Making the most out of the CBC Making the most out of the CBC and - - PowerPoint PPT Presentation

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. Pediatric Hematology-Oncology gy gy University of Kentucky College of Medicine

jdorazio@uky.edu

• bjectives
• bjectives
• Understand the clinical information that a complete blood
• bjectives
• bjectives
• Understand the clinical information that a complete blood

count (CBC) contains and how to get the most information

• ut 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 – 40% outpatient 60% inpatient

(Compared to ~1,000 chemistry panels per day)

p p

• Directed test for blood disorders
• Screening test for systemic diseases

Advia 2120 Hematology Analyzer

What comes with a CBC?

L f i f i b ll l bl d l Lots of information about cellular blood elements:

• Total number
• Composition
• Absolute numbers
• Total number
• Average size
• Amount of RBC’s
• Average size
• Amount of hgb in each
• Absolute numbers
• f each type
• Amount of hgb in each
• Uniformity of size

Di d M l i Diamond‐ Blackfan anemia TTP Iron deficiency S i ALL Pertussis Mononucleosis Fanconi Anemia Eosinophilia Autoimmune hemolysis Sepsis ALL HUS Thrombocytopenia AML Folate B12 Neutropenia y Immunodeficiency Chronic Hereditary Spherocytosis CML Folate, B12 deficiency Steroid use HIV infection Aplastic Anemia Chronic inflammation DIC Bernard‐Soulier syndrome Hemolytic Uremia Syndrome Hypoxia, polycythemia Steroid use HIV infection ITP Alloimmune thrombocytopenia Wiskott‐Aldrich Myelodysplasia Allergy

The CBC is one of the most commonly used i i di i screening tests in medicine

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?

A d CBC l k b d i i

• Automated CBC analyzers work by determining

light scattering profiles of individual blood cells

C ll D 4000 d h t l l Cell Dyn 4000 modern hematology analyzer, Abbott Laboratories, Chicago, IL

Hemoglobin (Hgb) g ( g )

• The oxygen‐carrying molecule in RBC’s
• Measured as grams per deciliter (g/dL) of

whole blood. d f l b

• Tetramer comprised of 4 globin proteins

and an iron‐containing heme moiety. Hemoglobin Alpha globin Beta globin Hgb A (adult) 2 2

2 2

Hgb A2 2 δ2 H b F (f t l) Hgb F (fetal) 2 γ2

Almost all analyzers calculate hemoglobin by the hemoglobin by the cyanomethemoglobin method.

Drabkin’s reagent 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 "crit" tubes are fragile and dangerous to use spun Air – Since crit tubes are fragile and dangerous to use, spun hematocrits are rarely used today.

• The automated hematology analyzer calculates the Hct from

Plasma The automated hematology analyzer calculates the Hct from the RBC and MCV by the following formula: Hct (%) = RBC x MCV Plasma Buffy coat (WBC) In general, hematocrit = 3x hemoglobin – Since the Hct is a calculated value, it is less accurate than Hematocrit (RBC) , hemoglobin Clay plug

Mean Corpuscular Volume (MCV) p ( )

• Average size of RBC’s
• “Normal” varies with age

– Elevated MCV = RBC’s larger than normal – For adults = 80‐94 fL – < 10 y/o, lower limit of l 70 fL + ( )

• “macrocytosis”

– Decreased MCV = RBC’s smaller normal = 70 fL + age (yrs) – Infants: much higher MCV’s – Decreased MCV = RBC s smaller than normal

• “microcyosis”

MCV s

• microcyosis

– Normal MCV = RBC’s “just right”

• “normocytosis”

Key y Concept

To make a proper RBC, there must be coordination p p , between proliferation of RBC precursor cells and hemoglobinization of maturing RBC’s

Hematopoeitic Mature

• - - 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. 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.

