CBC --- Interpretations

Abstract
Interpretation of different parameters reported on modern day analyzers is bit tricky and demand continuous monitoring and on-going learning. In present paper interpretation of different reported parameters has been discussed with approach to diagnosis of various abnormalities.

The CBC interpretation are useful in the diagnosis of various types of anemias. It can reflect acute or chronic infection, allergies, and problems with clotting.

 Component of the CBC:

Red Blood Cells (RBCs) Hematocrit (Hct) Hemoglobin (Hgb) Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin Concentration (MCHC) - Red cell distribution width (RDW) White Blood Cells (WBCs) Platelet

 RBC (varies with altitude): M: 4.7 to 6.1 x10^12 /L F: 4.2 to 5.4 x10^12 /L Biconcave disc shape with diameter of about 8 m Function: - transport hemoglobin which carries oxygen from the lung to the tissues -acid base buffer. Life span 100-120 days.

Hemoglobin :
M: 13.8 to 17.2 gm/dL F: 12.1 to 15.1 gm/dL Hematocrit : (packed cell volume) It is ratio of the volume of red cell to the volume of whole blood. M: 40.7 to 50.3 % F: 36.1 to 44.3 %

 MCV = mean corpuscular volume HCT/RBC count= 80-100fL

small = microcytic normal = normocytic large = macrocytic

MCHC= mean corpuscular hemoglobin concentration HB/RBC count= 26-34%

decreased = hypochromic normal = normochromic

 MCH (mean corpuscular hemoglobin) HB/HCT = 27-32 pg RDW (red cell distribution width) It is correlates with the degree of anisocytosis _ Normal range from 10-15%

 This important value is needed in the evaluation of any anemia. Normal range 1-2% Retic count goes up with
Hemolytic anemia

Retic goes down with

Nutritional deficiencies

_ Diseases of the bone marrow itself

Definition of Anaemia
Decrease

in the number of circulating red blood cell mass and there by O2 carrying capacity Most common hematological disorder by far Almost always a secondary disorder As such, critical for all practitioners to know how to evaluate / determine its cause / treat

First Question
The

onset of Anaemia Acute versus chronic Clues Hemodynamic stability Previous CBC Overt blood loss

Types of Anaemia

Screening Tests Anaemia

Clinical
Look

Signs and symptoms of Anaemia

for bleeding all possible sites

Look Cut

for the causes for anemia

Hemoglobin examination
WHO < 12.5 g Less than 12 g%

Routine

off marks for Hb

US < 13.5 g Subcontinent

Clinical Signs to be looked for

Skin / mucosal pallor, Skin dryness, palmar creases Bald tongue, Glossitis Mouth ulcers, Rectal exam Jaundice, Purpura Lymphadenopathy Hepato-splenomegaly Breathlessness Tachycardia, CHF Bleeding, Occult Blood

PCV or Hematocrit

57% 1%

Plasma

Buffy coat WBC Hct (PCV)

42%

The Three Basic Measures

Measurement Range
A. B. C.

Normal 5 million 4 to 6

RBC count

Hemoglobin

15 g%

12 to 17

Hematocrit 45 38 to 50 A x 3 = B x 3 = C - This is the rule of thumb Check whether this holds good in given results If not -indicates micro or macrocytosis or hypochromia.

Causes of Anaemia
1. 2. 3.

Decreased production of Red Cells

- Hypoproliferative, marrow failure

Increased destruction of Red Cells

- Hemolysis (decreased survival of RBC)

Loss of Red Cells due to bleeding

- Acute / chronic blood loss (hemorrhagic)

Anaemia First Test

RETICULOCYTE COUNT % RBC to be or Apprentice RBC Fragments of nuclear material RNA strands which stain blue

Normal Less than 2%

Reticulocytes

Supravital

Leishmans

Anaemia
Hb% < 12, Hct < 38%

Hypoproliferative
Retics < 2

Hemolytic
Retics > 2

Normal CBC

Workup Second Test

The

next step is What is the size of RBC ? MCV indicates the Red cell volume (size) Both the MCH & MCHC tell Hb content of RBC If the Retic count is 2 or less We are dealing with either
Hypoproliferative anaemia (lack of raw material) Maturation defect with less production Bone marrow suppression (primary/ secondary)

