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Imaging session Haematology MBChB V. Session 1 MJ Coetzee. Normal blood picture. Normal blood smear. Normal white cells. Normal red cells & platelets. Eosinophil. Basophil. Normal band cell. Normal bone marrow.

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normal blood smear
Normal blood smear

Normal white cells

Normal red cells& platelets

eosinophil
Eosinophil

Basophil

slide7

Stem cells give rise toe cells that develop into mature cells in the circulation

  • Problems with stem cells cause bone marrow failure and even leukaemia
normal bone marrow smear
Normal bone marrow smear

Normal bone marrow particle (1/3 adipose cells)

hypercellular bone marrow
Hypercellular bone marrow

Biopsy (histological picture)

Particle on smear

slide11

Hypocellular bone marrow

Adipose cells have replaced normal bone marrow

Bone

Aspirate particle

full blood count 1
Full blood count-1
  • The FBC is a group of tests that provides us with information about:
    • Red cells and their properties
    • Total white cell count and concentrations of types of white cells (differential count)
    • Concentrations of platelets
  • A blood smear is made and the morphology of the blood cells are reported
  • Often the ESR is done simultaneously
full blood count 2
Full blood count -2
  • Blood for a FBC is drawn into a purple tube,thatcontainsthe anticoagulant EDTA
  • The tube should reach the lab. within 2 hours - otherwise artifacts can occur
  • Manual blood counts entails involves pipetting by mouth and involves a risk of infection
  • Automated cell counters count red cells, white cells & platelets, en does Hb and red cell indices
haemoglobin 1
Haemoglobin-1
  • Normal Hb varies with age, sex & height above sea level
  • In Bloemfontein (1300 m) the normal Hb for adults is:
    • Men: 14,5-18,5 g/dl
    • Women: 12,5-16,5 g/dl
haemoglobin 2
Haemoglobin-2
  • Hb can also be measured in g/l and mmol/l
  • World Health Organisation
    • At sea level
    • Definitions of anaemia by experts
  • Children < 10 j < 9 g/dl
  • Adult men < 13 g/dl
  • Adult women < 12 g/dl
  • Pregnant women < 11 g/dl
red cell indices 1
Red cell indices-1
  • The Hb shows the presence/absence of anaemia
  • The red cell indices show the type of anaemia
  • The MCV (mean. corpuscular volume) is usually between 80-100 fl
    • MCV < 80 fl: microcytic
    • MCV 80-100 fl: normocytic
    • MCV > 100 fl: macrocytic
red cell indices 2
Red cell indices-2
  • The haematocrit reflects the portion of the blood that consists of RBCs.
    • It is used exstensively in the USA as an indicator of anaemia, but not elsewhere
  • The MCH (mean cell haemoglobin) reflects the amount Hb/RBC
  • The MCHC gives an idea of the colour of the RBCs
  • Nowadays the MCV is accurately measured and it is the most important
white cell count
White cell count
  • The total WCC is 4,0-11,0 x 109/l
  • Most of the white cells are neutrophils
  • A leucopenia is mostly caused by a decreased number of neutrophils, but not always
  • A leucocytosis is mostly caused by an increased number of neutrophils, but not always
  • Therefore it is important to know the absolute count of individual types white cells
report of the blood smear
Report of the blood smear
  • Although one can obtain a lot of information from the FBC, always read the comments on the blood morphology
  • The morphology can give information about e.g. malaria, left shift, activated lymphocytes, etc, while most machines cannot do this
    • Comments put the counts in perspective and lead one to determine the cause of an anaemia, etc.
round macrocytosis e g alcohol
Round macrocytosis(e.g. alcohol)

Oval macrocytes (e.g. megaloblastic anaemia

acanthocytes e g liver disease
Acanthocytes(e.g. liver disease)

Blood smear

Electron microscopy

polychromasia e g haemolysis
polychromasia, e.g. haemolysis

Rouleaux (e.g. TB, HIV)

slide27

Spherocytes: blood smear

Shape of normal RBCs & spherocytes

neutrophils
Neutrophils
  • Neutropenia
    • Mostly caused by suppression
    • Also called agranulocytosis
    • Causes: antithyroid, anti-inflammatory drugs, anticonvulsants, antipsychotics, cytostatics chemotherapy, radiation
    • Effects: infections (esp. respiratory), opportunistic, fungi
  • Neutrophilia (neutrophil leucocytosis)
    • Mostly caused by bacterial infections
    • With severe infections they can show toxic granulation
    • A leftshift indicates immature WBCs - infection
neutrophil leucocytosis
Neutrophil leucocytosis

