The Complete Blood Count and Peripheral Blood Smear Evaluation - PowerPoint Presentation

1. The Complete Blood Count and Peripheral Blood Smear Evaluation10

2. Learning Objectives—Level l At the end of this unit of study, the student should be able to:List the assays typically included in the complete blood count (CBC).Describe how to properly identify a patient prior to blood collection.List the pre-examination precautions that must be observed to produce quality results when performing a CBC.continued on next slide

3. Learning Objectives—Level l At the end of this unit of study, the student should be able to:List the typical units of measure for reporting the WBC, RBC, Hgb, Hct, and reticulocyte count.Define the terms MCV, MCH, MCHC, and RDW.continued on next slide

4. Learning Objectives—Level l At the end of this unit of study, the student should be able to:Given the hemoglobin, hematocrit, and RBC count, demonstrate the ability to use the formulas to calculate the RBC indices.Describe the process of evaluating the peripheral blood smear including macroscopically and microscopically using low and high power magnification microscopic settings.continued on next slide

5. Learning Objectives—Level l At the end of this unit of study, the student should be able to:Define poikilocytosis and anisocytosis, and describe and identify specific poikilocytes and anisocytes.Classify erythrocytes morphologically based on erythrocyte indices.Given the relative reticulocyte count and RBC count, calculate the absolute reticulocyte count.continued on next slide

6. Learning Objectives—Level l At the end of this unit of study, the student should be able to:Identify erythrocyte inclusions; describe their composition and staining characteristics.Recognize abnormal variation in erythrocyte distribution on stained smears.continued on next slide

7. Learning Objectives—Level l At the end of this unit of study, the student should be able to:Correlate polychromatophilia on a blood smear with other laboratory results of erythrocyte production and destruction.Describe the variations in the CBC reference ranges found in African Americans, newborns, and elderly people.

8. Learning Objectives—Level ll At the end of this unit of study, the student should be able to:Interpret RDW results.Assess bone marrow response to anemia given CBC and reticulocyte results.Identify poikilocytes on a blood smear, describe their mechanism of formation, and correlate them with pathological conditions.continued on next slide

9. Learning Objectives—Level ll At the end of this unit of study, the student should be able to:Correlate CBC and reticulocyte results with findings on a blood smear and troubleshoot any discrepancies.Select methods for differentiating erythrocyte inclusions.continued on next slide

10. Learning Objectives—Level ll At the end of this unit of study, the student should be able to:Evaluate distribution of erythrocytes on stained smears, and describe how the distribution could affect the CBC results.Correlate the age of a patient and the typical changes in CBC results compared to a normal adult CBC.

11. IntroductionThree phases of complete blood count (CBC)Pre-examinationPatient ID, collection, and handling of specimencontinued on next slide

12. IntroductionThree phases of complete blood count (CBC)ExaminationConcentration of WBCs, RBCs, plateletsCategorization of WBC subsetsRBC indices, hemoglobin, hematocritPost-examinationReporting and interpreting data

13. Pre-Examination—CBCPatient identificationName, hospital number, date of birthSpecimen collectionFollow safety requirementsPurple/lavender top tube containing EDTA

14. Pre-Examination—CBCSpecimen handlingProper transport (time and temperature)Blood smear prepared within 3 hrs of collectionInstrument analysis within 6–8 hrs of collection

15. Pre-Examination—CBCAutomated resultsInstrumentation utilizes different technologies to determine reporting parameters of CBCWBCs, RBCs, plateletsMeasured by impedance and optical light scattercontinued on next slide

16. Pre-Examination—CBCAutomated resultsInstrumentation utilizes different technologies to determine reporting parameters of CBCCell populations, interfering substances, instrument functionDetermined by scatterplots and histograms

17. Table 10-2 Parameters and Reference Intervals of a Typical Adult CBCa

18. CBC—Automated ResultsLeukocyte count (WBC), erythrocyte count (RBC), hematocrit (Hct), hemoglobin (Hb)WBCs reported as 109/LRBCs reported as 1012/Lcontinued on next slide

