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Interpretation of
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CompletekuBlood Counts
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Dr. Muhammad Hasan
Assistant Professor and Consultant Hematologist
Hematology and Transfusion Medicine
Email: hasan.hayat@aku.edu
Disclosure statement
I I do not have any financial relationship with proprietary entities

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producing, marketing, re-selling or distributing healthcare goods
or services consumed or used on patients in the past 12 months.
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 Introduction

• Basic and base line investigations not only for hematological disorders but also
for non- hematological disorders of any type.

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. e WBCs and Platelets
• Include various parameters related to RBCs,
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• Previously done with different manualu methods.
• Now automated analyzers do it inavery efficient way.
• Results of CBC should be interpreted in the light of relevant clinical history.
• Co-relation with blood film morphology is required in most of the cases.
• Co-relation with other investigations is also helpful.
Components of CBC
• RET
1. Red Blood Cells (RBCs) • RET-HE
Hematocrit (Hct)
Hemoglobin (Hb)
Mean Corpuscular Volume (MCV) du
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Mean Corpuscular Hemoglobin (MCH)
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Red cell distribution width (RDW)
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2. a
White Blood Cells (WBCs)
differential % or Absolute values
3. Platelet
Count • IPF
• MPV
A CBC report

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Reference Ranges for Adult
Test Male Female Unit
RBC Count 4.5 - 6.5
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3.9 - 5.5 x1012/L
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Hematocrit 41.9 - 48.7
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Hemoglobin a
13.7 - 16.3 11.1 - 14.5 g/dL
Platelet 150 - 400 150 - 400 x109/L
WBC 4.0 - 10.0 4.0 - 10.0 x109/L
Peripheral Film Review

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This is an essential feature of CBC and is a

must!
Sickle cell anemia

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Spherocytic Hemolytic Anemia

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Malarial Parasite

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Microangioathy

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CBC interpretation
• Single parameter
• Red cells/Hb
• White cells du
• Platelets
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• Multiple parameters k u
• Bicytopenia a
• Pancytopenia
• Panmyelosis
RED CELLS

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Hematocrit or PCV
• The cells packed at the bottom of centrifuged blood sample.
• PCV=MCV X red cell count
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• Measured as litre/litre or %. e
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Red cell indices
• MCV
Size of red cells
• RDW
• MCH du
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• MCHC
k uHemoglobin of red cells

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Reference ranges
• MCV……….76-96fl
• MCH……….26-32pg
• MCHC……..32-36 g/dL
MCV
• It reflects average cell size of the red cell
• Measured in femtolitres (fL)
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• It is given by automated system but can be calculated manually
as well
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• MCV= PCV a
RBC count
• Normal MCV= 76-96 fl
Red cell distribution width (RDW)
• It is a measure of anisocytosis of red cells.

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• When combined with MCV and reticulocyte count, it can predict
the type of anemia.
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• Reference range 13%
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Significance of MCV
• It helps in classifying anemia on morphological basis
• Red cells may be:
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1. Normocytic
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2. Microcytic
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3. Macrocytic a
MCH
• The quantity of hemoglobin present in one red cell on average
• Measured in picograms (pg)
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• Calculation
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MCH= Hb
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RBC count a
• Normal MCH= 26-32 pg
Significance of MCH
• Helps in identifying the type of anemia
• Red cells can be
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1. Normochromic
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2. Hypochromic
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3. Hyperchromic a
 MCHC

• MCHC= mean corpuscular hemoglobin concentration

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Can be calculated as:
MCH= HB/PCV du
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Normal range: 32-36 g/dl
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a conditions that generate low values for MCV
• Low values occur in the same
and MCH

• Increased values occur almost exclusively in the presence of congenital or

acquired spherocytosis
Classification of Anemia
1. Pathogenesis
According to underlying mechanism
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2. Morphological
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According to red cell indices
Classification of Anemia - Underlying Mechanism

Anemia du
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Hypo Hyper
Blood Loss
proliferative proliferative
Morphological Classification of
Anemia
1. Normochromic normocytic anemias
2. Hypochromic microcytic anemias
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3. Macrocytic anemia
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 Workup of Anemia - MCV