Mean Cell Volume (MCV)

volume (rather) is measured by The Mean Cell Volume or MCV and RDW
RBC

MCV

Microcytic

Normocytic

Macrocytic

< 80 fl
< 6.5

80 -100 fl
6.5 - 9

> 100 fl
>9

Anaemia Workup - MCV

MCV

Microcytic
Iron Deficiency IDA
Chronic Infections Thalassemias

Normocytic
Chronic disease
Early IDA Hemoglobinopathies Combined deficiencies Increased destruction

Macrocytic
Megaloblastic anemias
Liver disease/alcohol Hemoglobinopathies Marrow disorders Increased destruction

Hemoglobinopathies
Sideroblastic Anemia

Primary marrow disorders Metabolic disorders

Red cell Distribution Width - RDW

RDW

Normal

High

Population Uniform

Population Double

Anaemia Workup - 4th Test Peripheral Smear Study

Are

all RBC of the same size ? Are all RBC of the same normal discoid shape ? How is the colour (Hb content) saturation ? Are all the RBC of same colour/ multi coloured ? Are there any RBC inclusions ? Are intra RBC there any hemo-parasites ? Are leucocytes normal in number and D.C ? Is platelet distribution adequate ?

IDA -CBC

Microcytic Hypochromic - IDA

IDA Special Tests

Iron related tests Serum Ferritin (pmo/L) TIBC (g/dL) Serum Iron (g/dL) Saturation % Bone marrow Iron

Normal 33-270 300-340 50-150 30-50 ++

IDA < 33 > 400 < 30 < 10 Absent

IDA Summary

Microcytic

MCV < 80 fl, RBC < 6

RDW
Hypochromic 30%

Widened with low MCV

MCH < 27 pg, MCHC <

RI
Serum ferritin TIBC

<2
Very low < 30 (p mols/L) Increased > 400 (g/dL)

Serum Iron
BM Fe Stain Response to Fe Rx.

Very low < 30 (g/dL)

Absent Fe Excellent

IDA- Some Nuggets

Look for occult blood loss 2 days non veg. free Pica and Pagophagia Ice sucking Absorption of Haem Iron > Fe ++ > Fe+++ Food, Phytates, Ca, Phosphate, antacids absorption Ascorbic acid absorption Oral iron Rx. always is the best, ? Carbonyl Fe FeSO4 is the best. Reserve parenteral Rx. Packed cell transfusion in emergency Continue Fe Rx at least 2 months after normal Hb 1 gram in Hb every week can be expected Always supplement protein for the Globin component

Microcytic Anaemias
MCV < 80 fl Iron Def. Anemia Chronic Infection Serum Iron TIBC BM Perls stain 0

Thalassemia
Hemoglobinopathy
Lead poisoning

N
N

N N
N N

++
++++

++ ++
++++

Sideroblastic

Macrocytic Anaemias
A. Megaloblastic Macrocytic B12 and Folate B. Non Megaloblastic Macrocytic Anaemias 1. Liver disease/alcohol 2. Hemoglobinopathies 3. Metabolic disorders, Hypothyroidism 4. Myelodystrophy, BM infiltration 5. Accelerated Erythropoesis - destruction 6. Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants)

Anemia - Macrocytic (MCV > 100)

Premature gray hair consider MBA

Macrocytic anemias may be asymptomatic until

the Hb is as low as 6 grams

MCV 100-110 fl
must look for other causes of macrocytosis MCV > 110 fl almost always folate or B12 deficiency

MBA

Macrocytosis -MBA

HSN - MBA

Basophilic Stippling - MBA

BS occurs in Lead poisoning also

MBA - BM

Pernicious Anaemia - Tongue

Bald, smooth, lemon yellowish red tongue

Normocytic Anaemias
1.
2. 3. 4. 5.

6.
7.

