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 O
2
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 Signs and symptoms of
Anaemia
Look for bleeding all possible sites
Look for the causes for anemia
Routine Hemoglobin examination
Cut off marks for Hb
US < 13.5 g WHO < 12.5 g
Subcontinent Less than 12 g%
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% Plasma

1% Buffy coat WBC

42% Hct (PCV)
The Three Basic Measures
Measurement Normal
Range
A. RBC count 5 million 4 to 6
B. Hemoglobin 15 g% 12 to 17
C. 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. Decreased production of Red Cells
- Hypoproliferative, marrow failure
2. Increased destruction of Red Cells
- Hemolysis (decreased survival of RBC)
3. Loss of Red Cells due to bleeding
- Acute / chronic blood loss
(hemorrhagic)

Anaemia First Test
RETICULOCYTE COUNT %
Normal
Less than 2%
RBC to be or Apprentice RBC
Fragments of nuclear material
RNA strands which stain blue
Reticulocytes
Leishmans Supravital
Anaemia
Hypoproliferative
Hemolytic
Retics < 2 Retics > 2
Hb% < 12, Hct < 38%
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)
RBC volume (rather) is measured by
The Mean Cell Volume or MCV and RDW
Microcytic
< 80 fl
MCV
Normocytic Macrocytic
80 -100 fl > 100 fl
< 6.5 6.5 - 9 > 9
Anaemia Workup - MCV
Microcytic
MCV
Normocytic Macrocytic
Iron Deficiency IDA
Chronic Infections
Thalassemias
Hemoglobinopathies
Sideroblastic Anemia
Chronic disease
Early IDA
Hemoglobinopathies
Primary marrow disorders
Combined deficiencies
Increased destruction
Megaloblastic anemias
Liver disease/alcohol
Hemoglobinopathies
Metabolic disorders
Marrow disorders
Increased destruction
Red cell Distribution Width - RDW
Normal
Population
Uniform
RDW
High
Population
Double
Anaemia Workup - 4
th
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 Normal IDA
Serum Ferritin (pmo/L) 33-270 < 33
TIBC (g/dL) 300-340 > 400
Serum Iron (g/dL) 50-150 < 30
Saturation % 30-50 < 10
Bone marrow Iron ++ Absent
IDA Summary
Microcytic MCV < 80 fl, RBC < 6
RDW Widened with low MCV
Hypochromic MCH < 27 pg, MCHC <
30%
RI < 2
Serum ferritin Very low < 30 (p mols/L)
TIBC Increased > 400 (g/dL)
Serum Iron Very low < 30 (g/dL)
BM Fe Stain Absent Fe
Response to Fe Rx. 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
FeSO
4
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
Serum
Iron
TIBC BM Perls stain
Iron Def. Anemia

0
Chronic Infection

+ +
Thalassemia

N + + + +
Hemoglobinopathy
N N
+ +
Lead poisoning
N N
+ +
Sideroblastic

N + + + +
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 B
12
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. Chronic disease
2. Early IDA
3. Hemoglobinopathies
4. Primary marrow disorders
5. Combined deficiencies
6. Increased destruction
7. 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)
B
12
& Fe deficiency (PA with atrophic gastritis)
Thalassemia minor & B
12
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