MCV

Microcytic Normocytic Macrocytic

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Acute bloode
Iron Deficiency (IDA)
u . loss Megaloblastic anemias
(B12/folate deficiency)
Chronic diseases
(AOCD) Earlya
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Chronic diseases
IDA Liver disease/alcohol
Thalassemia Hemoglobinopathies MDS
Hemoglobinopathies Primary marrow Hypothyroidism
Sideroblastic Anemia disorders Medications
Lead poisoning Combined deficiencies
Increased destruction
Normochromic Normocytic Red Cells

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Hypochromic Microcytic Anemia

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Macrocytic Anemia

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Reticulocyte Count

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• Expressed as % of circulating RBCs
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• Take up reticulocyte stain (Supravital) - increased RNA
content k u
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N = 0.5 % to 1.5 % or = .005 to .015
Reticulocyte Count
• Decreased or increased red cell production
• Reticulocyte %
• Absolute reticulocyte count
• Absolute reticulocyte count = Total erythrocyte count (x10 12/L) x
Reticulocyte %
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(Patient’s Hct/45) . e
• Corrected reticulocyte count: Reticulocyte count x

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• Reticulocyte production index: %retic x Hct/45 x 1/CF
Hematocrit a
Correction Factor
45 1.0 • Normal RPI – 1 (Non-anemic patients)
35 1.5 • RPI - < 2 – hypoproliferative
25 2.0 • RPI ≥ 2 – hyperproliferative
15 2.5
Anemia based on MCV and
Reticulocyte Count
• Increased MCV
• High retic
• Low retic du
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• Decreased MCV
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• High retic
• Low retic
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• Normal MCV
• High retic
• Low retic
Decreased MCV

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Normal MCV

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Increased MCV

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olycythemia (Increased RBC, HGB, HCT) Rule of Three
RBC X 3 = Hb
Relative polycythemia Hb X 3 = Hct
• Dehydration/ diuretics
• Smoking
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Absolute polycythemia
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• High altitude k u
• Cardiovascular disease ( COPD, Right to left shunt, sleep apnea)

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• EPO secreting tumors ( RCC , HCC etc.)
• Exogenous erythropoietin administration (EPO doping)
• Certain hereditary causes extrinsic to RBC

• Polycythemia Vera
• EPO receptor mutations and other mutations in RBC
PLATELETS

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Platelets – Low

 Spurious thrombocytopenia
 Significant levels < 100 x109/L
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 Common causes
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Infections ( HBV, HCV, Dengue, HIV, other viral infections, malaria)
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 Primary Immune Thrombocytopenia (ITP)
Liver disease
Drugs (heparin, antibiotics, chemotherapy, antidepressants etc.)
Hypersplenism
Autoimmune disease
Gestational
Spurious Thrombocytopenia

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Platelets – High

 Significant levels > 450 x109/L

 Most likely causes du
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Iron deficiency k u
Reactive conditions e.g. infection, inflammation

Post splenectomy a
Essential Thrombocythaemia ( and other MPDs)
Mean platelet volume (MPV)

Average volume of circulating PLTs

Normally: ~8-12 fL du
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Increased MPV – PLT destruction ( e.g. ITP, infections)
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Decreased MPV – impaired PLT production ( e.g. aplastic anemia)
Immature Platelet Fraction (IPF)
• A measure of thrombopoietic activity.

• A modern parameter that measures young reticulated platelets (large

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platelets with elevated ribonucleic acid) in peripheral blood.
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Its quantification provides an assessment of bone marrow platelet production

production.
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in a similar way to how a reticulocyte count provides a measure of red cell
Usefulness of IPF
To determine mechanism of thrombocytopenia

Raised IPF: Conditions with high platelet Low/normal IPF: Individuals with bone marrow
turnover suppression
 Aplastic anemia
 ITP
 DIC
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 Other bone marrow failure syndromes
 TTP /HUS
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 Blood loss
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To assess need of platelet transfusion

IPF levels start increasing 48-72 hours before recovery in absolute platelet count therefore, it
can be used as a guide to platelet transfusion requirement in dengue infection, post-
transplant/ post-chemotherapy patients and other conditions.
 Disease surveillance

Monitoring of platelet recovery in regenerating bone marrow or treatment effectiveness such

as thrombopoietic agents, steroids, immune-suppressive agents, bone marrow transplant or
chemotherapy.