Problems with Problem with DNA Problems with Hemoglobin Production Synthesis

Iron B12 deficiency Marrow failure Iron Deficiency ↓ Globin (thalassemia) Folate deficiency Hydroxyurea y Hydroxyurea,

Chemo

Red cell distribution width (RDW) Red cell distribution width (RDW)

• quantitative measure of variation

q in red blood cell size (anisocytosis)

l RDW i 11 5 14 5 % – normal RDW range is 11.5 ‐ 14.5 %

• Nutritional anemias → high RDW’s

– Day‐to‐day variation in diet

I h it d i → l RDW’

• Inherited anemias → low RDW’s

– Fixed genetic lesion affecting hematopoiesis all the time

MCV and RDW

Normal Normal

Microcytosis Microcytosis

(cells) (cells)

• a

Microcytosis Low RDW (Thalassemia) Microcytosis High RDW (Fe deficiency)

Events Events RBC Size RBC Size ells)

Normal

ells)

Normocytosis Macrocytosis (Folate or B12)

Normal

Events (ce Events (ce RBC Size RBC Size

“Mentzer Index” Mentzer Index

William Mentzer, M.D. Pediatric Hematology/Oncology Professor Emeritus, UCSF

• helps differentiate whether microcytic anemia is

caused from iron deficiency or from thalassemia

Professor Emeritus, UCSF

caused from iron deficiency or from thalassemia.

Mentzer Index = MCV  RBC count Mentzer Index MCV  RBC count

< 11 > 13

Mentzer WC, 1973, "Differentiation of iron deficiency from thalassaemia trait". Lancet 1 (7808): 882.

thalassemia Fe deficiency

production destruction

Circulating red cell mass represents a balance between cellular production and destruction

To determine whether there is impaired RBC production or

cellular production and destruction.

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’s in the cytoplasm of RBC s

• Ribosomes persist in RBC’s for 24‐48h after

leaving the marrow g

– ongoing Hgb synthesis

• Reticulocytes are young red blood cells only

Reticulocytes are young red blood cells only 1‐2 days removed from the marrow.

• Why is the retic count normally ~1%?

y y

– Normal RBC life‐span ~ 120d – Each day the body must replace 1 ÷ 120 = ~1% Each day the body must replace 1 120 1%

• f the red cell mass

Reticulocyte Index Reticulocyte Index

M i f ti th j t th ti t M i f ti th j t th ti t

• More informative than just the retic count.
• Corrects for abnormal hematocrit.
• More informative than just the retic count.
• Corrects for abnormal hematocrit.

(A t l H t)

< 2% 2%

= Reticulocyte index (Percent reticulocytes) x (Actual Hct) (Normal Hct)

< 2% > 2%

Production problems Destruction problems

• Hypoproliferative Anemias

– Nutritional (iron, folate, B12) – Anemia of inflammation

• Hemolysis

– Immune‐mediated – Hemoglobinopathies

• Erythropoeitin defect
• Bone marrow failure
• Bone marrow infiltration

– Membranopathies – RBC metabolic abnormalities

• Blood loss

Bone marrow infiltration

• RBC maturation abnormality
• Mechanical RBC destruction

Clues to reticulocytosis on a CBC

Anemias, deconstructed… Anemias, deconstructed…

Mi ti N ti M ti

Picasso: Girl Before a Mirror, 1932

Microcytic (low MCV) Normocytic (MCV nl. for age) Macrocytic (high MCV) Underproduction (low retic’s*)

*for degree of anemia

• Iron deficiency
• Lead poisoning
• Anemia of inflammation
• TEC
• Viral suppression
• Bone marrow failure
• MDS
• Megaloblastic anemia
• DBA

for degree of anemia

RBC destruction

• Thalassemia
• Membrane disorders
• Hemoglobinopathies
• Enzymopathies
• Immune-mediated

(high retic’s)

• Thalassemia
• G6PD deficiency
• Microangiopathy
• Blood loss

hemolysis

Automated WBC Differential

• Histogram analysis of WBC’s
• each "dot" represents data from a

single cell.

• Each type of WBC displays a

ll size) monocytes neutrophils y y characteristic size and granularity

• In this case:
• 65 6% Neutrophils

scatter (ce

• 65.6% Neutrophils
• 26.2% Lymphocytes
• 5.6% Monocytes

Forward s eosinophils basophils lymphocytes y

• 2.2% Eosinophils
• 0.4% Basophils

Side scatter (cellular complexity) lymphocytes

CBC’s at UK

• Pretty much all CBC’s start with analysis by an automated

Pretty much all CBC s start with analysis by an automated CBC analyzer.

• ~75% of CBC’s have an automated differential only.