19. CBC—Automated ResultsLeukocyte count (WBC), erythrocyte count (RBC), hematocrit (Hct), hemoglobin (Hb)Hct reported as % or L/LMeasures volume RBCs occupy within whole bloodUsually calculated in automationMCV (fl) × RBC (× 1012/L)/1000 = Hct (L/L)continued on next slide

20. CBC—Automated ResultsLeukocyte count (WBC), erythrocyte count (RBC), hematocrit (Hct), hemoglobin (Hb)Hb reported as g/dL or g/L

21. CBC—Automated ResultsWBC, RBC, Hct, HbDiurnal variation WBC count lowest in morning, RBC, Hb, Hct counts are highest in the morningcontinued on next slide

22. CBC—Automated ResultsWBC, RBC, Hct, HbRule of ThreeRBC count × 3 = HbHb × 3 = HctMust agree within ±3% of measured value or indicates measurement error, instrument malfunction, or patient has pathology

23. RBC IndicesHelp classify the RBCsSize and Hb contentHb, Hct, and RBC count used to calculate indicesIndicesMean cell volume (MCV)Mean cell hemoglobin (MCH)Mean cell hemoglobin concentration (MCHC)

24. RBC IndicesIndices correlate with RBC morphology seen on the stained blood filmUsed to help classify anemiasMay be falsely increased or decreased Must determine if there are any technical problems that could give false resultsCorrelate indices with Hb, Hct, RBC count

25. RBC IndicesMean cell volume (MCV)Average volume of individual RBCsExpressed in femtoliters (fL) (10-15)Measured directly on automated cell counterscontinued on next slide

26. RBC IndicesMean cell volume (MCV)Can be manually calculatedHct (L/L) × 1000/RBC count (× 1012/L) = MCV (fL)Reference interval80–100 fLcontinued on next slide

27. RBC IndicesMean cell volume (MCV)Used to classify cells asNormocytic, microcytic, macrocyticCorrelates with appearance of cells on smear↑ MCV = cells appear larger (macrocytic)↓ MCV = cells appear smaller (microcytic)continued on next slide

28. RBC IndicesMean cell volume (MCV)Abnormalities provide clues to the disease process

29. Table 10-3 Classification of Erythrocytes Based on MCV

30. RBC IndicesMean cell hemoglobin (MCH)Measurement of the average weight of Hb in individual RBCs (picograms, 10-12g)Calculated from the Hb and RBC countHb (g/dL) × 10/RBC (× 1012/L) = MCH (pg)Reference interval28–34 pg

31. RBC IndicesMean cell hemoglobin (MCH)Does not take into account the size of the cellMust be interpreted along with the MCVDirect linear relationship with MCVSmaller cells will have less Hb (less volume)Larger cell will have more Hb

32. RBC IndicesMean cell hemoglobin concentration (MCHC)Ratio of Hb mass to volumeCalculated from the Hb and HctHb (g/dL)/Hct (L/L) = MCHC (g/dL)Reference interval32–36 g/dL continued on next slide

33. RBC IndicesMean cell hemoglobin concentration (MCHC)Indicates whether the general RBC population is normochromic or hypochromicHypochromic if area of central pallor > 1/3 of cell sizecontinued on next slide

34. RBC IndicesMean cell hemoglobin concentration (MCHC)Hyperchromic should be used sparinglySpherocyte is the only cell with a MCHC > 36 g/dLA decreased surface-to-volume ratio due to loss of membrane, usually normal amounts of Hb in the red cell

35. Table 10-4 Classification of Erythrocytes Based on MCHC

36. Red Cell Distribution Width (RDW)MCV represents an average of RBC volumeLess reliable in describing the RBC population when there are variations in RBC size

37. Red Cell Distribution Width (RDW)RDW is the red cell distribution widthDescribes variation in red cell size (anisocytosis)Coefficient of variation of MCV (RDW-CV)

