Anemia and CBC interpretation77777 .pptx

ANEMIA

1. ANAEMIA

2. OUTLINE Definition Volume changes and Anaemia Erythropoesis Causes Classification Clinical features Management

3. Definition: Strictly defined as a decrease in red blood cell mass. The World Health Organization, (WHO), criterion for anemia in adults is a hemoglobin (Hb) value of less than 12.5 g/dL.

4. Normal Haematopoiesis Foetus – 0-2 mo; Yolk sac 2-7mo; liver/spleen 5-9mo; bone marrow Infants – Bone marrow of all bones Adults – Vertebrae, ribs, sternum, skull, sacrum, proximal ends of femur

5. Causes of Anaemia There are 3 major causes of anemia; Decreased RBC production ( Hypoproliferation ) Low reticulocyte count (<75,000/ m L) Lack of nutrients (B12, folate, iron) Bone Marrow Disorder Renal disease Inflammation Bone Marrow Suppression Increased RBC destruction (Hemolysis) Inherited and Acquired Hemolytic Anemias High reticulocyte count (>100,000/ m L) High LDH, increased unconjugated (indirect) bilirubin, decreased haptoglobin Blood Loss / HAEMORRHAGIC If chronic, leads to hypoproliferative anemia due to iron deficiency High reticulocyte count (>100,000/ m L)

6. Others: Genetic etiologies : Hemglobinopathies Thalassemias Enzyme abnormalities of the glycolytic pathway Defects of the RBC cytoskeleton Rh null disease Hereditary xerocytosis Abetalipoproteinemia Fanconi anemia

7. Nutritional etiologies Iron deficiency anemia Vit B12 deficiency Folate deficiency Starvation and generalized malnutrition

8. Physical etiologies Trauma Burns Frostbite Prosthetic valves

9. Chronic disease and malignancies Kidney disease Liver disease Chronic infection Neoplasia Collagen vascular disease

10. Infectious etiologies Viral- hepatitis, infectious mononucleosis, CMV Bacterial- clostridia, gram negative sepsis Protozoal- malaria, leishmaniasis , toxoplasmosis

11. Hemolytic Anemias Hereditary spherocytosis Glucose-6-phosphate dehydrogenase (G6PD) Deficiency Most common enzyme defect in erythrocytes X-linked Brisk hemolysis when patients exposed to oxidative stress from drugs, infections or toxins. Thrombotic Thrombocytopenic Purpura (TTP) Thrombocytopenia and microangiopathic hemolytic anemia, fever, renal insufficiency, neurologic symptoms Schistocytes on smear Hemolytic Uremic Syndrome Thrombocytopenia, Microangiopathic hemolytic anemia, renal insufficiency Autoimmune Hemolytic Anemia Warm-antibody mediated IgG antibody binds to erythrocyte surface most common Diagnosed by POSITIVE Coomb’s Test ( detects IgG or complement on the cell surface) Can be caused drugs Treated with corticosteroids or splenectomy if refractory Cold agglutinin Disease IgM antibodies bind to erythrocyte surface Does not respond to corticosteroids, but usually mild. Infections Malaria Babesiosis Sepsis Trauma Includes some snake, insect bites

12. Common causes of anaemia in Newborns Includes; blood loss, immune hemolytic disease (ie, Rh or ABO incompatibility), congenital infection, twin-twin transfusion, congenital hemolytic anaemia (G6PD, hereditary spherocytosis) “Physiologic” anaemia is most common in infants

13. Classification of anemia Morphologic Normocytic: MCV= 80-100fL Macrocytic: MCV > 100 fL Microcytic : MCV < 80 fL Pathogen esis (underlying mechanism) Blood loss (bleeding) Decreased RBC production Increased RBC destruction/pooling

14. Normocytic Anemias Acute post-hemorrhagic anemia Hemolytic anemia (except thalassemia and some other Hb disorders) Aplastic anemia Pure red cell aplasia Bone marrow infiltration Endocrin diseases Renal failure Liver disease Chronic disease anemia Protein malnutrition Hypovitaminosis C