75% of CBC s have an automated differential only.

– Clue to automated differential = reported % with tenths values.

Neutrophils 54 8% Neutrophils 55% Neutrophils 54.8% Lymphs 23.6% Monocytes 15.2% Eosinophils 4.3% Basophils 2.1% Neutrophils 55% Lymphs 24% Monocytes 15% Eosinophils 4% Basophils 2%

• If the automated analysis picks up certain “flags”, then the

CBC i i k d f l b h H h

Automated Differential Manual Differential

CBC is ticked for a manual assessment by the Heme techs.

Nucleated RBC’s Blast forms High WBC (> 50 000) Platelet count < 30,000 Immature neutrophils (> 50,000) Abnormal Macrocytosis Abnormal Absolute monocyte count Absolute lymphocyte count Variant lymphocytes Marked Anisocytosis Certain RBC Pl t l t Low MCV Morphology Abnormalities Platelet clumps

Bottom line Bottom line…

• Today’s automated hematology analyzers are very good for most

routine applications, but they’re not perfect. A d CBC’ ’ li bl d ib h l h l f

• Automated CBC’s can’t reliably describe the actual morphology of

WBC’s or RBC’s

– Machines can “flag” certain RBC or WBC abnormalities (e.g. 2+ anisocytosis) g ( g y )

• If the diagnosis that you are considering correlates with a specific WBC
• r RBC morphology, then order a manual slide review.

– Leukemia (blasts) – RBC membrane disorder (spherocytes)

Lik i if th CBC d ’t “fit” ith th li i l i t th

• Likewise, if the CBC doesn’t “fit” with the clinical picture, then more

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’s Heme techs are excellent and reliable
• Clinical Lab s 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. Spherocytes 2 Polychromasia 2. Polychromasia 3. Sickled forms 4. Nucleated RBC’s

Describe those RBC’s! Describe those RBC s!

Just look at all that variation in red cell size!

1. Poikilocytosis 2 Polychromasia 2. Polychromasia 3. Anisocytosis 4. Target Forms g

Describe those RBC’s! Describe those RBC s!

I say! Have you ever seen such differences in red cell shape?!

1. Polychromasia 2 Anisocytosis 2. Anisocytosis 3. Poikilocytosis 4. Target Forms g

Describe those RBC’s! Describe those RBC s!

Which term best describes this smear? Which term best describes this smear?

1. Schistocytes 2 Sickled Forms 2. Sickled Forms 3. RBC Stippling 4. Spherocytes

The spleen: final resting place for many

p y

g p y a spherocyte…

Describe those RBC’s! Describe those RBC s!

S hi b k d ll f Schistocytes are broken red cell fragments that form with microangiopathy and abnormal shearing.

1. Sickled Forms 2 Schistocytes 2. Schistocytes 3. Reticulocytosis 4. Spherocytes p y

Describe those RBC’s! Describe those RBC s!

Did someone mention targets?! This patient might have hemoglobin C!

1. Polychromasia 2 Anisocytosis 2. Anisocytosis 3. Poikilocytosis 4. Target Forms g

Name that Cell! Name that Cell!

B C ll T C ll B Cells, T Cells and NK Cells, Oh My!

• 1. Monocyte
• 2. Lymphocyte
• 3. Neutrophil
• 4. Blast

Name that Cell! Name that Cell!

1. Neutrophil 2. Eosinophil 3. Granular Lymphocyte 4. Basophil

Finding basophils in the peripheral g p p p 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. Neutrophil 2. Monocyte 3. Eosinophil 4 hil 4. Basophil

Name that Cell! Name that Cell!

1. Band 2. Monocyte 3. Lymphocyte 4. Basophil

Now THAT’s a fine band!

Name that Cell!

Hey look‐ it’s a little neutrophil

1. Neutrophil

p smiley face!

2. Monocyte 3. Eosinophil 4 hil 4. Basophil

Name that Cell! Name that Cell!

Prepare to be phagocytized!

• 1. Neutrophil
• 2. Monocyte
• 3. Lymphocyte
• 4. Basophil

Name that Cell! Name that Cell!

• 1. Monocyte

y

• 2. Band
• 3. Reactive lymphocyte
• 3. Reactive lymphocyte
• 4. 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.