38. Red Cell Distribution Width (RDW)Calculated indexRDW = SD of MCV × 100/Mean MCV

39. Red Cell Distribution Width (RDW)Abnormal ↑ RDW valuesIndicates an increased heterogeneity of RBC size Use caution when interpreting RDW-CVNormal RDW-CV = ↑ MCV, heterogeneous cell population↑ RDW-CV = low MCV, homogenous population

40. ReticulocytesReticulocyteImmature anuclear RBCContains organellesResidual ribosomes for Hb synthesis

41. ReticulocytesBefore lose RNA and become a mature RBCMature 2–3 days in the BM then 1 day in PBAppear as polychromatophilic (bluish tinge) RBCs on Romanowsky (Wright) stained smear

42. Figure 10-1 The large erythrocytes with a bluish tinge are polychromatophilic erythrocytes, which are larger than the more mature erythrocytes. Note also the spherocytes (peripheral blood; Wright-Giemsa stain; 1000 magnification).

43. Reticulocyte CountIndicates effective BM activityOne of the most useful and cost-effective lab tests in monitoring anemiaSupravital stain (methylene blue or brilliant cresyl blue) used to identify reticulocytes

44. Reticulocyte CountMethod for counting reticulocytesManual methodsAutomated methods (more precise)Test results are expressed asPercentage of reticulocytes in relation to total RBC count (relative count)Reference interval ~ 0.2–2.5%

45. Figure 10-2 The erythrocytes with the particulate inclusions are reticulocytes. The inclusions represent reticulum that stains with the supravital stain brilliant cresyl blue (peripheral blood; 1000 magnification).

46. Reticulocyte CountAbsolute reticulocyte countMore informative index of erythropoietic activityRelative reticulocyte count (%) can appear ↑ due to ↑ in number of reticulocyte in circulation or ↓ in total RBCscontinued on next slide

47. Reticulocyte CountAbsolute reticulocyte countCalculationAbsolute reticulocyte (×109/L) = RBC count (×1012/L) × Reticulocyte count (%)

48. Platelet Count and MPVPlatelet count = number of platelets × 109/LMPV (mean platelet volume) represents average volume of individual platelets (similar to MCV for RBCs)

49. Platelet Count and MPVBoth platelet count and MPV used to assess thrombopoiesis and pathologic conditions related to platelets↓ platelet count can represent ↓ thrombopoiesis, ↑ platelet destruction or consumption↑ platelets seen in reactive or malignant conditions

50. WBC DifferentialAnalysis and enumeration of various WBC subtypesManuel or automatedBlood smear stained with Romanowsky-type (Wright's) stain100 leukocytes viewed and classified, reported as % of each cell typeInterpret ↑ or ↓ in cell types, absolute concentration calculated

51. Peripheral Blood SmearBlood smear is reviewed for overall quality, morphology of WBCs, RBCs, Platelets, and WBC differential is performedSmear is prepared and stainedExamined macro- and microscopicallyValues correlated with parameters reported by instrument

52. Peripheral Blood SmearLow Power MagnificationUsed to quickly assess general appearance and distribution of WBCs, RBCs, PlateletsHigh concentration of WBCs at feathered edge indicates poor cell distributionLarge or abnormal WBCs pushed to outer edges of smearcontinued on next slide

53. Peripheral Blood SmearLow Power MagnificationUsed to quickly assess general appearance and distribution of WBCs, RBCs, PlateletsRuptured cells called smudge cellsRBCs should be evenly distributed and well separated at feathered edge of smear

54. Table 10-5 Summary of the Microscopic Peripheral Blood Smear Examination

55. Peripheral Blood SmearLow power magnificationStacking or aggregation of RBCs associated with pathologic conditionsCold agglutininsIgM antibodies directed against RBC antigensRBCs will agglutinate and form irregular clusters of varying size (grapelike clusters)continued on next slide

56. Peripheral Blood SmearLow power magnificationStacking or aggregation of RBCs associated with pathologic conditionsCold agglutininsAutomated cell counters show grossly ↑ MCH and ↓ RBCs, normal HbEffect of cold agglutinins can be prevented by keeping blood at 37°C

57. Figure 10-3 This blood smear is from a patient with cold agglutinin disease. Notice the clumping of the erythrocytes (peripheral blood; Wright-Giemsa stain; 1000 magnification).

