Hematology Studies and Lab Reports
Normal Blood Cells:
2
THE WBC
Identify the
segmented
neutrophil,
band neutrophil,
lymphocyte,
monocyte,
eosinophil,
basophil, and
platelet in the
image
3
Neutrophil – targets bacteria/fungi. Fine, faintly pink granules when stained.
Have many lobes within which can look like one single lobe (banded) or
several (segmented). First responders, main component in pus.
Eosinophil – targets larger parasites, modulates allergic rsvp. Pink orange
granules. Have 2 lobes.
Basophil – releases histamine for inflamm rsvp. Large and blue. Can be bi or
tri lobed, but hard to see because of the multitude of dark granules.
Lymphocyte – Bcells release antibodies and assist in activating T cells. Also are
T cells and NK cells. Stain deeply, “eccentric.”
Monocyte – migrate from blood stream to tissues then change into
macrophages or dendritic cells (which also help activate T cells). Kidney bean
shaped lobes.
Macrophages – phagocytes that engulf debris and pathogens. Stimulate
lymphocytes and other cells that rsvp to pathogens.
4
band neutrophil,
eosinophil,
segmented
neutrophil
lymphocyte,
basophil,
monocyte,
5
6
Bone Marrow Cellularity:
Normal
Hypercellular
Hypocellular
7
Normal RBC
The red blood cells here are
normal, happy RBC's. They have a
zone of central pallor about 1/3 the
size of the RBC. The RBC's
demonstrate minimal-
variation in size
(anisocytosis) and
shape (poikilocytosis). A
few small fuzzy blue platelets are
seen. In the center of the field are a
band neutrophil on the left and a
segmented neutrophil on the right.
8
Steps in Erythropoisis
Early
Proerythroblast
(Pronormoblast)
Intermediate Late
Polychromatophilic
Normoblast
Basophilic
Normoblast
Reticulocyte
Orthochromatophilic
Normoblast
Erythrocyte
9
HCT (Hematocrit) (114)
The packed cell volume (HCT) is the percentage of
total volume occupied by packed red blood cells when a
given volume of whole blood is centrifuged at a constant
speed for constant period of time. The HCT is one of the
most precise methods of determining the degree of
anemia or polycythemia.
Plasma
(55% of whole blood
Buffy coat: leukocyctes and
platelets(<1% of whole blood
Erythrocytes
(45% of whole blood)
10
MCH (149)
 (Mean Corpuscular Hemoglobin): Indicates the weight
of hemoglobin in a single red blood cell.
MCH increase or decrease along with an increase or
decrease in MCV is a significant finding if there is a need
for folic acid and/or B12
A decrease in MCH with a decrease in MCV indicates a
need for iron, copper, or B6.
11
MCV (150)
 (Mean Corpuscular Volume): This measurement
indicates the volume in cubic micron occupied by an
average single red blood cell. MCV increase or decrease
along with an increase or decrease in MCH is a significant
finding for folic acid and/or B12 need (increase) or iron,
copper or B6 need (decrease). MCV and MCH should
always be viewed together.
12
Complete Blood Count (85)
WBC: Total and differential counts
RBC:
HGB (Hemoglobin):
HCT (Hematocrit):
MCV (Mean Corpuscular Volume):
MCH (Mean Corpuscular Hemoglobin):
MCHC (Mean corpuscular hemoglobin concentration):
PLATELETS: Platelets are concerned with the clotting of the blood and also
clot retraction.
13
WBC :Differential Count (220)
SEG :
A type of neutrophil, its
primary function is
phagocytosis.
BANDS:
Non-segmented neutrophils (metamylocytes)
the youngest forms that are normally found in the peripheral blood.
These forms increase in the presence of acute infections with or
without an absolute increase in the total WBC.
14
WBC :Differential Count
LYMPH :
Lymphocytes help to destroy the toxic products of protein
metabolism. Lymphocytes originate from lymphoblasts in the
spleen, lymph glands, tonsils, thymus, bone marrow, and
possibly the appendix.
NK cell
15
WBC :Differential Count
MONO : monospot test (125) EBV antibodies (95)
Monocytes phagocytize some bacteria, particulate matter,
and protozoa.
The monocytes remain to phagocytize fragments of cells,
etc; hence, the reason for an elevation of the monocytes
during the recovery phase of infection.
16
The WBC's seen here are "atypical" lymphocytes. They are
atypical because they are larger (more cytoplasm) and have
nucleoli in their nuclei. The cytoplasm tends to be indented by
surrounding RBC's. Such atypical lymphocytes are often
associated with infectious mononucleosis.