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White blood cells

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 Total WBC May be Misleading
 The absolute count of each of the cell types is more useful than
the total. It reflects true increase or decrease of each specific
WBC
 The total count may be misleading, e.g. low neutrophils with an
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elevated lymphocyte count may produce a total white count that
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falls within the reference range. e
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Differential % a
Neutrophil 40-75
Lymphocyte 20-45
Eosinophil 1-6 Absolute count= % of DLC x TLC
Monocyte 2-10 100
Basophil 0-1
Neutrophils – High ( >8 x109/L)
 Most common causes
• Infection/inflammation
• Necrosis/malignancy
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• Any stressor/heavy exercise
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• Drugs
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•
•
Pregnancy
CML a
 Red flags
• Person particularly unwell
• Severity
• Rate of change of neutrophilia
• Presence of left shift
Neutrophils – Low (<1.5 x109/L)
 Significant levels
< 0.5 x 109/L (high risk infection)
 Most common causes du
• Viral (overt or occult) . e • Aplastic anemia

• Autoimmune/idiopathic
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lymphoma, metastasis)
• Drugs
 Red flags
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Hypersplenism/ splenomegaly
B12 folate deficiency
• Person particularly unwell • Myelodysplatic syndrome
• Inherited bone marrow failure
• Severity
syndromes
• Rate of change of neutropenia
• Lymphadenopathy,
hepatosplenomegaly
Lymphocytes
 Lymphocyte – Low
• Not usually clinically significant
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 Lymphocyte – High ( >5x10 /L indadults)
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• Isolated elevated count not usually significant
Causes
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Acute infection (viral, bacterial)
• Smoking
• Hyposplenism
• Acute stress response
• Autoimmune thyroiditis
• CLL ( or any other LPD)
Monocytes
 Monocytes – Low
• Not clinically significant
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 Monocytes – High ( >1 x109/L)
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 Represent chronic infections (e.g.
 Chronic Myelomonocytic Leukemia
Tuberculosis, syphilis, endocarditis)
Eosinophils
 Eosinophils – Low
• No real cause for concern

• Eosinophils – High ( >0.6 x109/L) 2) Idiopathic eosinophilia (No

1) Secondary (reactive) eosinophilia
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• Allergy/atopy ( asthma/ hay fever)
.e for eosinophilia)
• Parasitic infections
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• Dermatological disorders (non-allergic)
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Drugs (Including antibiotics, anticonvulsants)
(Hematological neoplasms where the
Eosinophils form part of the neoplastic
• Vasculitides clone)
Group of very rare entities
• Neoplasms (non-haematological and haematological)
• Respiratory disease ( Loffler syndrome, allergic
bronchopulmonary aspergillosis)
Basophils
 Basophils – Low
• Difficult to demonstrate
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 Basophils – High
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 Associated with a
• Myeloproliferative disorders
• Other rare causes
Bi or Pancytopenia
• May be a temporary insult to the bone marrow
• Peripheral destruction/sequestration
• Megaloblastic anemia

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• Rarely indicates marrow failure e
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• May require bone marrow examination
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Panmyelosis
• Usually, a myeloproliferative disorder
• May require bone marrow examination and/or chromosomal
studies
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Interpret Results in Clinical Context
• All haematology results need to be interpreted in the context of a
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thorough history and physical examination, as well as previous
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results
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from the instrument
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• Some labs interpret the results while others provide the print out

• REMEMBER THAT LAB IS LOOKING AT NUMBERS ONLY

History and Clinical Examination
 Important features of history and clinical examination:
• Pallor, jaundice
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• Fever, lymphadenopathy
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• Bleeding/bruising
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• Hepatomegaly, splenomegaly
• Frequency and severity of infections, mouth ulcers, recent
viral illness
• Exposure to drugs and toxins
• Fatigue/weight loss
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Thank e you
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