Practical Utilization of the Complete Blood Count

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Introduction. Overview of Components of CBCWhite Blood CellsHemoglobin / HematocritPlateletsCell MorphologySecondary Testing. Complete Blood Count - CBC. WBCHemoglobin / HematocritMCVRDWMCHC / MCHPlateletsDifferential CountManual Machine. When Assessing Cytopenias Always Think Three Thi
Practical Utilization of the Complete Blood Count

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1. Practical Utilization of the Complete Blood Count Joseph M. Flynn, D.O.,MPH, FACP Division Hematology-Oncology THE Ohio State University Columbus, OH April 18, 2008

2. Introduction Overview of Components of CBC White Blood Cells Hemoglobin / Hematocrit Platelets Cell Morphology Secondary Testing

3. Complete Blood Count - CBC WBC Hemoglobin / Hematocrit MCV RDW MCHC / MCH Platelets Differential Count Manual Machine

4. When Assessing Cytopenias Always Think Three Things Not making enough Losing cells Cell destruction

5. WHITE BLOOD CELLS

6. Blood Cell Formation

7. White Blood Cells Neutrophils Absolute Neutrophil Count WBC x Neu% (segmented neutrophils and bands) Lymphocytes Monocytes Eosinophils Basophils

8. What to Do if WBC Abnormal Take a Good History Physical Examination Look at Old CBC?s!!!!

9. Neutrophils 60 - 70 % of Circulating Leukocytes Half Life Six to Seven Hours in blood One to Two Days in Connective Tissue Primary Defense against Bacteria

10. Neutrophils Neutropenia Absolute Neutrophil Count < 1500 (Often < 1000 in African Americans) Neutrophilia Absolute Neutrophil Count > 8000 Leukemoid Reaction Elevation in WBC Typically < 50,000

11. Neutropenia Decreased Production Infections Severe Bacterial Viral Rickettsial Drugs Antibiotics NSAIDS Others Hematological Disease Dietary Shock Severe Renal Disease Decreased Survival Infections Drugs Immune mediated SLE Cyclic

12. Evaluation of Neutropenia

13. Benign (Ethnic) Neutropenia Characterized by neutrophil counts 800 to 1400/mm3 Generally a benign course Sometimes associated with periodontal disease No increase in infections Bone marrow is typically normocellular Seen in African American, some Jewish populations

14. Neutrophilia Acute Infections Leukocyte: 15-25 X 109/L. Inflammation Postoperatively, neutrophilia occurs for 12-36 hours as a result of tissue injury Metabolic Uremia, DKA Eclampsia Chemicals Steroids Epinephrine

15. Neutrophilia Acute Hemorrhage Related to the release of adrenal corticosteroids and/or epinephrine Acute Hemolysis Myeloproliferative disorders Tissue Injury Tobacco Use Physiological Stress Exercise Emotional Stress Menstruation

16. Steroid Effect Increases total and relative PMN?s Peak is 4-6 hours Normalizes in 24 hours after steroids stopped Usually see a concurrent decrease in Lymphocytes and Monocytes

17. Lymphocytosis Infections Viral Hepatitis CMV Tuberculosis Addisons Disease Leukemia Ulcerative Colitis / Crohn?s Disease Vasculitis Drug Hypersensitivity

18. Lymphopenia Increased Destruction Corticosteroids Congestive Heart Failure Loss through GI tract Decreased Production Malignancies Immunoglobulin Disorders HIV Infection Lupus

19. Eosinophilia > 250/ CU MM Highest Levels in am Allergic Diseases Parasitic Infections: Trichinosis, Schistosomiasis Leukemias Familial Addison?s Disease, Hypopituitarism Drugs: Aspirin Collagen Vascular Diseases: Churg-Strauss, Scleroderma/dermatomyositis, RA, SLE, Periarteritis Nodosa

20. Monocytosis > 10% of differential Elevated in: Leukemia Hodgkins / Non Hodgkins lymphoma Post Splenectomy Protozoan Infections Rickettsial Infections: Rocky Mountain Fever, Typhus Sarcoidosis Collagen Vascular Diseases Enteritis

21. Hemoglobin Boys and girls are same until @ age 11 Boys values slowly become higher Adult levels reached Age 15 Women Age 18 Men African Americans 0.5 - 1.0gm (5-10 g/dL) lower than northern Europeans Positional differences Upright vs post bedtime

22. Changes in Hgb Not Due to Blood Loss or Abherrent Condition Increased: Increased WBC WBC >50,000 Smoking Dehydration Triglycerides >2000 Decreased Position Pregnancy Diurnal Race Females IV fluids

23. MCV Falsely Abnormal Cold Agglutinins Hyperglycemia Reticulocytosis Leukocytosis Acute Hemolysis

24. RDW vs MCV Normal RDW ; Low MCV Thalassemia Chronic Disease Normal RDW ; High MCV Aplastic Anemia Myelodysplasia Alcohol Normal RDW ; Normal MCV Chronic disease (90%) Hereditary Spherocytosis Acute Bleed Cirrhosis Uremia