Chronic disease Early IDA Hemoglobinopathies Primary marrow disorders Combined deficiencies Increased destruction Anaemia of investigations ICU

Anaemia of Chronic Disease

Thyroid

diseases Malignancy Collagen Vascular Disease Rheumatoid Arthritis SLE Polymyositis Polyarteritis Nodosa

IBD Ulcerative Colitis Crohns Disease Chronic Infections HIV, Osteomyelitis Tuberculosis Renal Failure

Dimorphic Anaemia
Folate & Fe deficiency (pregnancy, alcoholism)
B12 & Fe deficiency (PA with atrophic gastritis)

Thalassemia minor & B12 or folate deficiency Fe deficiency & hemolysis (prosthetic valve)

Folate deficiency & hemolysis (Hb SS disease) Peripheral smear exam is critical to assess these

RDW

is increased very much

RBC Size Anisocytosis Different sizes of RBC

Poikilocytosis Different Shapes of RBC

Polychromasia - Spherocytosis

Target Cells
1. Liver Disease
2. Thalassemia 3. Hb D Disease 4. Post splenectomy

 WBCs are involved in the immune response. The normal range: 4 11x10^9 /L Two types of WBC: 1) Granulocytes consist of:
Neutrophils: 50 - 70% Eosinophils: 1 - 5% Basophils: up to 1% 2) Agranulocytes consist of:

- Lymphocytes: 20 - 40%
Monocytes: 1 - 6%

The type of cell affected depends upon its primary function:

In bacterial infections, neutrophils are most commonly affected In viral infections, lymphocytes are most commonly affected In parasitic infections, eosinophils are most commonly affected.

polymorphneuclear leukocytes (PMN,s)

Nucleus 3-5 lobes. Diameter 10-14 m 50-70% WBC =2.5-7.5x10^9/ L

Function: Phagocytosis of bacteria and cell debris

Numbers rise with all manner of stress, especially bacterial infections

 Neutrophil disorders Neutrophilia an increase in neutrophils Conditions associated with neutrophilia are: 1-Bacterial infections (most common cause) 2-Tissue destruction e.g. tissue infarctions, burns. 3- leukemoid reaction 4-Leukemia

 Neutropenia this may result from 1-Decreased bone marrow production e.g. BM hypoplasia.

2-Ineffective bone marrow production E.g. megaloblastic anemias and myelodysplastic syndromes.
3- post acute infection _ e.g. typhoid fever, brucellosis.

 Bilobed nucleus 1-5% of WBC =0.04-0.4x10^9/L Diameter about 10-14 m Function: Involved in allergy, parasitic infections

Contains: eosinophilic granules

 Eosinophilia may be found in

Parasitic infections Allergic conditions and hypersensitivity reaction

 No specific granules 20-40% of WBC =1.55-3.5x10^9/ L

Diameter 8-10 m
T cells: cellular (for viral infections) B cells: humoral (antibody) Natural Killer Cells

Lymphocytosis may indicate

_ Viral infection e.g. Infectious mononucleosis, CMV or pertussis. _ Bacterial infection e.g. TB Lymphopenia caused by _Stress. _Steroid therapy _ Irradiation

 (Leukocytosis) may indicate: _ Infectious diseases _Inflammatory disease (such as rheumatoid arthritis or allergy) _Leukemia _Severe emotional or physical stress _Tissue damage (e.g. necrosis,or burns) (Leukopenia) may result from: _ Decreased WBC production from BM. _ Irradiation. _ Exposure to chemical or drugs.

Fever Malaise Weakness Others depend on each system which is involved e.g. chest: cough, SOB and chest pain abdomen: diarrhea, vomiting, dehydration. CNS: headache, visual disturbance, Neck stiffness and so 0n.

Infection of the mouth and throat. Painful skin ulceration. Recurrent infection. Septicemia.

Small granular non-nucleated discs. Diameter about 2-4 m Normal range; 150-300x10^9 /L Destroyed by macrophage cells in the spleen. Function; involved in coagulation and blood haemostasis. Life span 7-10 days

 Numbers of platelets
Increased (Thrombocythemia)
Pregnancy. Exercise. High attitudes. splenectomy

Decreased (Thrombocytopenia)
Menstruation. Haemorrhage. Bone marrow destruction or suppression e.g. leukemia

The values have to fit the clinical situation.

 Petechial hemorhage. Easy bruising. Mucosal bleeding

e.g. _ epistaxes. _ gum bleeding