15. Microcytic anemias Iron deficiency anemia Thalassemia Sideroblastic anemia Lead poisoning Anemia of chronic diseases (some cases)

16. Macrocytic anemias Megaloblastic Non-megaloblastic

17. Megaloblastic Macrocytic Anemias Vit B 12 deficiency Folic acid deficiency

18. Non-megaloblastic Macrocytic Anemias Anemia of acute bleeding Hemolytic anemias Leukemias (esp: acute) Myelodysplastic syndromes Liver disease Aplastic anemia Diseases infiltrative to the bone marrow Alcoholism Hypothyroidism Scurvy

19. Causes of B12 deficiency Low intake (Nutritional) No supply for 3 years Malabsorption Gastric causes Pernicious anaemia Abnormality of intrinsic factor Total or partial gastrectomy Intestinal Causes Ileal resection Crohns disease Stagnant loop syndrome Congenital malabsorption with preteinuria Tropical sprue

20. Vitamin B12 Deficiency Versus Folate Deficiency Vitamin B 12 Deficiency Folate Deficiency MCV > 100 > 100 Smear Macrocytosis with hypersegmented neutrophils Macrocytosis with hypersegmented neutrophils Pernicious anemia Yes NO Homocystine Elevated Elevated Methylmalonic Acid Elevated NORMAL

21. Anemia leads to two symptom complexes ; Tissue hypoxia Fatigue,dyspnea on exertion etc Compensatory attempts Tachycardia,hyperventilation etc

22. Compensating mechanisms in anemia : The release of oxygen to the tissues is increased (reduced oxygen affinity of Hb)

23. Compensating mechanisms in anemia The rate of blood circulation and cardiac output increases. An increase in plasma volume maintains total blood volume in normal or near normal ranges. Redistribution of blood flow.

24. Different patients may have different severity of symptoms even for the same level of Hb. The severity of the symptoms of anemia are related to; The severity of anemia The age,CVS,pulmonary status etc of the patient The rate of the development of anemia Gradual or Rapid onset

25. Clinical symptoms and findings of anemia on examination General Fatigue, weakness Tiredness, lassitude , reduced exercise tolerence Generalized muscular weakness Pallor of skin or mucous membranes In pernicious anemia there is a lemon yellow pallor. Pallor + mild scleral icterus suggests hemolytic anemia. Pallor+ petechiae suggests severe bone marrow failure

26. S kin/mucosal changes Premature graying of hair:pern icious a nemia Hair loss and fragility + spooning of the nails:iron deficiency Chronic leg ulcers:Sickle cell or other hemolytic anemia Glossitis/burning sense :Pern icious anemia, iron deficiency(rare) Chelitis(angular stomatitis):iron def. Sideropenic dysphagia: iron def. Painful ulcerative mouth lesions: aplastic anemia/leukemia

27. S ymptoms and signs Central nervous system (CNS) Headache Faintness D i z z i n e s s Tinnitus Decreased concentration ability Drowsiness,decreased muscle strength Clouding of consciousness Symptoms are more prominent in older patients Paresthesias:Vitamin B12 deficiency (or other).

28. S ymptoms and signs Cardiovascular System . High output state: Collapsing pulse, high pulse pressure Cardiomegaly Congestive failure Ischemic ECG changes

29. Symptoms and signs Respiratory Dyspnea Hperventilation

30. Clinical symptoms and findings of anemia Gastrointestinal system Anorexia Flatulence Nausea Constipation Weight loss

31. Clinical symptoms and findings of anemia Ocular findings : fundus Pale and sometimes Hemorrhages Papillaedema Conjunctiva and sclera pallor Icterus Splinter hemorrhages petechiae

32. Clinical symptoms and findings of anemia Renal System Slight proteinuria Concentrating defects Further reduction of renal function in patients with previous renal impairment

33. Iron deficiency: clinical presentation Symptoms specific for iron deficiency Postcricoid esophageal web Glossitis Angular stomatitis

34. Pagophagia or pica(ice eating) Spooned nails ( koilonychia )

35. Vitamin B12 deficiency: Clinical presentation Early graying of hair Burning sensation of the tongue Loss of proprioception Parathesias and sometimes unusual sensations often described as pain.