58. Peripheral Blood SmearLow power magnificationStacking or aggregation of RBCs associated with pathologic conditionsRouleauxAlignment of RBCs—one on top of anotherResembles a stack of coinsCan be seen normally when collected blood is allowed to stand in tubes or in the thick portion of the blood smearcontinued on next slide

59. Peripheral Blood SmearLow power magnificationStacking or aggregation of RBCs associated with pathologic conditionsRouleauxPathologic states: seen with an ↑ in fibrinogen or globulinsIs inhibited with some abnormal shapes (e.g., sickle) and when RBCs are suspended in saline

60. Figure 10-4 The erythrocytes are stacked on top of one another like a stack of coins (rouleaux). This blood smear is from a patient with multiple myeloma, a malignant plasma cell disorder. The cells stack because of the large amount of protein in the plasma (peripheral blood; Wright-Giemsa stain; 1000 magnification).

61. Peripheral Blood SmearLow power magnification↓ Platelet estimationPlatelet clumps can be pushed to outer edge of smearPlatelets adhere to neutrophils (satellitism)Both can be eliminated using sodium citrate as anticoagulantFibrin strands indicate blood coagulated (improper mixing after venipuncture)

62. Figure 10-5 Platelet satellitism. The neutrophil in the center is surrounded by platelets (peripheral blood; Wright-Giemsa stain; 1000 magnification).Image courtesy of Constitution Medical, Inc., Westborough, MA. All rights reserved.

63. Peripheral Blood SmearLow power magnificationDetermine critical area to perform cell morphology examinationIdentify using 40X objectiveCharacterized by RBC proximity to one anotherFew overlapping or touching RBCsUniform distribution

64. Figure 10-6a Normocytic, normochromic erythrocytes. Compare the size of the cells to the nucleus of the lymphocytes. (peripheral blood; Wright-Giemsa stain; 1000 magnification).

65. Peripheral Blood SmearHigh power magnificationWBC differential performed100 cells classified to determine relative number (%)Identify any morphologic abnormalitiesPlatelet estimate performedCompared to instrument generated countMorphology notedcontinued on next slide

66. Peripheral Blood SmearHigh power magnificationRBC morphology assessedSize, shape, color, inclusions, and compared to instrument report

67. Erythrocyte Morphology

68. Erythrocyte (RBC)Called a discocyte due to biconcave shapeSize 7–8 mcMMCV 80–100 fL

69. Erythrocyte (RBC)Central area of pallor surrounded by a rim of pink-staining HbPallor is caused by the closeness occurring between the two concave portions of the membraneOccupies about ⅓ of the diameter of the cell

70. AnisocytosisVariation in red cell sizeDetected by reviewing the blood smearAlso by reviewing the RDW and MCVMacrocytesRBCs are larger than normalMCV > 100 fLcontinued on next slide

71. AnisocytosisVariation in red cell sizeMicrocyticRBCs are smaller than normalMCV < 80 fLMCV is an average of all cells

72. Figure 10-7a Erythrocytes with anisocytosis. (peripheral blood; Wright-Giemsa stain; 1000 magnification).

73. AnisocytosisRDW > 14.5 %Suggests different sizes of RBCs are presentTo evaluate RBC size microscopicallyRBCs are compared with the nucleus of a normal small lymphocyte.Normocytic RBCs are about the same size as the nucleus of small lymphocyte.

74. Figure 10-6a Normocytic, normochromic erythrocytes. Compare the size of the cells to the nucleus of the lymphocytes. (peripheral blood; Wright-Giemsa stain; 1000 magnification).