5 8 6.1 478 5.8 17.9 478

MCV: 57 fL P46 L38 M12 E4 RDW: 23 % MCHC: 32 fL P46,L38,M12,E4 Retic: 1.3%

• Pallor seems to have developed gradually.
• No jaundice, no dark urine, no fevers

P l b t ll i l f l

• Pale but well-appearing, playful
• No organomegaly

Toddler with pallor.

5.8 6.1 17.9 478 MCV: 57 fL

25% 25% 25% 25%

P46,L38,M12,E4 MCV: 57 fL Retic: 1 3% RDW: 23 % MCHC: 32 fL Retic: 1.3%

Which Which diagnosis is diagnosis is most likely? most likely?

1. Iron deficiency anemia 2. Thalassemia a asse a 3. Vitamin B12 deficiency 4. Autoimmune hemolysis

1 2 3 4

4 y/o immigrant from Nigeria.

7.7 10.8 21.8 423

MCV 83 fL P61,L28,M8,E3 MCV: 83 fL RDW: 19.1 % 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.

10.8 7.7 21.8 423 MCV: 83 fL

25% 25% 25% 25%

P61,L28,M8,E3 MCV: 83 fL Retic: 9.3% RDW: 19.1 %

25% 25% 25% 25%

Which Which diagnosis is diagnosis is most likely? most likely?

• 1. Trypanosomiasis
• 2. G6PD deficiency
• 3. Thalassemia
• 4. Sickle Cell Disease

1 2 3 4

4 y/o with widespread bruising.

5 8 12.1 3 5.8 35.8 3

MCV: 87 fL

60 28 6 2 4

RDW: 12.3 % MCHC: 34 fL P60,L28,M6,E2,Atyp4 Retic: 1.3% 1. No family history of bruising/bleeding. 2. Normal medical history. 3 N i d bl di i h l i i i 3. No increased bleeding with neonatal circumcision. 4. Petechiae and purpura appeared suddenly overnight.

4 y/o with widespread bruising.

5.8 12.1 35.8 3

25% 25% 25% 25%

P60,L28,M6,E2,Atyp4 MCV: 87 fL R ti 1 3% RDW: 12.3 % MCHC: 34 fL

25% 25% 25% 25%

Retic: 1.3%

Which dia Which diagnosis is nosis is most likel most likely? y? g y g y 1. Acute Leukemia 2. Idiopathic Aplastic Anemia 3. Child abuse 4. ITP (Primary autoimmune thrombocytopenia)

1 2 3 4

y p )

Teenager with Crohn’s disease and pallor. 2 8 6.7 110 2.8 19.8 110

MCV: 107 fL P41,L48,M9,E2 Retic: 2 3% RDW: 19.1 %

• Diagnosed 4 years prior with IBD

Retic: 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

25% 25% 25% 25%

MCV: 107 fL Retic: 2.3% RDW: 19.1 %

25% 25% 25% 25%

Which Which diagnosis is diagnosis is most likely? most likely?

1 M l l k i

• 1. Myelogenous leukemia
• 2. Steroid effect

3 L h

• 3. Lupus erythematosus
• 4. Vitamin B12 deficiency

1 2 3 4

Child in ICU with thrombocytopenia

8 5 10.1 48 8.5 29.4 48

MCV: 87 fL Retic: 3.2% P64,L26,M8,E2 MCV: 87 fL

• Admitted yesterday with high fevers and obtundation.

Bl d lt iti f ti d

• Blood culture positive for gram-negative rods.

Child in ICU with thrombocytopenia

8.5 10.1 29 4 48

25% 25% 25% 25%

29.4 P64,L26,M8,E2 MCV: 87 fL Retic: 3.2%

25% 25% 25% 25%

P ,L ,M ,E

Which Which diagnosis is diagnosis is most likely? most likely? 1. Endocarditis 2. Disseminated intravascular coagulation (DIC) coagulation (DIC) 3. Sickle cell anemia 4. Dehydrated red cells

1 2 3 4

5 y/o with fever, pallor and bruising

133.8 8.1 23.9 47

25% 25% 25% 25%

23.9 MCV: 79fL RDW: 13 % MCHC 33 4 fL

25% 25% 25% 25%

Retic: 0.4% MCHC: 33.4 fL

1. Sepsis 2. Viral infection 3. Acute leukemia 4 I fl t

1 2 3 4

4. Inflammatory response

9 y/o with abdominal cramping.