36. Folate deficiency: clinical presentation Sore tongue Cheilosis Symptoms associated with steatorrhea (color, bulk, frequency, and odor of stools as well as if they float on water)

37. Ddx Alpha thalassemia Aplastic anemia Beta thalassemia Fe deficiency anemia Hemolytic anemia Pernicious anemia Sickle cell anemia Megaloblastic anemia

38. Investigations CBC mRDT Peripheral blood smear Reticulocyte count TIBC (Total Iron binding capacity) Serum iron Level Serum Ferritin level Serum homocystine Serum methyl malonic acid Serum Vit B12 level

39. Direct Coomb’s test for (Autoimmune Anemia, warm(IgG) and cold (IgM) antibodies) Haptoglobins level Bilirubin and LDH Iron saturation Bone marrow biopsy (Lack of iron in erythroid precusors ) Liver, renal, hormonal function tests

40. Lab Analysis in Hemolytic Anemia Increased indirect bilirubin Increased LDH Increased reticulocyte count Normal reticulocyte count is 0.5 to 1.5% > 3% is sign of increased reticulocyte production, suggestive of hemolysis Reduced or absent haptoglobin < 25 mg /dL suggests hemolysis Haptoglobin binds to free hemoglobin released after hemolysis

41. Evaluating the Patient with Anemia Check Hemoglobin/Hematocrit If female, is Hgb < 12 or Hct < 36? If male, is Hgb < 13.5 or Hct < 41? In newborns <14 6-9 months < 11 6-12 months <13.5

42. Management Any history of medical problems that could cause anemia? Sickle cell Disease Thalassemia Renal Disease Hereditary Spherocytosis Malaria Sepsis Trauma GITB

43. MANAGEMENT History of ; Dietary intake Environmental exposure (lead poisoning, hair dyes, insecticides, solvents) Family history of (blood transfusion of relatives,splenectomy , cholelithiasis , bleading disorders, etc ) Patients hobbies, prior medical treatment, drugs While searching for acute blood loss inquire about pregnancies, abortions, and menstrual loss.

44. History cont : Change in bowel stools should also be reported, GIT complaints, abnormal urine ,hepatic disease, etc Thorough dietary history including the foods that the patient eats and those that he doesn’t as well as their quantity

45. Mx Cont Blood/or blood products transfusion (for active bleeding, severe symptomatic anaemia) Erythropoietin can be used for chronic anemia Treat specific deficiency Treat underlying condition Diet (iron, Folic acid, Vit B12) Bone marrow transplant for aplastic anemia, malignancy or use immunosuppressant agents Splenectomy for hypersplenism, AIH anemia , hereditary hemolytic disorders)

46. Blood and blood products Whole blood Packed red blood cells(Limit volume, should be administered to actively bleeding patients, and those with severe and symptomatic anemia ) Fresh frozen blood(contains coagulation factors, protein C and S). Used for treating coagulopathies as well as TTP Cryoprecipitate – for Von Willebrand disease. Contains fibrinogen, factor VIII and vWF Platelets- thrombocytopenia

47. Iron 150-200mg/day supplement Expect Hb increase of at least 2 g/dL after 3 weeks After anemia corrected, continue for 4-6 months or until ferritin > 50 m g/L Parenteral iron therapy If pt unable to tolerate oral iron, has persistent iron deficiency despite iron iron, or has iron malabsorption Iron dextran, ferric gluconate, iron sucrose, ferumoxytol All with risk of anaphylactic reaction and serum sickness

48. Blood transfusion indications Depends on many factors not necessarily very low HCT or Hb

49. Splenectomy: For treatment of patients with auto-immune hemolytic anemias and certain hereditary disorders ( elliptocytosis , spherocytosis etc )

50. newborns Alloimmune hemolytic disease, Anemia of prematurity, and iatrogenic Blood loss, Perinatal blood loss,

51. Infants (1-3months Hematocrit is <20 % ,(HB <6.7 g/dL) and reticulocyte count is low (ie, <2% Transfusion at higher HCT levels may be warranted in premature infants and those with cyanotic congenital heart disease