75. MicrocytesRBCsDiameter < 7.0 mcMMCV < 80 fLUsually hypochromic but can be normochromicMicrocytes in the shape of spheresMicrospherocytesCan appear hyperchromic

76. Figure 10-6b The erythrocytes are microcytic (much smaller than the lymphocyte nucleus).

77. MacrocytesRBCsDiameter > 8.0 mcMMCV > 100 fLUsually contains an adequate amount of HbNormal MCHC Normal to ↑ MCHcontinued on next slide

78. MacrocytesRBCsYounger RBCs are larger than mature RBCs for 1 day, then spleen grooms then to normal size.When reticulocyte count ↑, the MCV can be ↑

79. Figure 10-6c The erythrocytes are macrocytic (much larger than the lymphocyte nucleus) (peripheral blood; Wright-Giemsa stain; 1000× magnification).

80. PoikilocytosisTerm used to describe nonspecific variation in shape of RBCsSome shapes and sizesCharacteristic of specific underlying hematological disorder or malignanciesSome morphology may be artifactual Poorly made or improperly stained smears

81. Figure 10-7c Poikilocytosis with acanthocytes, helmet cell, elliptocytes, echinocytes, schistocytes (3), and spherocytes (4). There is also anisocytosis with microcytes and macrocytes. At least two of the macrocytes are polychromatophilic (peripheral blood; Wright-Giemsa stain; 1000× magnification).

82. Table 10-8 Erythrocyte Morphologiescontinued on next slide

83. Table 10-8 (continued) Erythrocyte Morphologiescontinued on next slide

84. Table 10-8 (continued) Erythrocyte Morphologiescontinued on next slide

85. Table 10-8 (continued) Erythrocyte Morphologies

86. Acanthocyte (Spur cell)Small spherical cells (do not have central pallor) with irregular thornlike projectionsProjections may have small bulblike tipsRBC membranes have altered lipid contentIncreased free cholesterol accumulation leading to increased fluidity in RBC membrane

87. Codocytes or Target CellsThin, bell-shaped cells↑ surface-to-volume ratioOn blood smear look like a target cell with a bull's eye in the centerBull's eye is surrounded by an achromic zone and a thin outer ring of pink-staining Hbcontinued on next slide

88. Codocytes or Target CellsThin, bell-shaped cellsCan appear as artifacts when wet smear not dried correctly or made in high humidity environment

89. Figure 10-8 Codocytes, also called target cells (peripheral blood; Wright-Giemsa stain; 1000 magnification).

90. Dacryocytes or Teardrop Cells RBCs that are elongated on one end to form a teardropFormed when RBCs containing inclusions traverse the spleenThe area with the inclusion has difficulty passing through the splenic filterCell is stretched, cannot return to its normal shape

91. Figure 10-9 Note the presence of dacryocytes (teardrops) (1). Note also the echinocytes (2), acanthocytes, and spherocytes (3) (peripheral blood; Wright-Giemsa stain; 1000× magnification).

92. Sickle Cells or DrepanocytesElongated, crescent-shaped RBC with pointed endsSome forms have more rounded ends with a flat side (are reversible)

93. Sickle Cells or DrepanocytesHb is abnormal and polymerizes into rods in ↓ O2 tension or ↓ pH conditionsFirst it transforms into a holly leaf shapeAs Hb polymerization continues, it changes to a sickle cellHas ↑ mechanical fragility

94. Echinocytes or Burr cellsSmaller than normal RBCs with regular, spinelike projectionsIs reversible (can revert to a discocyte)Can become a spherocyteDue to removal of the membrane spines in spleencontinued on next slide

95. Echinocytes or Burr cellsSmaller than normal RBCs with regular, spinelike projectionsCommon artifact in stained blood smearsDue to "glass effect" when making smearCan appear within several days of storing blood at 4°Ccontinued on next slide

96. Echinocytes or Burr cellsSmaller than normal RBCs with regular, spinelike projectionsTrue echinocytes thought to be related to an ↑ in the area of the outer leaflet of the RBC membrane.