25% 25% 25% 25%

1. Helminth infection 2. Lactose intolerance 3. Clostridium difficile colitis 4. Irritable bowel syndrome

1 2 3 4

4. Irritable bowel syndrome

Another toddler with pallor

6 8 7.1 348 6.8 21.9 348

MCV: 57 fL P54 L28 M17 E1 RDW: 11 % MCHC: 32 fL P54,L28,M17,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

25% 25% 25% 25%

P54,L28,M17,E1 MCV: 57 fL Retic: 10.3% RDW: 11 % MCHC: 32 fL

25% 25% 25% 25%

%

Which Which diagnosis is diagnosis is most likely? most likely? 1. Iron deficiency anemia 2. Thalassemia 3. Chronic renal failure (EpO deficiency) 4. Anemia of inflammation

1 2 3 4

4. Anemia of inflammation

2 y/o with pneumococcal sepsis

6 8 12.1 498 6.8 36.9 498

MCV: 81 fL P65 L23 M11 E1 RDW: 12 % MCHC: 34 fL P65,L23,M11,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

25% 25% 25% 25%

P65 L23 M11 E1 MCV: 81 fL RDW: 12 % MCHC: 34 fL

25% 25% 25% 25%

P ,L ,M ,E

Which Which diagnosis is diagnosis is most likely? most likely? 1. Common variable immunodeficiency 2. HIV infection - AIDS 3. Asplenia 4. Congenital neutropenia

1 2 3 4

7 y/o with pallor.

8 3 5.1 401 8.3 15.4 401

MCV: 103 fL P32 L48 M14 E2 nRBC4 RDW: 26 % MCHC: 34.3 fL P ,L ,M ,E ,nRBC 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
• Hyperdynamic precordium with III-IV/VI systolic murmur.
• No organomegaly.

7 y/o with pallor.

8.3 5.1 15.4 401

25% 25% 25% 25%

P32,L48,M14,E2,nRBC4 MCV: 103 fL RDW: 26 % MCHC: 34.3 fL

25% 25% 25% 25%

, , , , Retic: 34.5%

Which dia Which diagnosis is nosis is most likel most likely? y? g y g y 1. Autoimmune hemolytic anemia 2. Disseminated intravascular coagulation (DIC) 3. Acute Leukemia

1 2 3 4

4. Folic acid deficiency

6 y/o with splenomegaly.

8 1 5.5 8.1 24.4 288

Retic: 8.2% P44 L46 M8 E2 MCV: 87 fL Retic: 8.2% MCHC: 36 Direct Coomb’s: negative P ,L ,M ,E

• Child is asymptomatic
• Splenomegaly appreciated on routine exam by an apt clinic resident

Ph t th b

• Phototherapy as a newborn
• Mother with history of cholecystectomy as a teenager

6 y/o with splenomegaly.

5.5 8.1 24 4 288

25% 25% 25% 25%

24.4 P44 L46 M8 E2 MCV: 87 fL Retic: 8.2% MCHC: 36

25% 25% 25% 25%

Coomb’s neg P44,L46,M8,E2

Wh Whic ich dia diagnosis is sis is most li st like kely? y? Wh Wh h g o

• ke

ke y

1. B‐thal trait 2 G6PD deficiency 2. G6PD deficiency 3. Hereditary spherocytosis 4. Storage disease (Gaucher’s)

1 2 3 4

18 month old well child with anemia

7 6 5.3 248

25% 25% 25% 25%

7.6 14.4 248

MCV: 89 fL Retic: 0.2% 25% 25% 25% 25% P49,L41,M9,E1 MCV: 89 fL RDW: 13.3 ESR: 6 sec 1 Iron deficiency 1. Iron deficiency 2. Folate deficiency 3. Transient erythroblastopenia of hildh d (TEC)

1 2 3 4

childhood (TEC) 4. Aplastic Anemia

Teenager with low-grade fevers, malaise and splenomegaly

25% 25% 25% 25% 25% 25% 25% 25%

1 Acute myelogenous leukemia 1. Acute myelogenous leukemia 2. Infectious mononucleosis (EBV) 3. Systemic lupus erythematosus 4 Histiocytosis

1 2 3 4

4. Histiocytosis

Teenager with fevers, recently back from a mission trip.