52. Infants (≥4 mo) Hgb levels <7 g/dL (hematocrit <21 percent).

53. Indications for BT in Sickle cell disease Acute chest syndrome Acute stroke, and primary and secondary stroke prevention Aplastic crisis and splenic sequestration crisis Prevention of recurrent priapism Reduction of perioperative complications using preoperative transfusion

54. Sickle Cell Anemia

55. Spherocytosis

56. TTP / HUS – microangiopathic hemolysis with schistocytes

57. Malaria

58. Anemia of Chronic Disease Occurs in people with inflammatory conditions such as collagen vascular disease, malignancy or chronic infection. Usually normocytic, normochromic (but can become hypochromic, microcytic over time) Iron replacement is not necessary May benefit from erythropoietin supplementation.

59. Pathophysiology

60. COMPLETE BLOOD COUNT INTERPRETATION.

61. I NTRODUCTION •The complete blood count (CBC) is one of the most commonly ordered blood tests. It is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by automated analyzer to different components of blood in less than a minute. •A major portion of the complete blood count is the measure of the concentration of white blood cells, red blood cells, platelets and their various parameters. •It can be used as a screening test for many disorders and as a prognostic or follow up tool.

62. PARAMETERS T he complete blood count, Typically, includes the following: 1.White blood cell count (WBC or leukocyte count) 2.WBC differential count 3.Red blood cell count (RBC or erythrocyte count) 4.Hematocrit (Hct) 5.Hemoglobin (Hbg) 6.Mean corpuscular volume (MCV) 7.Mean corpuscular hemoglobin (MCH) 8.Mean corpuscular hemoglobin concentration (MCHC) 9.Red cell distribution width (RDW) 10.Platelet count 11.Mean Platelet Volume (MPV)

63. Indications for CBC A CBC can be ordered if a patient has any of signs and symptoms that may be related to disorders that affect blood cells. 1.When an individual has fatigue or weakness, s&s of infection, s&s of inflammation, bruising, or bleeding A CBC can help diagnose the cause and/or determine the severity. 2. CBC will often be ordered on a regular basis to monitor certain conditions that affect cells. CBC may be performed frequently to determine if the treatment is effective.

64. Treatments s uch as chemotherapy, can affect bone marrow production of cells. Some medications like Zidovudine can cause anemia, carbimazole, dapsone etc can cause neutropenia, others can decrease WBCs count overall , Heparin induced thrombocytopenia A CBC may therefore be ordered on a regular basis to monitor these drug treatments.

65. RED BLOOD CELLS - 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 o f about 8 µm F unction : - transport hemoglobin which carries oxygen from the lung to the tissues -acid –base buffer. Life span 100-120 days.

66. LOW RBC COUNT It i s known as anemia Causes: - Acute or chronic bleeding - RBC destruction e.g hemolytic anemia - Nutritional deficiency e.g. iron deficiency, vitamin B12 and folate deficiency - Bone marrow disorders or damage - Chronic inflammatory disease - Kidney failure

67. HIGH RBC COUNT - Polycythemia Causes; - Dehydration - Pulmonary disease ( COPD-chronic hypoxia-increased erythropoietin production) - K idney or other tumors that produce excess erythropoietin e.g adrenal adenoma, Ca liver - S moking - G enetic causes (altered oxygen sensing, abnormality in hemoglobin oxygen release e.g 2,3-BPG deficiency (facilitates the supply of oxygen to the tissues by binding to hemoglobin) - Polycythemia vera; a stem cell disorder characterized as a panhyperplastic, malignant, and neoplastic marrow disorder. Its most prominent feature is an elevated absolute red blood cell count because of uncontrolled red blood cell production.