17
WBC :Differential Count
EOS :
Eosinophils have an important role
in detoxification, disintegration and
removal of protein. Eosinophils are
commonly elevated in allergy sensitivity
and parasites.
18
WBC :Differential Count
BASO :
With inflammation, basophils deliver heparin to the effected
tissue to prevent clotting.
19
The nucleated
RBC in the
center contains
basophilic
stippling of the
cytoplasm. This
suggests a toxic
injury to the
bone marrow,
such as with lead
poisoning.
20
Differential diagnosis of Anemia (397)
Sickle Cell Disease:
22
This is sickle cell anemia in sickle cell crisis. The abnormal
hemoglobin SS is prone to crystallization when oxygen
tension is low, and the RBC's change shape to long, thin sickle
forms that sludge in capillaries, further decreasing blood flow
and oxygen tension. Persons with sickle cell trait
(Hemoglobin AS) are much less likely to have this happen.
23
Hereditary Spherocytosis:
24
Hypochromic Microcytic RBC
25
Microcytic Anemia (IDA)
26
VITAMIN B-12: (216)
FOLIC ACID: (105)
Pernicious anemia is the megaloblastic anemia caused by
malabsorption of Vitamin B12. This is usually caused by decreased
production of intrinsic factor, a substance essential to Vitamin B12
absorption, in the stomach. This test may also be performed as part
of the testing to determine the cause of nervous system disorders.
Folic acid (folate) is one of the "B" vitamins needed to metabolize
homocysteine.Vitamin B12, another B vitamin, helps keep folate in its
active form, allowing it to keep homocysteine levels low.
27
Megaloblastic anemia:
Vitamin B12/Folic acid deficiency
Second most common type of anemia.
Multi System disease – All organs with increased cell
division.
Macrocytic anemia, pancytopenia.
Pernicious anaemia –
autoimmune, Gastric atrophy,VitB12 def.
28
Macrocytic Anemia
(Megaloblastic):
29
Vitamin B12 Absorption
B12
Stomach
B12
IF
Parietal cells produce
Intrinsic Factor
IF
B12
IF
B12
Ileum IF receptors
B12 absorption
30
SCHILLING TEST
Assesses ability of terminal ileum to absorb vitamin B12
Oral preparation of vitamin B12 tagged with Co-57
Prior to this ‘normal vitamin B12 injection is given to facilitate excretion of
oral B12 administered
Test measures how much of this radioactive isotope is excreted in urine
May be given with Inrinsic factor as well to see if excretion in urine
increases.
In pernicious anemia patients
Without Intrinsic factor the excretion is less than7%
When given intrinsic factor tagged B12 is given the excretion rate is greater
then 7-20%
If both are low then it may suggest other cause for malabsorption
31
Anemia with high
Reticulocyte counts (186)
Differential diagnosis:
Bleeding – blood loss internal/external
Hemolysis – immune, mechanical, toxic, inf.
Laboratory evaluation
Blood film, nRBC, spherocytes, Parasites,
Retics.
Hemolysis – indirect Bilirubin, Haptoglobin,
Direct and indirect Coombs test
Hemoglobin electrophoresis, G6PD screen etc.
32
Anemia with Low MCV and
Low Retics
Differential diagnosis
Iron deficiency
Anemia of chronic disease
Laboratory evaluation
Serum Iron levels, iron-binding capacity, and ferritin
Blood smear – Micro/hypo, Pencil cells.
33
C.B.C
Haemoglobin - 15±2.5, 14 ±2.5 - g/dL
PCV - 0.47 ±0.07, 0.42 ±0.05 - l/dL (%)
Haematocrit, effective RBC volume - better
RBC count - 5.5 ±1, 4.8 ± 1 x1012/L
MCHC - Hb/PCV - 30-36 - g/dL
Hb synthesis within RBC
MCH - Hb/RBC - 29.5 ± 2.5 pg/L
Average Hb in RBC
MCV - PCV/RBC 85 ± 8 - fL
34
automated instrument data
35
Microcytic Hypochromic Report (398, 400)
36
The CBC here shows a markedly increased MCV, typical for
megaloblastic anemia. The MCV can be mildly increased in
persons recovering from blood loss or hemolytic anemia,
because the newly released RBC's, the reticulocytes, are
increased in size over normal RBC's, (399)
37
Anemia Screen (398-400)
IRON:
IRON BINDING CAPACITY:
PERCENT OF IRON SATURATION: Measurement of iron in serum.