97. ElliptocytesAlso called pencil or cigar cellsVary from elongated oval shapes (ovalocytes) to elongated rodlike cellsHave central area of biconcavity with Hb concentration at both ends continued on next slide

98. ElliptocytesAlso called pencil or cigar cellsFormed after cells leave the BM Reticulocytes and young erythrocytes normal in shapeMechanism of formation assumed to involve alterations in RBC membrane skeletoncontinued on next slide

99. ElliptocytesAlso called pencil or cigar cellsHereditary elliptocytosisElliptocytes are the predominant shape

100. Figure 10-10 Note the morphologic differences between (a) elliptocytes and (b) ovalocytes (peripheral blood; Wright-Giemsa stain; 1000× magnification).

101. Keratocytes or Helmet Cells Have concavity on one side and two hornlike protrusions on either endProduced by impalement on a fibrin strandThe two halves of the RBC hang over the strandThe membranes touch and fusecontinued on next slide

102. Keratocytes or Helmet Cells Have concavity on one side and two hornlike protrusions on either endProduced by impalement on a fibrin strandProduces a vacuole-like inclusion on one side called blister cellThe vacuole bursts—leaving a notch with two spicules

103. KnizocytesCells with more than two concavitiesMost have a dark-staining band across the center with pale area on either side Surrounded by a rim of pink-staining HbMechanism of formation is unknown

104. LeptocytesThin, flat cells with normal or larger than normal diameterVolume (MCV) is usually decreased↑ surface-to-volume ratioDue to ↓Hb content or ↑ surface areaUsually cup shaped like a stomatocyteCup has little depthTarget cells can be formed from leptocytes on dried blood smears

105. Schistocytes (RBC Fragments)Caused by mechanical damage to cellsVariety of shapesTriangular, comma shaped, helmet shapedUsually microcyticNormal deformability but reduced survivalcontinued on next slide

106. Schistocytes (RBC Fragments)Caused by mechanical damage to cellsFragments can assume a spherical shape—may hemolyze or be removed by spleen

107. Figure 10-7c Poikilocytosis with acanthocytes, helmet cell, elliptocytes, echinocytes, schistocytes (3), and spherocytes (4). There is also anisocytosis with microcytes and macrocytes. At least two of the macrocytes are polychromatophilic (peripheral blood; Wright-Giemsa stain; 1000× magnification).

108. SpherocytesRBCs that have lost their biconcavity due to ↓ surface-to-volume ratioDensely stained sphere lacking central pallorOften appear microcytic but volume (MCV) is usually normalOnly RBC that can be called hyperchromic because of ↑ MCHC

109. Figure 10-7c Poikilocytosis with acanthocytes, helmet cell, elliptocytes, echinocytes, schistocytes (3), and spherocytes (4). There is also anisocytosis with microcytes and macrocytes. At least two of the macrocytes are polychromatophilic (peripheral blood; Wright-Giemsa stain; 1000 magnification).

110. Stomatocytes or Mouth CellsRBCs that have a slitlike area of pallorWet-prep appear as cup-shaped uniconcave discsShape is reversibleThought to be the result of an increase in the lipid content or area of the inner leaflet

111. Stomatocytes or Mouth CellsCan appear as artifact on smearCare should be taken when calling stomatocytes

112. Figure 10-11 Stomatocytes. Note the slitlike area of pallor (peripheral blood; Wright-Giemsa stain; 1000 magnification).