68. Hemoglobin Is the protein that carries oxygen in the red blood cells. ●13.0-18.0 g/dl in males ●11.5.0 to 16.5 g/dl in females 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 %( 45%) –F: 36.1 to 44.3 %(40%) •Low Hematocrit is due to anemia

69. Increased Hematocrit is caused by : •Increased risk of shock syndrome •Polycythemia vera •COPD • Erythropoietin use •Dehydration •Capillary leak syndrome (severe hypotension, hypoalbuminemia, and hemoconcentration) •Sleep apnea •Anabolic steroid use (⬆️erythropoesis)

70. The MCV indicates the average volume of the red blood cells. MCV = = Normal range 76-100fl Volume of RBC in femtoliters ( fl ) / μ l of blood RBC / μ l of blood Hematocrit * 10 RBC count in millions Mean Corpuscular Volume (MCV)

71. - L ow MCV indicate that RBCs are smaller than normal (microcytic) and is usually caused by; Thalassemias,anemia of chronic d’se , iron deficiency anemia, lead poisoning, congenital sideroblastic anemia. - Hi gh MCV indicate that RBCs are larger than normal ( macrocytic) and there two types in this category: Megaloblastic macrocytic anemia ( nuclear maturation defect) Non- megaloblastic macrocytic anemia

72. Megaloblastic macrocytic anemia There are macrocytes in bone marrow smear Causes: - Medication affecting folate metabolism - Vit B12 deficiency - F olate deficiency - Atrophic gastritis - Gastro-intestinal malabsorption - N itrous oxide abuse - Primary bone marrow disorders

73. Non- M egaloblastic Macrocytic Anemias Causes: Alcohol abuse Emphysema Hypothyroidism Accelerated erythropoiesis (high reticulocyte count) Hemolytic anemias Post-hemorrhagic anemia Increased red cell surface membrane Obstructed jaundice Hepatic disease post splenoctomy Bone marrow disorders ( myelophthisic anemia. Myelodysplastic anemia) myelodysplastic syndrome, aplastic anemia acquired sideroblastic anemia

74. 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 Thalassemias Anemia of chronic dz Iron deficiency anemia Lead poisoning Congenital sideroblastic anemia Sideroblastic Anemia

75. The MCH indicates the average weight of hemoglobin in the red blood cells. MCH = = Normal value for the MCH : 27~32pg An MCH lower than 27pg is found in microcytic anemia and also with normocytic, hypochromic RBCs. An elevated MCH occurs in macrocytic anemia and in some cases of spherocytosis in which hyperchromia may be present. Weight of hemoglobin in 1 μ l of blood Number of red blood cells in 1 μ l of blood Hemoglobin * 10 Red blood cell count in millions ( pg ) 1 g = 10 12 pg 1 ml = 10 3 μ l Mean Corpuscular Hemoglobin (MCH)

76. The MCHC is an expression of the average concentration of hemoglobin in the red blood cells. It gives the ratio of the weight of hemoglobin to the volume of the red blood cells. MCHC = = Normal value for the MCHC : 32~36 % Hemoglobin in g/dl Hematocrit /dl * 100 (to convert to %) Hemoglobin * 100 Hematocrit % Mean Corpuscular Hemoglobin Concentration (MCHC)

77. The MCHC tells you whether the cell pack is more or less in hemoglobin than usual. This results in the red cells appearing more( hyperchromic ) or less red ( hypochromic ), as hemoglobin is what gives them their red color . MCHC is low in microcytic anemia ( e.g. iron deficiency anemia) MCHC is high in macrocytic anemia ( folic acid and vit B12 deficiency) , hereditary spherocytosis , sickle cell disease, homozygous hemoglobin C disease.

78. RDW is an index of the variation of red cell size ( volume) in a specimen of blood. Normal range is 10-15% Low value indicate uniformity in size of red blood cells. High value indicates mixed population of small and large RBCs; immature RBCs tend to be larger. E.g. in iron deficiency anemia or pernicious anemia, there is high variation ( anisocytosis ) in RBC size ( along with variation in shape- poikilocytosis ), causing an increase in the RWD Red Cell Distribution Width (RDW)

