30%.
Source: Vampire Handbook, Boston Children’s Hospital
1 y/o with pallor
82
8.2
8.2
23.9
351
25%
25%
25%
2
3
25%
MCV: 71 fL
RDW: 18.4 %
Retic: 2.6%
1.
2
2.
3.
4.
Lead poisoning
Malaria
Babesiosis
Hemoglobin C disease
1
4
Febrile infant with pancytopenia
25%
25%
25%
2
3
25%
1. Lysosomal storage disease
2. Histoplasmosis
3. Chronic Granulomatous
Disease (CGD)
4 Pneumococcal
4.
P
l sepsis
i
1
4
12 y/o with fever, bruising and pallor.
25%
1.
2.
3
3.
4.
Candidal infection
Histoplasmosis
Burkitt’ss lymphoma/leukemia
Burkitt
Gaucher’s disease
1
25%
25%
2
3
25%
4
Albino child with frequent infections.
25%
1.
2.
3
3.
4.
Abetaproteinemia
Tyrosinase neutropenia
Chronic granulomatous disease
Chediak-Higashi syndrome
1
25%
25%
2
3
25%
4
This is not a staining artifact!
This is not a staining artifact!
25%
1.
1
2.
3.
4.
25%
25%
2
3
25%
Obstructive liver disease
Abetalipoproteinemia
Thalassemia
Severe burns
1
4
Common Sources of Error for Automated CBC machine
Cryoproteins
Giant platelets
Nucleated RBCs
Uremia
WBC count >50,000/μL
Platelet clumping
Carboxyhemoglobin
Smudge cells
Heparin
Hyponatremia
Clotting
Agglutination
DIC
Hemolysis
Medications
RBC inclusions
Hyperbilirubinemia
Infections
Excess EDTA
Lipemia
p
Hyperglycemia
Anemia: not enough red cells. I d
Inadequate
t oxygen-carrying
i hemoglobin
h
l bi capacity
it
Howell jolly bodies
Howell jolly bodies
Sickle cell disease
Sickle cell disease
Elliptocytes
Elliptocytes (ovalocytes) : elongated
RBC
- Large number (up to 100%) is the
hallmark of hereditary elliptocytosis
- Low number (up to 5 - 10%) is observed
in various situations, including iron
deficiency and megaloblastic anemias
- If they are very large = macro ovalocytes
(see "macrocytes")
stomatocytes
Stomatocytes : folded RBC leading to an
aspect mimicking a mouth and its lips (slitlike appearance)
- Many situations, including hemolytic
anemias, either constitutive or acquired
Cold agglutinin disease
Cold agglutinin disease
Cold agglutinin disease ; aggregates
disappear after the sample is warmed at
37°C
echinocytes
Echinocytes or crenated or contracted
cells : up to 50 protrusions (spines or
spurs) may be observed
- They correspond usually to an artifact
(glass slides, old samples, saline solutions)
- Excess in lipids (not diet fed samples)
- Various congenital haemoglobin and
enzymatic disorders
- Acute renal failure
Rouleaux formation, myeloma
Rouleaux formation, myeloma
Rouleaux formation: RBC do not stick to
each other in normal conditions because
their external membrane is negatively
charged; if neutralization occurs, RBC stick
face to face, leading to the so-called
"rouleaux formation"
- All inflammatory disorders (slide)
- monoclonal gammopathies with excess of
monoclonal immunoglobulin (does not
occur in light chain myeloma)
Acanthocytes : crenation is limited (3 to
12 spines
i
or spurs))
Hereditary acanthocytosis
(abetalipoproteinemia) Liver diseases
(cirrhosis)
(c
os s) with
t dys
dyslipidemia
p de a
As a part of artefact, mixed to echinocytes
Basophilic stippling
Basophilic stippling
Basophilic stippling : numerous thin and
dark granules scattered throughout the
RBC, related to abnormal hemoglobin
synthesis
th i
- Thalassemic syndromes (including
thalassemic trait)
g ,
- Sideroblastic anemias ((lead,, drugs,
idiopathic)
- Agnogenic myeloid metaplasia
- Newborn (stippling is delicate)
babesia
plasmodium
Cabot rings
Cabot rings
Cabot rings
Cabot
rings : remnants of the : remnants of the
mitotic spindle, appearing as purple rings or loops within RBC
‐ All major dyserythropoietic
All
j d
h
i i
changes
Papenheimer bodies
Papenheimer bodies
Pappenheimer bodies : small dark RBC
inclusions ; usuallyy one to three within the
cell, they are located near the periphery of
the cytoplasm
- All dyserythropoietic states lead to their
production and number may raise sharply
production,
(up to 100% of RBC) in splenectomized or
asplenic patients