10.7 11.2 32.9 448

25% 25% 25% 25%

MCV: 83 fL RDW: 15 % MCHC: 34 fL

25% 25% 25% 25%

Retic: 2.3%

1. Sleeping sickness 2. Liver fluke infection 3. Malaria 3. Malaria 4. Chagas disease

1 2 3 4

School-age child with bruising and low- grade fever grade fever

28 4 8.3 52

25% 25% 25% 25%

28.4 24.7 52 MCV: 91 fL RDW: 13 %

25% 25% 25% 25%

Retic: 1.7% MCHC: 33.4 fL

1. Acute myelogenous leukemia y g 2. Reactive left shift 3. ITP 4 Listeria infection

1 2 3 4

4. Listeria infection

8 y/o girl with swollen cervical lymph node

25% 25% 25% 25% 25% 25% 25% 25%

1. Lymphoma 2. Atypical bacterial infection 2. Atypical bacterial infection 3. Mumps infection 4. An amazing shot of all the major normal WBC’s in the same field

1 2 3 4

Take home

• The CBC and peripheral blood smear
• ffer a wealth of information regarding

g g pathophysiology.

– Heme/onc diagnoses – Atopy, Rheumatology – Infectious disease

“John always review the

– Others

Th i b fit t i i bl d

John, always review the primary data yourself…”

• There is benefit to reviewing blood

smears yourself, especially in difficult

• r challenging cases
• r challenging cases.

Howard Weinstein, MD Chief, Pediatric Hematology/Oncology, MGH

Or ask your friendly hematologist for help!

jdorazio@uky.edu; 323‐6238

What the !@#$ are they talking about?

• Polychromasia,

Polychromatophilia

RBC’s of different staining color, implies reticulocytosis

y p

• Poikilocytosis

RBC’s of different shape, mixed population (old + transfused cells) RBC’s of different size;

• Anisocytosis
• Schistocytosis

RBC s of different size; reticulocytosis, high RDW RBC fragments, microangiopathic processes (DIC), shearing

• Elliptocytes, Ovalocytosis
• Drepanocytosis

RBC’s look elliptical, membranopathy Sickle cell forms Hgb S disease

• Drepanocytosis
• Spherocytosis

Sickle cell forms, Hgb S disease No central pallor in rbc’s; HS or AIHA

• Howell‐Jolly bodies

Functional asplenia

Acanthocytes Schistocytes Spherocytes y y p y Echinocytes Elliptocytes Drepanocytes Target cells Stomatocytes Poikilocytes

Decreased Increased Neutrophils

• Kostmann’s syndrome
• Cyclic neutropenia
• Infections
• Tissue destruction

y p

• Bone marrow failure
• Leukemia
• Autoimmune neutropenia
• Benign neutropenia of childhood
• Corticosteroids
• Leukemoid reaction
• GCSF administration

g p

• Infection/sepsis
• Drug‐induced (Bactrim, chemotherapy)
• Myelodysplasia

Lymphocytes

• Congenital immunodeficiency
• Severe infection
• Drugs (Corticosteroids alkylating)
• Viral infection (e.g. EBV)
• Some fungal, parasitic infections
• Rare bacterial infection (Pertussis)

Drugs (Corticosteroids, alkylating)

• GI disease
• Acquired Immunodeficiency

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
• Parasitic infections
• Allergic conditions

ACTH administration Allergic conditions

• Drug therapy

Basophils

• Corticosteroids
• Bone marrow failure
• Myeloproliferative syndromes

Normal blood cells Normal blood cells

band monocyte l t l t lymphocyte platelet neutrophil eosinophil basophil

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 of Hgb inside each RBC

g g

• High MCH’s go along with large

(macrocytic) RBC’s

• Low MCH’s correlate with microcytosis

and anemias caused by impaired Hgb th i synthesis.

