1INTERPRETING BLOOD COUNTS Contents 1. 2. 3. 4. 5. 6. 7. 8.

The counting machine The blood film How to look at the blood count Normal hemoglobin and MCV values A diagnostic scheme for anemias Microcytic Anemia Macrocytic Anemia Normocytic Anemia 9. Recognizing hemolysis 10. Leukocytes and platelets 11. Glossary of terms (http://meds.queensu.ca/medicine/dept med/hemonc/anemia/handout.htm) 12. Additional Investigations (http://meds.queensu.ca/medicine/dept med/hemonc/anemia/handout.htm) 13. QUIZ (http://meds.queensu.ca/medicine/dept med/hemonc/anemia/Quiz/eric/anemia_ quiz.swf)

1. The blood counting machine will measure the a. amount of hemoglobin per unit volume (Hb g/L) b. number of red blood cells per unit volume (RBC x 1012/L) c. size of the red blood cells (MCV fL) d. number of white blood cells per unit volume (WBC x 109/L) e. number of platelets per unit volume (platelets x 109/L) f. differential WBC if no abnormal cells are present (absolute numbers of the various white blood cells) g. reticulocyte count (x 109/L the number of young [<48 h] red cells) 2. The blood film Microscopic examination of the blood film gives information about the appearance of the blood cells, and a differential WBC even in the presence of abnormal white cells 3. How to look at the blood count a. Concentrate on the Hb, MCV, WBC, and Platelets. If all four are normal, then significant blood disease is unlikely to be present b. If the Hb is low LOOK AT THE MCV and the reticulocyte count c. Examine the differential d. Read the report on the blood film 4. Normal hemoglobin values The patients Hb and MCV must be compared with the correct reference population for that patient (fortunately the laboratory reports the relevant reference ranges) Hemoglobin values relative to an adult female Group Neonates Children and younger teens Adult males Elderly both sexes
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Hemoglobin High: falls over 3-6 months Low Higher by about 20 (testosterone) Often lower without obvious illness

MCV High: falls over 3-6 months Low Normal Normal

5. Figure 1: a diagnostic scheme for the anemias based on red cell size

6. The Microcytic Anemias The most important causes are a. Iron deficiency b. Hemoglobinopathies, especially thalassemia c. The 'anemia of chronic disease' (some cases only) The easiest way to sort these out is to measure the serum ferritin. In uncomplicated iron deficiency, the ferritin is low. In other microcytic anemias the ferritin is normal. Unfortunately, when iron deficiency is accompanied by some other chronic disease process (e.g. rheumatoid arthritis), the serum ferritin may be spuriously normal. The 'gold standard' for the assessment of iron stores is the bone marrow aspirate, but this is rarely necessary. 7. The Macrocytic Anemias These may be classified into (a) Megaloblastic: the bone marrow has a specific morphological abnormality called megaloblastosis. Its presence usually indicates a deficiency of either vitamin B12 or folic acid. (b) Non-megaloblastic: Alcohol, liver disease, and myelodysplasia are common examples 8. The Normocytic Anemias
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Think in terms of pathophysiology (a) Underproduction of erythrocytes: (Reticulocytes low) i. the anemia of chronic disease ii. marrow failure iii. renal failure (decreased erythropoietin) (b) Loss or destruction of erythrocytes with increased marrow output (Reticulocytes high) i. hemolysis ii. blood loss (acute only) 9. Recognizing hemolysis a. raised reticulocyte count b. decreased serum haptoglobin concentration c. raised Lactate Dehydrogenase (LDH) d. blood film may show specific abnormality (e.g. spherocytes or fragments) 10. Leukocytes and platelets For any change in either the WBC or platelets, consider 2 possibilities, a primary bone marrow problem, versus a reactive increase or destructive decrease Problem Increased leukocytes Decreased leukocytes Increased Platelets Decreased platelets Primary Marrow Disorder Leukemia etc Marrow failure syndromes e.g. myelodysplasia Myeloproliferative disorder e.g. P vera Marrow failure syndromes e.g. myelodysplasia Additional findings Abnormal WBC (e.g. blasts) Pancytopenia is usual Giant and abnormal platelets Pancytopenia is usual Reactive or Destructive infection, neoplasia, inflammation Infection, hypersplenism infection, bleeding, neoplasia, inflammation Immune thrombocytopenia Additional findings Neutrophils increased, toxic and left-shifted Often none May be neutrophilia and left shift None