FERRITIN:
TRANSFERRIN:
VITAMIN B-12:
FOLIC ACID:
38
Management of Oral Anticoagulant Therapy
Principles & Practice (98-99,488)
Coagulation and Fibrinolysis
Coagulation Factors
t-PA, Urokinase
Fibrinogen
Plasminogen
PAI-1
Fibrin
Plasmin
Lp(a)
Homocysteine
Cysteine
Fibrinolysis
Glutathione
40
Prothrombin Time (PT) (182)
Historically, a most reliable and “relied upon” clinical test
However:
Proliferation of thromboplastin reagents with widely varying sensitivities to
reduced levels of vitamin K-dependent clotting factors has occurred
Concept of correct “intensity” of anticoagulant therapy has changed significantly
(low intensity)
Problem addressed by use of INR (International Normalized Ratio)
41
INR: International Normalized Ratio
A mathematical “correction” (of the PT ratio) for differences in the sensitivity of
thromboplastin reagents
Relies upon “reference” thromboplastins with known sensitivity to antithrombotic effects of
oral anticoagulants
INR is the PT ratio one would have obtained if the “reference” thromboplastin had been
used
Allows for comparison of results between labs and standardizes reporting of the
prothrombin time
42
J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687
983.
INR Equation
(
)
Patient’s PT in Seconds ISI
INR =
Mean Normal PT in Seconds
INR = International Normalized Ratio
ISI = International Sensitivity Index
43
How Different Thromboplastins
Influence the PT Ratio and INR
Blood from
a single
patient
Thromboplastin
Reagent
Patient’s Mean
PT
Normal
PTR
(Seconds)
(Seconds)
A
16
12
1.3
B
18
12
1.5
C
21
13
1.6
D
24
11
2.2
E
38
14.5
2.6
ISI
INR
44
How Different Thromboplastins
Influence the PT Ratio and INR
Blood from
a single
patient
Thromboplastin
reagent
Patient’s Mean
PT
Normal
PTR
ISI
INR
(Seconds)
(Seconds)
A
16
12
1.3
3.2
2.6
B
18
12
1.5
2.4
2.6
C
21
13
1.6
2.0
2.6
D
24
11
2.2
1.2
2.6
E
38
14.5
2.6
1.0
2.6
45
Bone Marrow Maturation
46
47
Blood Group
Antigens
Antibodies
Can give
blood to
Can receive
blood from
AB
A and B
None
AB
AB, A, B, 0
A
A
B
A and AB
A and 0
B
B
A
B and AB
B and 0
0
None
A and B
AB, A, B, 0
0
48
Bleeding Disorders (408-409)
Hemophilia
Von Willebrand Disease (vWD)
Coagulation Process
Stage 1: Release of platelet factors to initiate clotting
Stage 2: Generation of Thromboplastin by other factors
Stage 3: Conversion of prothrombin to thrombin
Stage 4: Formation of fibrin from fibrinogen
50
Hemophilia
Hemophilia :Affects 18,000 in US
caused by deficiencies of either
clotting factor VIII or IX
Hemophilia A (factor VIII
deficiency), which affects about
80% of hemophilic patients, and
hemophilia B (factor IX
deficiency) > 30% normal value
Elevated PTT and
Normal PT and
Normal platelet count;
it is confirmed by specific factor
assays
Von Willebrand Disease
(vWD)
Most common bleeding disorder
affects 1-2% (more common in
women)
causes platelet dysfunction
Screening coagulation tests reveal :
normal platelet count;
normal INR;
prolonged bleeding time; and,
normal PTT
Diagnosis is based on low levels of
VWF antigen and abnormal ristocetin
cofactor activity.
.
51
PTT (168)
Partial thromboplastin time (PTT) screens plasma for abnormalities
in factors of the intrinsic and common pathways
A normal range of 28 to 34 sec is typical.
A normal result indicates that at least 30% of all coagulation factors
in the pathway are present in the plasma
prolongs the PTT, and the PTT is often used to monitor heparin
52
PT/INR
The PT screens for abnormalities in the extrinsic and common
pathways of coagulation
The PT screens for abnormalities in the extrinsic and common
pathways of coagulation
A typical normal range for the PT is between 10 and 13 sec. An INR >
1.5 or a PT ≥ 3 sec longer than a laboratory's normal control value is
usually abnormal and requires further evaluation.
53
A patient with a prolonged aPTT and a normal PT is considered to have a defect in the
"intrinsic" coagulation pathway.
A patient with a prolonged PT and a normal aPTT has a defect in the "extrinsic"
coagulation pathway (tissue factor is "extrinsic" to the plasma).
Prolongation of both the aPTT and the PT suggests that the defect lies in a common
pathway.
54