Toxic granulation

slide32

Band cell (left shift)

Döhle bodies (infection)

lymphocytes
Lymphocytes
  • Lymphopenia
    • Mostly caused by drugs, e.g. steroids
  • Lymphocytosis
    • Mostly caused by viral infections
    • With severe virus infections the lymphocytes can appear activated
monocytes eosinophils
Monocytes & eosinophils
  • Monocytosis
    • Mostly caused by chronic infections, e.g. TB
  • Eosinophilia
    • Parasitic infections, allergies, skin conditions, neoplasia
slide40
HIV

Loose nuclear fragments

Acid-fast bacilli in bone marrow (TB)

malaria
Malaria

Thick smears

Falciparum trophozoites

Falciparum gametocytes(longstandinginfection

Non-falciparum malaria (large cells)

slide44

Pallor

“Strawberry” tongue:Fe deficiency

Hands useful, regardless of ethnicity

slide47

No Fe stainin marrow particle

Normal (blue) Fe stain of marrow particle

slide50

Oval macrocyte

Megaloblastic BM

causes inside the rbc membrane
Causes inside the RBC membrane
  • RBC cytoskeleton under phospholipid-membrane
    • Complex mutations
  • Hereditary spherocytosis
    • Different mutations give rise to loss of membrane (soccer ball RBCs)
  • Rx: splenectomy 

Gall stones after chronic haemolysis (barium in gall bladder)

causes inside the rbc
Causes inside the RBC
  • Enzyme deficiencies
    • G6PD deficiency common in Africa
  • Haemoglobinopathies
    • Thalassaemias, sickle Hb
  • Infections
    • Malaria
      • Falciparum 
slide62

Fanconi anaemia

  • Sister (L) is small,has abnormal thumbs,café-au-lait spots& an indwelling catheter forher regular trans-fusions
  • Sister (R) normal
platelets
Platelets
  • Thrombocytopenia
    • Decreased production (bone marrow failure) or increased destruction (ITP)
  • Thrombocytosis
    • Reactive: infections, post-splenectomy
    • Thrombocytaemia: essential thrombocythaemia
slide69
Paper case 1
  • A. is a forty-five year-old lady that is prematurely grey. She complains that she has become increasingly tired over the last few months. She can hardly walk around a block. She is also losing her balance. She is pale, slightly jaundiced and has cracks in the corners of her mouth. Her tongue is raw and her pulse is fast. She has lost her sense of vibration in her arms and legs. She has a white cell count of 2.5 x 109/l (normal 4-11 x 109/l), haemoglobin of 6 g/dl (normal 12.5-16.5 g/dl) and platelets of 100 x 109/l (normal 150-400 x 109/l). Her red cells are oval and macrocytic. The nuclei of her neutrophils are hypersegmented.
slide70
Paper case 2
  • N. is a 50-year old man that presents with exercise intolerance. He eats a balanced diet. He had a partial gastrectomy for a bleeding ulcer, five years ago. His full blood count shows: white cells 4 x 109/l, haemoglobin 9 g/dl and platelets 100 x 109/l. The rapport says that he has oval macrocytes.
slide71
Paper case3
  • Ms H. is 30 years old. She has three children and is pregnant. Her husband lost his job recently and they live in Joe Slovo informal settlement. She feels increasingly tired and presented at the Polyclinic. She becomes unsteady and complains that her heart beats fast. She has developed a taste for clay.
  • She is pale and has slight ankle oedema. Her pulse is 90/min. She is 30 weeks pregnant. Her haemoglobin is 8 g/dl with a mean cell volume (MCV) of 65 fl.
slide72
Paper case4

T. is an 18-year old woman that has become increasingly pale and tired over the last fortnight. Her eyes are yellow. Her left upper abdomen is tender. Her mother had a similar condition as a youngster and had a splenectomy. After the operation her mother’s symptoms never recurred. T’s FBC shows the following: WBCs 7 x 109/l, haemoglobin 8 g/dl and platelets 250 x 109/l. Her blood smear shows spherocytes and her reticulocyte count is raised.

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