25. RDW vs MCV HIGH RDW ; Low MCV Iron Deficiency S-Thalassemia RBC fragmentation HIGH RDW ; HIGH MCV B12/Folate Autoimmune hemolysis Cold Agglutinins HIGH RDW ; Normal MCV Early Factor Deficiency SS disease SC dz Sideroblastic anemia Myelofibrosis

26. Pathophysiologic Classification Anemia Due to Decreased RBC Production Due to RBC Destruction 0.8 % rbc?s destroyed daily Best suited for relating disease processes to their mechanisms Limited in the complexity of mechanisms and lack of solidly established mechanisms

27. Microcytosis Differential Diagnosis Iron Deficiency Thalassemia Beta-Thalassemia: Elevated Hgb A2 or F alpha Thalassemia diagnosis of exclusion Anemia of Chronic Disease Though 75% patients are normocytic Sideroblastic anemia - rare Lead poisoning - rare

28. Iron Deficiency Most common cause of microcytosis Clinical Clues Iron Studies Iron Total Iron Binding Capacity Ferritin Iron Saturation (Serum Iron / TIBC ) < 10 % saturation

29. Iron

30. When Do I Get a Hemoglobin Electropheresis Iron studies not indicative of another process Family history of hemoglobinopathy African American Asian decent Mediterranean decent Microcytosis in face of mild-No anemia

31. Macrocytosis MCV > 100 Folate/B12 20 - 30% Chronic Liver dx 15 - 20% ** Alcoholism 10 - 12% - Chemotherapy 10 - 15% Reticulocytosis 7% Myelodysplastic Common Unknown 25% Distance runners Hypothyroidism ** Hyperlipidemia **

32. Evaluation of Macrocytosis History Physical False Macrocytosis Cold agglutinins: RBC clumping Hyperglycemia: Hyperosmolarity Leukocytosis: WBC counted as RBC

33. Evaluation of Macrocytosis B12 / Folate Look for hypersegmented neutrophils Thyroid Studies If clinically indicated Liver Associated Enzymes Reticulocyte Count

34. Megaloblastic Anemia Hypersegmented Neutrophils Any neutrophil with > six segments or More than five percent with five segments or Majority of cells with four segments Presence of Macroovalocytes Egg - shaped cells

35. Megaloblastic Anemia Diagnosis Serum folate levels may be misleading Alcohol lowers the folate levels Correcting serum folate can be seen after a meal Determine the cause of the deficiency Ie. Pernicious anemia, Malabsorption, Diet Red cell changes are not seen in all vitamin deficient patients MCV usually > 110 though > 130 more specific Look at RDW Cell Morphology

36. Diagnosing Vitamin Deficiencies Serum cobalamin < 200 pg/ml: consistent with Cobalamin deficiency >300 pg/ml: Normal Serum folate concentrations If Folate is >4ng/ml then not folate deficient If Folate is < 2ng/ml then folate deficient If Borderline, Check Red blood cell levels

37. Diagnosing Vitamin Deficiencies Methylmalonic acid and Homocysteine Good if Cobalamin and Folate are equivocal Both elevated = Cobalamin Deficiency 95% Sensitivity 99% Specificity If Homocysteine only elevated = Folate Deficiency 85% Sensitivity Anti-Intrinsic factor Antibodies Confirms Pernicious Anemia

39. Normocytic Anemia Differential Diagnosis Acute Hemorrhage Hemolysis Aplastic Anemia Renal Failure Myelophthisis Sickle cell anemia Chronic Disease Combined Microcytosis / Macrocytosis

40. Normocytic Anemia Evaluation Clinical History Review CBC for multiple Cell line deficiencies RDW / Smear Malnutrition Direct Antibody Test Chemistries Consider Bone Marrow Biopsy

41. Red Blood Cells Spherocytes Sickle Cells Schistocytes Tear Drop Cells Basophilic Stippling Howell-Jolly Bodies

42. Schistocytes Differential Diagnosis Mechanical Valves Stenotic Valves Malignant Hypertension Disseminated Intravascular Coagulation DIC Hemolytic Uremic Syndrome ? HUS Thrombotic Thrombocytopenic Purpura

43. Platelets Size should be <1/3 that of RBC Thrombocytopenia: < 150,000 < 100,000 is important number Should be suspected when platelets are found in <1 in 10 fields on high power Thrombocytosis: >450,000/cu mm Pseudothrombocytopenia

44. Thrombocytopenia Decreased Production Acute Infection Increased Destruction Consumption Primary or Hereditary

45. Thrombocytopenia > 50,000: Typically no bleeding 20 ? 50,000: Post operative bleeding and minor mucosal bleeding 5 ? 20,000: Can have significant bleeding <5,000: Severe bleeding possible Unless ITP

46. Pseudothrombocytopenia EDTA related platelet clumping Clinically insignificant Cold Agglutinins Giant Platelets Erythrocytosis

47. Idiopathic Thrombocytopenic Purpura IDIOPATHIC Bleeding unlikely unless < 10,000 Diagnosis of exclusion Bone marrow biopsy necessary only in those > 60 years old

48. Thrombocytosis Infection Acute Phase Reactant 1/3 of patients Inflammatory State Malignancy Recent Surgery Iron Deficiency Anemia Trauma Myeloproliferative Disorder >600,000 on two occasions


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