79. RDW Normal Population Uniform High Anisocytosis Red cell Distribution Width - RDW

80. Can be absolute or % Normal range is 25-85x10^9/L or 1-2%. Low reticulocyte count indicates a condition is affecting the production of red blood cells, such as bone marrow damage, or a nutritional deficiency ( iron, B12 and folate) High reticulocyte count indicates a peripheral cause of anemia, such as bleeding or hemolysis or response to treatment e.g. iron supplementation for iron deficiency anemia Reticulocyte Count

81. Evaluation of white blood cells, the cells that are part of the body's defense system against infections and cancer and also play a role in allergies and inflammation WBC count is a count of the total number of white blood cells in a person's sample of blood. The normal number of WBCs in the blood is 4,500-11,000 white blood cells per microliter ( u L ). Normal value may vary slightly among different labs Neutrophils 40-75% of WBCs. Lymphocytes 20-45% of WBCs. Eosinophils 1-6% of WBCs. Monocytes 2-10% of WBCs. Basophils 0-1 % of WBCs. WHITE BLOOD CELL COUNT (WBC)

82. Caused by : Bone marrow disorders or damage e.g aplastic anemia, chemotherapy, radiotherapy, myelofibrosis Viral infections such as common cold and influenza Malaria, typhoid, dengue, tuberculosis, rickettsial infections Autoimmune conditions as rheumatoid arthritis and systemic lupus erthrymatosus (SLE) Severe infections (sepsis) Lymphoma or other cancer that spread to the bone marrow Leukopenia (low white cell count)

83. VII. Diseases of immune system (e.g. HIV and AIDS) VIII. Deficiencies of folate, copper or zinc Enlargement of the spleen Lyme disease Drugs e.g clozapine, bupropion, valproic acid, minocycline, lamotrigine Immunosuppressive drugs include: cyclosporine, leflunomide , tacrolimus

84. PSEUDOLEUKOPENIA - Develops upon the onset of infection Leukocytes (predominantly neutrophils responding to injury first) start migrating towards the site of infection and can be scanned at the site of infection. - causing the bone marrow to produce more white blood cells to combat infection as well as to restore leukocytes in circulation, but as the blood sample is taken upon the onset of infection, it contains low amount of WBCs, which is why it is called Pseudoleukopenia — Can also be due to Leucocyte aggregation invitro, EDTA induced platelet clamping, etc

85. Caused by : Infection, most commonly  bacterial or viral Inflammation Leukemia, Myeloprolifrtive disorders Allergies, asthma Tissue death (trauma, burns, heart attack) Intense exercise or severe stress Leukocytosis (high white cell count)

86. NEUTROPHILS polymorphonuclear leukocytes ( PMNs ) Nucleus 3-5 lobes. Diameter 10-14 µm 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 DIFFERENTIAL COUNTS

87. Conditions associated with neutrophilia are: acute or chronic infections (Bacterial infections most common cause) Tissue destruction e.g . tissue infarctions, burns . leukemoid reaction Leukemia Myeloproliferative disorders ( e.g.myelofibrosis ) Acute stress Chronic inflammation Hyperactive marrow Post splenectomy Cigarrete smoking Epinephrine and exercise NEUTROPHILIA (an increase in neutrophil)

88. Causes: Decreased production in the bone marrow due : Aplastic anemia Arsenic poisoning Blood cancer Hereditary disorders e.g. congenital neutropenia, cyclic neutropenia Radiation Vitamin B12, folate or copper deficiency Certain medications (carbamazepine, chloramphenicol, chlorpropamide , acetazolamide) OP NEUTROPENIA (a decrease in neutrophil)

89. 2. Increased destruction Autoimmune neutropenia Chemotherapy treatment 3.Marginalisation and sequestration Hemodialysis 4.Medications Flecainide ( a class 1C cardiac antiarrthymiac drug) Phenytoin Indomethacin Chlorpromazine Cotrimoxazole (trimethoprim/ sulfamethoxazole ) Note: often a mild neutropenia is seen in viral infections . In addition a morning neutropenia is a side effect of some antipsychotic drugs.

