Interpreting Blood Counts
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 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 Recognizing hemolysis Leukocytes and platelets Glossary of terms Additional Investigations
Interpreting Blood Counts
Dilys Rapson John Matthews
Interpreting Blood Counts
The machine will measure
Interpreting Blood Counts
The blood film
1. 2. 3. 4. 5. 6. 7.
amount of hemoglobin per unit volume (Hb g/L) number of red blood cells per unit volume (RBC x 1012/L) size of the red blood cells (MCV fL) number of white blood cells per unit volume (WBC x 109/L) number of platelets per unit volume (platelets x 109/L) differential WBC if no abnormal cells are present (absolute numbers of the various white blood cells) reticulocyte count (x 109/L the number of young [<48 h] red cells)
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
Interpreting Blood Counts
How to look at the blood count 1. Concentrate on the Hb, MCV, WBC, and Platelets. If all four are normal, then significant blood disease is unlikely to be present 2. If the Hb is low LOOK AT THE MCV and the reticulocyte count 3. Examine the differential 4. Read the report on the blood film
Normal blood film
Normochromic normocytic red cells
Segmented neutrophil
Lymphocyte
Monocyte
Basophil Eosinophil
Normal Hemoglobin Values compared with normal adult females
Group Neonates Children and younger teens Adult males Hemoglobin High: falls over 3-6 months Low MCV High: falls over 3-6 months Low
Higher by about 20 (testosterone)
Normal Normal
Elderly Often lower without both sexes obvious illness
Microcytic (low MCV) Anemia
3 important causes
Macrocytic Anemia
Iron deficiency Hemoglobinopathy Anemia of Chronic Disease (some cases)
Megaloblastic B12 or folate deficiency Non-megaloblastic eg liver disease, myelodysplasia, ethanol
Normocytic Anemia
Underproduction of erythrocytes Anemia of Chronic Disease Marrow Failure Renal failure Loss or destruction of erythrocytes Hemolysis 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)
Macrocytic red cells Hypochromic microcytic red cells
Dual red cell population (dimorphic)
Reticulocyte
Spherocytes Sickle Cell
bite cell
blister cells
Bite Cells
hemi-ghost
10. Leukocytes and platelets
Red cell fragments
Problem 10 Marrow Disorder Additional findings Abnormal WBC (e.g. blasts) Pancytopenia is usual Reactive or Destructive infection, neoplasia, inflammation Additional findings
High WBC Leukemia etc Low WBC Marrow failure (e.g. MDS)
Neutrophils
toxic and leftshifted
Infection, Often none hypersplenism infection, bleeding, neoplasia, inflammation Immune (ITP) May be neutrophilia and left shift None
Increased Platelets
Myeloprolifer Giant and ative abnormal disorder e.g. platelets P vera Pancytopenia is usual
Decreased Marrow failure e.g. platelets MDS
Dhle bodies in cytoplasm
Neutrophilia
Band cell with toxic granulation and vacuoles
Thrombocytosis
Lymphocytosis
Thrombocytopenia
Glossary
Blast Cell
Howell-Jolly Bodies
Hypersegmented neutrophil
Leukoerythroblastic picture
Polychromasia
Rouleaux
Case 1
A 55 year old woman has developed severe alcoholic liver cirrhosis
She is pale and deeply jaundiced. She has spider nevi, red palms and ascites. Her spleen can be felt 8 cm below the left costal margin, and her liver is enlarged and firm, 7 cm below the right costal margin.
Target cells
Case 1
WBC x 109/L Hb g/L MCV fl Platelets x 109/L Reticulocytes x 109/L Neuts x 109/L Lymphs x 109/L Monos x 109/L Nucleated RBC x 109/L 3.0 50 96 58 300 1.3 1.5 0.2 0.1 [4-11] [120-160] [79-98] [150-450] [20-80] [2-7.5] [1.5-4] [0.2-0.8] [0]
Case 1
Haptoglobin < 0.1 g/L (normal LDH 850 u/L (normal 94-178)
Film Comment: Numerous acanthocytes ?spur cell hemolytic anemia
Case 2
A black female walks in to the ER complaining of fatigue. She has recently immigrated from Tropical Africa.
She has pale mucous membranes, tachycardia, a dynamic apex beat, and a systolic ejection murmur at the apex of the heart.
Case 2
WBC x 109/L Hb g/L MCV fl Platelets x 109/L Reticulocytes x 109/L Neuts x 109/L Lymphs x 109/L Monos x 109/L Eos x 109/L Basos x 109/L 5.0 43 56 750 10 2.0 1.5 0.2 1.3 [4-11] [120-160] [79-98] [150-450] [20-80] [2-7.5] [1.5-4] [0.2-0.8] [0-0.7] [0-0.1]
Film Comment: severe microcytic anemia
Case 2
Ferritin 2 (normal 20-400)