11. Glossary of Useful Blood Count Descriptors (see website for atlas) a. Anisocytosis: red cells of unequal size. Reflected in increased RDW (Red cell Distribution Width) b. Band cell: the stage of neutrophil maturation immediately before full maturity. Named after the shape of its nucleus. Appears in the blood during infections, and other marrow 'stress' c. Blast Cell: early committed marrow precursor of mature red and white cells. This cell accumulates in the marrow in acute leukemia, and may appear in the blood in large numbers. d. Dimorphic Blood Film: two populations of red cells - one microcytic and the other normocytic. Seen in treated or transfused iron deficiency, and sideroblastic anemia e. Erythroblast: any nucleated red cell precursor f. Granulocyte: collective term for neutrophils, eosinophils and basophils (all have granules in their cytoplasm) g. Howell-Jolly bodies: round nuclear remnants within the red cells. Indicate splenectomy or hyposplenism
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h. i. j. k. l. m. n. o. p. q. r. s. t.

u. v. w. x. y.

Hypersegmented neutrophils: a neutrophil with six or more lobes. Usually (but not inevitably) means vitamin B12 or folate deficiency Hypochrom(as)ia: pale red cells. Always accompanied by microcytosis Left Shift: the presence of slightly immature granulocytes (e.g. bands and metamyelocytes), suggesting infection Leukoerythroblastic: the presence in the peripheral blood of erythroblasts and myelocytes (which are precursors of mature cells) in the blood. Often indicates marrow infiltration e.g. by secondary cancer, or fibrosis Macrocytosis: large red cells Microangiopathy: indicates mechanical damage to red cells with red cell fragments on the blood film Microcytosis: small red cells Metamyelocyte: the stage of neutrophil maturation immediately before the band cell. Appears in the blood during infections, and other marrow 'stress' situations Myelocyte: a white cell precursor. A component of the 'leukoerythroblastic' blood film Pancytopenia: a reduction in all the formed elements of the peripheral blood. Often indicates marrow failure Poikilocytosis: a traditional term for red cells of unequal shape Polychromasia: grey coloured red cells on film, indicating presence of increased reticulocytes Reticulocyte: an erythrocyte newly released from the bone marrow, identifiable by a network or 'reticulum' of RNA in its cytoplasm (a special stain is needed to show this). After about 48 h, this RNA disappears. An increased absolute number of reticulocytes indicates increased marrow erythropoiesis. Rouleaux: red cells in stacks, as coins. Indicates high ESR, e.g. infection, myeloma, cancer, collagen disease etc. Schistocyte: a red cell which has undergone mechanical damage - synonymous with red cell fragment Spherocyte: a spherical red cell due to disproportionate membrane loss. Either inherited, or acquired from (usually) immune causes Sickle cell: a crescent-shaped red cell characteristic of Sickle Cell Anemia Target cell: red cell with central area of Hb giving the appearance of a target. Seen in many conditions, including hemoglobinopathy and liver disease

12. Additional Investigations a. Serum iron: reduced in iron deficiency, and in infections, inflammations, and malignant disease. Not very useful in the diagnosis of iron deficiency. Always used with a measurement of 'Total Iron Binding Capacity' (see below) b. Total Iron Binding Capacity (TIBC). The total quantity of iron which the plasma can bind. Reflects the concentration of serum transferrin. Raised in iron deficiency, but low in infections, inflammations and malignant disease c. Serum ferritin: reflects total body iron stores, except in the presence of liver disease or acute inflammation d. Serum vitamin B12: low in vitamin B12 deficiency. Commonly low in the elderly, and significance unclear, but should not be ignored e. Serum folate: used to diagnose folate deficiency: in the past, erythrocyte folate was recommended as a better test, but now we know that the serum folate (an easier test) is sufficient for clinical purposes f. Direct and indirect bilirubin: the increased load of bilirubin from hemolysis is unconjugated (indirect) and does not appear in the urine. A raised indirect bilirubin indicates either an increased load of bilirubin, or hepatocellular dysfunction.
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Serum haptoglobin: this is a heme binding protein. It mops up free heme in the circulation, and the complex is then cleared by the RE system. A low haptoglobin indicates hemolysis (of any cause), or liver cell failure (low synthesis). Bone marrow aspirate and biopsy: these are used to diagnose primary hematological and marrow conditions e.g. leukemia, secondary cancer, myeloma etc. Hemoglobin electrophoresis: used to diagnose hemoglobinopathy. A solution of hemoglobin is prepared from the red cells, and analysed by electrophoresis. Abnormal hemoglobins can be recognized by their characteristic position on the paper or gel.

13. The Quiz: an online interactive diagnostic challenge. 12 cases with abnormal blood counts for you to investigate and diagnose. Try to be parsimonious and achieve a diagnosis with as few investigations as you can. We will analyze the cases together in class towards the end of the course. Follow the link or go to http://meds.queensu.ca/medicine/deptmed/hemonc/anemia/Quiz/eric/anemia_quiz.swf

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