90. No specific granules 20-40% of WBC =1.55-3.5x10^9/ L Diameter 8-10 µm T cells: cellular ( for viral infections) B cells: humoral (antibody) Natural Killer Cells LYMPHOCYTES

91. Causes : Autoimmune disorders such as SLE, rheumatic arthritis Infections like HIV, viral hepatitis, typhoid fever, influenza Bone marrow damage e.g. chemotherapy and radiotherapy Corticosteroids LYMPHOCYTOPENIA ( low lymphocyte count)

92. Causes: Acute viral infections such chicken pox, CMV, EBV, herpes, rubella Certain bacterial infections e.g. pertussis, whooping cough, tuberculosis Toxoplasmosis Chronic inflammatory disease e.g.. ulcerative colitis Lymphocytic leukemia, lymphoma Acute stress LYMPHOCYTOSIS ( a high lymphocyte count)

93. Causes: Usually one low count is not medically significant but repeated low counts can indicate: Bone marrow damage or failure Hairy cell leukemia Chronic infections e.g. TB, fungal infections Infections within the heart e.g. bacterial endocarditis Collagen vascular disease e.g. lupus, scleroderma, rheumatoid arthritis, vasculitis . Monocytic or myelomonocytic leukemia ( acute or chronic) Low Monocyte count: Monocytosis ( high monocyte count)

94. Causes: Asthma, allergies such as hey fever Drug reactions ( e.g hypersensivity reactions to macrolides, aminoglycosides, tetracyclines , clindamycin, metronidazo;e Parasitic infections (e.g. ascariasis , trichinosis) Inflammatory disorders e.g. celiac disease, inflammatory bowel disease, cholecyctitis Leukemia, lymphomas EOSINOPHILIA

95. As in eosinophils, numbers are normally low in the blood; usually not medically significant. Rare allergy reactions ( hives, food allergy) Inflammation (rheumatoid arthritis, ulcerative colitis) Some leukemias BASOPENIA BASOPHILIA

96. Normal platelet count are in the range of 150,000 to 400,000 per microliter. However it slightly changes among different laboratories. THROMBOCYTOPENIA CAUSES Immune thrombocytopenia (ITP) formerly known as immune thrombocytopenia purpura Cirrhosis Splenomegaly ( Gaucher’s disease) Familiar thrombocytopenia Chemotherapy, radiotherapy Babesiosis , Dengue, Onyalai , Rocky mountain spotted fever Thrombotic thrombocytopenic purpura HELLP syndrome PLATELET COUNT

97. Hemolytic uremic syndrome Drug induced thrombocytopenia (heparin, acetaminophen, quinidine, sulfa drugs) Pregnancy associated Neonatal alloimmune associated Aplastic anemia, leukemia, lymphoma Transfusion associated

98. THROMBOCYTOSIS CAUSE Reactive : Chronic infection ( pneumonia, UTI, sepsis, meningitis) Chronic inflammation ( inflammatory bowel disease, rheumatoid arthritis, nephritis, dermatitis..) Malignancy Post splenectomy Iron deficiency Acute blood loss

99. 2.Myeloproliferative disorders : Essential thrombocytosis Polycythemia vera 3. Congenital 4.Cancer ( lung, breast, gastrointestinal, ovarian and lymphoma

100. Typical range of platelet is 9.7-12.8fL Low value indicates that average size is small; older platelets are generally smaller then younger ones and a low MPV might mean that a condition is affecting of platelets by the bone marrow e.g aplastic anemia, High volume indicates a high number of larger younger platelets in the blood; this may be due to the bone marrow producing platelets rapidly into circulation e.g myeloproliferative diseases, inflammatory bowel disease, ITP, pre- eclampsia MEAN PLATELET VOLUME

101. A PDW increased means there is increased variation in the size of platelets which may mean a condition is present that is affecting the platelets e.g acute leukemia, ITP, chronic myeloid leukemia, CRF, acute bleeding Low PDW not clinically important PLATELET DISTRIBUTION WIDTH

102. All three lines depressed Aplastic anemia, myelodysplastic syndrome, chemotherapy Polycythemia vera (secondary) LOW BLOOD COUNT HIGH BLOOD COUNT

103. Reference Davidsons 23 rd edition Medscape (UpToDate) Uganda clinical guidelines 2020