CBC Interpretition

1. CBC --- InterpretationsCBC --- Interpretations

2. AbstractAbstract
Interpretation of different parameters reported on Interpretation of different parameters reported on
modern day analyzers is bit tricky and demand modern day analyzers is bit tricky and demand
continuous monitoring and on-going learning. In continuous monitoring and on-going learning. In
present paper interpretation of different reported present paper interpretation of different reported
parameters has been discussed with approach to parameters has been discussed with approach to
diagnosis of various abnormalities. diagnosis of various abnormalities.

3. 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.

4. •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

5. •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 µm
•Function: - transport hemoglobin
which carries oxygen from the lung to
the tissues
-acid –base buffer.
•Life span 100-120 days.

6. 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 %

7. –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

8. •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%

9. •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

10. Definition of Anaemia Definition of Anaemia
►Decrease in the number of circulating red Decrease in the number of circulating red
blood cell mass and there by Oblood cell mass and there by O
22 carrying carrying
capacitycapacity
►Most common hematological disorder by farMost common hematological disorder by far
►Almost always a secondary disorderAlmost always a secondary disorder
►As such, critical for all practitioners to know As such, critical for all practitioners to know
how to evaluate / determine its cause / how to evaluate / determine its cause /
treattreat

11. First QuestionFirst Question
►The onset of AnaemiaThe onset of Anaemia
►Acute versus chronicAcute versus chronic
►CluesClues
Hemodynamic stabilityHemodynamic stability
Previous CBCPrevious CBC
Overt blood lossOvert blood loss

12. Types of AnaemiaTypes of Anaemia

13. Screening Tests – Anaemia Screening Tests – Anaemia
►Clinical Signs and symptoms of Clinical Signs and symptoms of
AnaemiaAnaemia
►Look for bleeding – all possible sitesLook for bleeding – all possible sites
►Look for the causes for anemiaLook for the causes for anemia
►Routine Hemoglobin examinationRoutine Hemoglobin examination
►Cut off marks for Hb – Cut off marks for Hb –
US < 13.5 g US < 13.5 g WHO < 12.5 gWHO < 12.5 g
Subcontinent Subcontinent Less than 12 g%Less than 12 g%

14. Clinical Signs to be looked forClinical Signs to be looked for
►Skin / mucosal pallor,Skin / mucosal pallor,
►Skin dryness, Skin dryness, palmar palmar
creasescreases
►Bald tongue, GlossitisBald tongue, Glossitis
►Mouth ulcers, Mouth ulcers, Rectal examRectal exam
►Jaundice, PurpuraJaundice, Purpura
►LymphLymphadenopathyadenopathy
►Hepato-splenomegalyHepato-splenomegaly
►BreathlessnessBreathlessness
►Tachycardia, CHFTachycardia, CHF
►Bleeding, Bleeding, Occult BloodOccult Blood

15. PCV or HematocritPCV or Hematocrit
►57% Plasma57% Plasma
►1% Buffy coat – WBC1% Buffy coat – WBC
►42% Hct (PCV)42% Hct (PCV)

16. The Three Basic MeasuresThe Three Basic Measures
MeasurementMeasurement NormalNormal
RangeRange
•RBC countRBC count 5 million5 million 4 to 6 4 to 6
•HemoglobinHemoglobin 15 g%15 g% 12 to 1712 to 17
•HematocritHematocrit 4545 38 to 5038 to 50
A x 3 = B x 3 = C - This is the rule of thumbA x 3 = B x 3 = C - This is the rule of thumb
Check whether this holds good in given resultsCheck whether this holds good in given results
If not -indicates micro or macrocytosis or If not -indicates micro or macrocytosis or
hypochromia.hypochromia.

17. Causes of AnaemiaCauses of Anaemia
•Decreased Decreased productionproduction of Red Cells of Red Cells
- Hypoproliferative, marrow failure- Hypoproliferative, marrow failure
2.2.Increased destruction of Red CellsIncreased destruction of Red Cells
- Hemolysis (decreased - Hemolysis (decreased survivalsurvival of RBC) of RBC)
3.3.Loss of Red Cells due to bleedingLoss of Red Cells due to bleeding
- Acute / chronic blood - Acute / chronic blood lossloss
(hemorrhagic)(hemorrhagic)

18. Anaemia – First TestAnaemia – First Test
RETI CULOCYTE COUNT %RETI CULOCYTE COUNT %
Nor mal
Les s t han
2%
• ‘RBC to be’ or Apprentice RBC
• Fragments of nuclear material
• RNA strands which stain blue