113. Variations in Hemoglobin Color Normal RBCs have a MCH of ~ 30 pgMCHC is better indicator of color on smearsNormal RBCsCentral pallor is ~ 1/3 of the diameter of the RBCcontinued on next slide

114. Variations in Hemoglobin Color HyperchromicThe only RBC that contains more Hb than normal in relation to its volume is the spherocytecontinued on next slide

115. Variations in Hemoglobin Color HypochromiaRBCs contain less Hb than normalCentral pallor >1/3 of the diameter of the RBCAre the result of decreased or impaired Hb synthesisMCHC will be decreased

116. Figure 10-12 Microcytic, hypochromic erythrocytes. Compare the size of the erythrocytes with the nucleus of the lymphocyte. Normocytic cells are about the same size as the nucleus. There is only a thin rim of hemoglobin around the periphery of the cells indicating that they are hypochromic (peripheral blood; Wright-Giemsa stain; 1000× magnification).

117. Variations in Hemoglobin Color Polychromatophilic RBCs (reticulocytes)Usually larger than normal RBCsBluish tinge on Romanowsky stainCaused by the residual RNA in the cytoplasmLarge numbers are associated with an erythroid hyperplastic marrow due to ↓ RBC survivalHemorrhage

118. Table 10-9 Variations in Erythrocyte Color

119. Red Blood Cell InclusionsRBCs do not normally contain any particulate inclusions.Associated with certain disease states when presentTheir presence may help direct further anemia investigation.

120. Red Blood Cell InclusionsBasophilic stipplingBluish-black granular inclusionsDistributed across the entire cell areaGranules may vary in size and distributionSmall diffuse granules to coarse and punctatecontinued on next slide

121. Red Blood Cell InclusionsBasophilic stipplingComposed of aggregated ribosomesBelieved that stippling is produced during slide prep as artifact (not seen in living cells)continued on next slide

122. Red Blood Cell InclusionsBasophilic stipplingArtifactCan occur when slide is dried slowly or stained rapidlySeen in lead poisoning, anemia associated with abnormal Hb synthesis, thalassemia

123. Red Blood Cell InclusionsCabot ringsReddish violet RBC inclusionsIn the formation of a figure 8 or oval ringThought to be remnants of spindle fibers from mitosisSeen in severe anemias and dyserythropoiesis

124. Red Blood Cell InclusionsHowell-Jolly BodiesDark purple or violet spherical granulesAre nuclear (DNA) fragmentsUsually occur singly in RBCs, rarely more than two per cellcontinued on next slide

125. Red Blood Cell InclusionsHowell-Jolly BodiesAssociated with nuclear maturation abnormalitiesSeen in post-splenectomy, megaloblastic anemias, some hemolytic anemias, functional asplenia, severe anemia

126. Red Blood Cell InclusionsHeinz BodiesDo not stain with Romanowsky stainStain with supravital stainAppear as 2–3 mcM round masses lying just under or attached to the cell membraneComposed of aggregated denatured Hbcontinued on next slide

127. Red Blood Cell InclusionsHeinz BodiesSeen inG6PD deficiency, unstable Hb disorders, oxidizing drugs or toxins, post-splenectomy

128. Table 10-10 Abnormal Erythrocyte Inclusionscontinued on next slide

129. Table 10-10 (continued) Abnormal Erythrocyte Inclusions

130. Red Blood Cell InclusionsSideroblastsNucleated RBCs that contain stainable iron granulesSiderocytesNon-nucleated mature RBCs that contain stainable iron granules

131. Red Blood Cell InclusionsBoth stained by Perl's Prussian blue stainStains iron aggregates blue20–60% all erythroblasts in BM contain iron↑ or ↓ in pathologic statesReticulocytes and RBCs don't normally contain stainable iron aggregates unless patient is splenectomized.

132. Table 10-11 Normal Erythrocytic Cell Inclusions

133. Red Blood Cell InclusionsPappenheimer bodiesDamaged secondary lysosomes and mitochondria, variable in their composition of protein and ironAppear as clusters of small granules in RBCs and erythroblastsRomanowsky stains protein matrix of granules

134. CBC Data ReviewLaboratory professional will analyze and interpret data generated by automated analyzer and blood smear review.Identify abnormal results, pathologies, and discrepancies in dataShould be able to recommend reflex or follow-up testing

135. CBC Data ReviewDelta checks compare patient's current lab values with previous lab values.Aid in identifying errorsImportant in diagnosis and monitoring therapy