Mean corpuscular hemoglobin i (MCHC) concentration (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’s concentrated inside RBC s

• Spherocytosis
• Abnormal Hgb (S, C)

If MCHC 35 fL thi k h t ! g ( , )

• Severe burns

If MCHC > 35 fL, think spherocytes!

crit (%) hematoc

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 1 y/o with pallor

8 2 8.2 351

25% 25% 25% 25%

8.2 23.9 351 MCV: 71 fL RDW: 18.4 %

25% 25% 25% 25%

Retic: 2.6%

1. Lead poisoning 2 Malaria 2. Malaria 3. Babesiosis 4. Hemoglobin C disease

1 2 3 4

Febrile infant with pancytopenia

25% 25% 25% 25% 25% 25% 25% 25%

• 1. Lysosomal storage disease
• 2. Histoplasmosis
• 3. Chronic Granulomatous

Disease (CGD) 4 P l i

1 2 3 4

• 4. Pneumococcal sepsis

12 y/o with fever, bruising and pallor. 12 y/o with fever, bruising and pallor.

25% 25% 25% 25% 25% 25% 25% 25%

1. Candidal infection 2. Histoplasmosis 3 Burkitt’s lymphoma/leukemia

1 2 3 4

3. Burkitt s lymphoma/leukemia 4. Gaucher’s disease

Albino child with frequent infections. Albino child with frequent infections.

25% 25% 25% 25% 25% 25% 25% 25% 1. Abetaproteinemia 2. Tyrosinase neutropenia 3 Chronic granulomatous disease

1 2 3 4

3. Chronic granulomatous disease 4. Chediak-Higashi syndrome

This is not a staining artifact! This is not a staining artifact!

25% 25% 25% 25% 25% 25% 25% 25%

1 Obstructive liver disease

• 1. Obstructive liver disease
• 2. Abetalipoproteinemia
• 3. Thalassemia

1 2 3 4

• 4. Severe burns

Common Sources of Error for Automated CBC machine

Cryoproteins Heparin Giant platelets Clotting Smudge cells Carboxyhemoglobin Heparin Nucleated RBCs Uremia Hyponatremia Agglutination DIC Platelet clumping WBC count >50,000/μL Hemolysis Medications RBC inclusions DIC Medications Hyperbilirubinemia Lipemia RBC inclusions Excess EDTA p Hyperglycemia Infections

Anemia: not enough red cells.

I d t i h l bi it Inadequate oxygen-carrying hemoglobin capacity

Howell jolly bodies Howell jolly bodies

Sickle cell disease Sickle cell disease

Elliptocytes Elliptocytes

Elliptocytes (ovalocytes) : elongated RBC

• Large number (up to 100%) is the

hallmark of hereditary elliptocytosis 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

Stomatocytes : folded RBC leading to an aspect mimicking a mouth and its lips (slit- like appearance) like appearance)

• Many situations, including hemolytic

anemias, either constitutive or acquired

Cold agglutinin disease Cold agglutinin disease

Cold agglutinin disease ; aggregates Cold agglutinin disease ; aggregates disappear after the sample is warmed at 37°C

echinocytes echinocytes

Echinocytes or crenated or contracted 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 enzymatic disorders

• Acute renal failure

Rouleaux formation, myeloma Rouleaux formation, myeloma

Rouleaux formation: RBC do not stick to 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 gammopathies with excess of monoclonal immunoglobulin (does not

• ccur in light chain myeloma)

Acanthocytes : crenation is limited (3 to 12 i ) 12 spines or spurs) Hereditary acanthocytosis (abetalipoproteinemia) Liver diseases (cirrhosis) with dyslipidemia (c

• s s)

t dys 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 th i synthesis

• Thalassemic syndromes (including

thalassemic trait)

• Sideroblastic anemias (lead, drugs,

( , g , idiopathic)

• Agnogenic myeloid metaplasia
• Newborn (stippling is delicate)

babesia babesia

plasmodium plasmodium

Cabot rings Cabot rings

Cabot rings : remnants of the Cabot rings : remnants of the mitotic spindle, appearing as purple rings or loops within RBC All j d h i i ‐ All major dyserythropoietic changes

Papenheimer bodies Papenheimer bodies

Pappenheimer bodies : small dark RBC inclusions ; usually one to three within the ; y cell, they are located near the periphery of the cytoplasm

• All dyserythropoietic states lead to their

production and number may raise sharply production, and number may raise sharply (up to 100% of RBC) in splenectomized or asplenic patients