19. ReticulocytesReticulocytes
Leishman’sSupravital

20. AnaemiaAnaemia
Hypoproliferative Hemolytic
Retics < 2 Retics > 2
Hb% < 12, Hct < 38%

21. Normal CBC Normal CBC

22. Workup – Second TestWorkup – Second Test
►The next step is The next step is ‘What is the size of RBC’ ?‘What is the size of RBC’ ?
►MCV indicates the Red cell volume (size)MCV indicates the Red cell volume (size)
►Both the MCH & MCHC tell Hb content of RBCBoth the MCH & MCHC tell Hb content of RBC
►If the Retic count is 2 or lessIf the Retic count is 2 or less
►We are dealing with either We are dealing with either
Hypoproliferative anaemia (lack of raw material)Hypoproliferative anaemia (lack of raw material)
Maturation defect with less productionMaturation defect with less production
Bone marrow suppression (primary/ secondary)Bone marrow suppression (primary/ secondary)

23. Mean Cell Volume (MCV)Mean Cell Volume (MCV)
►RBC volume (rather) is measured byRBC volume (rather) is measured by
►The Mean Cell Volume or MCV and RDWThe Mean Cell Volume or MCV and RDW
Microcytic
< 80 fl
MCV
Normocytic Macrocytic
80 -100 fl > 100 fl
< 6.5 µ 6.5 - 9 µ > 9 µ

24. Anaemia Workup - MCVAnaemia 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

25. Red cell Distribution Width - RDWRed cell Distribution Width - RDW
Normal
Population
Uniform
RDW
High
Population
Double

26. Anaemia Workup - 4Anaemia Workup - 4
thth
Test Test
Peripheral Smear StudyPeripheral Smear Study
►Are all RBC of the same size ?Are all RBC of the same size ?
►Are all RBC of the same normal discoid shape ?Are all RBC of the same normal discoid shape ?
►How is the colour (Hb content) saturation ?How is the colour (Hb content) saturation ?
►Are all the RBC of same colour/ multi coloured ?Are all the RBC of same colour/ multi coloured ?
►Are there any RBC inclusions ?Are there any RBC inclusions ?
►Are intra RBC there any hemo-parasites ?Are intra RBC there any hemo-parasites ?
►Are leucocytes normal in number and D.C ?Are leucocytes normal in number and D.C ?
►Is platelet distribution adequate ? Is platelet distribution adequate ?

27. IDA -CBC IDA -CBC

28. Microcytic Hypochromic - IDA Microcytic Hypochromic - IDA

29. IDA – Special TestsIDA – Special Tests
Iron related testsNormal IDA
Serum Ferritin (pmo/L)33-270 < 33
TIBC (µg/dL) 300-340> 400
Serum Iron (µg/dL) 50-150 < 30
Saturation % 30-50 < 10
Bone marrow Iron ++ Absent

30. IDA SummaryIDA Summary
►MicrocyticMicrocytic MCV < 80 fl, RBC < 6 MCV < 80 fl, RBC < 6 µµ
►RDWRDW Widened with low MCVWidened with low MCV
►HypochromicHypochromic MCH < 27 pg, MCHC < MCH < 27 pg, MCHC <
30%30%
►RIRI < 2< 2
►Serum ferritinSerum ferritin Very low < 30 (p mols/L)Very low < 30 (p mols/L)
►TIBCTIBC Increased > 400 (µg/dL)Increased > 400 (µg/dL)
►Serum IronSerum Iron Very low < 30 (µg/dL)Very low < 30 (µg/dL)
►BM Fe StainBM Fe Stain Absent FeAbsent Fe
►Response to Fe Rx.Response to Fe Rx.Excellent Excellent

31. IDA- Some NuggetsIDA- Some Nuggets
►Look for occult blood loss – 2 days non veg. freeLook for occult blood loss – 2 days non veg. free
►Pica and Pagophagia – Ice suckingPica and Pagophagia – Ice sucking
►Absorption of Haem Iron > FeAbsorption of Haem Iron > Fe
++ ++
> Fe > Fe
++++++
►Food, Phytates, Ca, Phosphate, antacids Food, Phytates, Ca, Phosphate, antacids ↓↓absorptionabsorption
►Ascorbic acid Ascorbic acid ↑↑absorptionabsorption
►Oral iron Rx. always is the best, ? Carbonyl Fe Oral iron Rx. always is the best, ? Carbonyl Fe
►FeSOFeSO
44 is the best. Reserve parenteral Rx. is the best. Reserve parenteral Rx.
►Packed cell transfusion in emergencyPacked cell transfusion in emergency
►Continue Fe Rx at least 2 months after normal HbContinue Fe Rx at least 2 months after normal Hb
►1 gram 1 gram ↑↑in Hb every week can be expectedin Hb every week can be expected
►Always supplement protein for the Globin componentAlways supplement protein for the Globin component