136. Post-Examination—CBCReport dataLaboratory information system (LIS)Data includes reference intervals for each testFlags for abnormal results

137. Post-Examination—CBCRecognition of dataCritical limits represent critical low and high values for CBC parametersPanic values (life-threatening) must be confirmed, documented, called to physician

138. CBC VariationsNewborns WBC count higher (25 × 109/L)Granulocytes ↑, drops within 72 hrsImmature WBCs in circulation for 2 weeksRBCs macrocyticReticulocyte count 2–6%Nucleated RBCs, up to 10/100 WBCs, can be presentcontinued on next slide

139. CBC VariationsNewborns At birth, highest RBC, Hb, Hct values followed by gradual ↓MCV neonates 108 fL↓ to 77 fL between 6 months–2 yearsMCHC remains constant

140. CBC VariationsChildrenLymphs are predominant cell until age 44–5 years, equal numbers of lymphocytes and granulocytes6 years, same WBC subsets as adults

141. CBC VariationsElderlyBM cellularity decreases with ageAnemia becomes more prevalent due to:Iron deficiencyVitamin B12 deficiencycontinued on next slide

142. CBC VariationsElderlyAnemia becomes more prevalent due to:Anemia of chronic inflammationKidney disease↓ testosterone levelsMalignancies occur at higher incidence

143. CBC VariationsEthnic GroupsAfrican AmericansLower Hb, Hct, MCVs than Caucasians30% prevalence of α-thalassemiaWBCs lower, particularly granulocytes, but lymphocytes are highercontinued on next slide

144. CBC VariationsEthnic GroupsSexesMales have higher Hb, Hct, RBC, WBC counts than femalesFemales have higher platelets, slightly lower MCV, MCH

145. CBC VariationsGeographic locationReference intervals for Hb, Hct, RBCs are higher for those living at high altitudes.

146. Chapter 10—Case StudyA 48-year-old female was admitted to a hospital due to wheezing, cough, fatigue, and difficulty breathing. Her history included diabetes and hypertension. Her CBC showed:Hb 8.2 g/dLRBC 1.73 × 1012/LMCV 109.8 fLcontinued on next slide

147. Chapter 10—Case StudyA 48-year-old female was admitted to a hospital due to wheezing, cough, fatigue, and difficulty breathing. Her history included diabetes and hypertension. Her CBC showed:WBC, Platelets were within the reference limitsConsider the actions the laboratory professional should take.continued on next slide

148. Chapter 10—Case StudyQuestion 1: Calculate the Hct, MCH, and MCHC from the initial results.Question 2: Evaluate the calculated Hct, MCH, and MCHC as compared to the reference intervals for a 48-year-old female.continued on next slide

149. Chapter 10—Case StudyBecause of the abnormal values found in the CBC, the lab professional made a blood smear and performed a WBC differential with RBC and platelet evaluation. The primary abnormal finding is found in the following smear image.continued on next slide

150. Chapter 10—Case Studycontinued on next slide

151. Chapter 10—Case StudyQuestion 3: What should the laboratory professional report about the RBCs in the critical area of this smear?Question 4: Which results of the CBC might be affected by the findings on the smear?Question 5: Explain why the abnormal values in the CBC occurred in this case.continued on next slide

152. Chapter 10—Case StudyQuestion 6: Predict the RDW value for the RBCs from this patient as increased or normal.continued on next slide

153. Chapter 10—Case StudyThe lab professional warmed the EDTA blood sample from the patient at 37°C for 15 minutes, reran the CBC, and made a new smear.New CBC values:Hb 8.2 g/dLRBC 2.63 × 1012/LMCV 91 fLcontinued on next slide

154. Chapter 10—Case Studycontinued on next slide

155. Chapter 10—Case StudyQuestion 7: Calculate the hematocrit, MCH, and MCHC on the warmed specimen. How have they changed?Question 8: Explain what could have happened in this case.