32. Microcytic AnaemiasMicrocytic Anaemias
MCV < 80 fl
Serum
Iron
TIBCBM Perls stain
Iron Def. Anemia↓↓ ↑↑ 0
Chronic Infection↓↓ ↓↓ + +
Thalassemia ↑↑ N + + + +
Hemoglobinopathy N N + +
Lead poisoning N N + +
Sideroblastic ↑↑ N + + + +

33. Macrocytic AnaemiasMacrocytic Anaemias
A. Megaloblastic Macrocytic A. Megaloblastic Macrocytic –– B12 and Folate B12 and Folate↓↓
B. Non Megaloblastic Macrocytic AnaemiasB. Non Megaloblastic Macrocytic Anaemias
–Liver disease/alcoholLiver disease/alcohol
–HemoglobinopathiesHemoglobinopathies
–Metabolic disorders, HypothyroidismMetabolic disorders, Hypothyroidism
–Myelodystrophy, BM infiltrationMyelodystrophy, BM infiltration
–Accelerated Erythropoesis -Accelerated Erythropoesis - ↑↑destruction destruction
–Drugs (cytotoxics, immunosuppressants, Drugs (cytotoxics, immunosuppressants,
AZT, anticonvulsants)AZT, anticonvulsants)

34. Anemia - Macrocytic (MCV > 100)Anemia - Macrocytic (MCV > 100)
Premature gray hair – consider MBAPremature gray hair – consider MBA
Macrocytic anemias may be asymptomatic Macrocytic anemias may be asymptomatic
untiluntil
the Hb is as low as 6 gramsthe Hb is as low as 6 grams
MCV 100-110 flMCV 100-110 fl
must look for other causes of macrocytosismust look for other causes of macrocytosis
MCV > 110 fl MCV > 110 fl
almost always folate or Balmost always folate or B
1212 deficiency deficiency

35. MBA MBA

36. Macrocytosis -MBA Macrocytosis -MBA

37. HSN - MBA HSN - MBA

38. Basophilic Stippling - MBABasophilic Stippling - MBA
BS occurs in Lead poisoning also

39. MBA - BMMBA - BM

40. Pernicious Anaemia - Tongue Pernicious Anaemia - Tongue
Bald, smooth, lemon
yellowish red tongue

41. Normocytic AnaemiasNormocytic Anaemias
1.1.Chronic diseaseChronic disease
2.2.Early IDAEarly IDA
3.3.HemoglobinopathiesHemoglobinopathies
4.4.Primary marrow disordersPrimary marrow disorders
5.5.Combined deficienciesCombined deficiencies
6.6.Increased destructionIncreased destruction
7.7.Anaemia of investigations Anaemia of investigations
-ICU-ICU

42. Anaemia of Chronic DiseaseAnaemia of Chronic Disease
►Thyroid diseasesThyroid diseases
►MalignancyMalignancy
►Collagen Vascular Collagen Vascular
DiseaseDisease
Rheumatoid ArthritisRheumatoid Arthritis
SLESLE
PolymyositisPolymyositis
Polyarteritis NodosaPolyarteritis Nodosa
•IBD
– Ulcerative Colitis
– Crohn’s Disease
•Chronic Infections
– HIV, Osteomyelitis
– Tuberculosis
•Renal Failure

43. ‘‘Dimorphic’ AnaemiaDimorphic’ Anaemia
►Folate & Fe deficiency (pregnancy, alcoholism)Folate & Fe deficiency (pregnancy, alcoholism)
►BB
1212
& Fe deficiency (PA with atrophic gastritis) & Fe deficiency (PA with atrophic gastritis)
►Thalassemia minor & BThalassemia minor & B
1212
or folate deficiency or folate deficiency
►Fe deficiency & hemolysis (prosthetic valve)Fe deficiency & hemolysis (prosthetic valve)
►Folate deficiency & hemolysis (Hb SS disease)Folate deficiency & hemolysis (Hb SS disease)
►Peripheral smear exam is critical to assess thesePeripheral smear exam is critical to assess these
►RDW is increased very muchRDW is increased very much

44. RBC Size – AnisocytosisRBC Size – Anisocytosis
Different sizes of RBCDifferent sizes of RBC

45. PoikilocytosisPoikilocytosis
Different Shapes of RBC Different Shapes of RBC

46. Polychromasia - Spherocytosis Polychromasia - Spherocytosis

47. Target CellsTarget Cells
1.Liver Disease
2.Thalassemia
3.Hb D Disease
4.Post splenectomy

48. •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%

49. 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.

50. • polymorphneuclear leukocytes
(PMN,s)
•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

51. •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

52. –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.

53. •Bilobed nucleus
•1-5% of WBC
=0.04-0.4x10^9/L
•Diameter about 10-14 µm
•Function: Involved in allergy,
parasitic infections
•Contains: eosinophilic granules

54. –Eosinophilia may be found in
•Parasitic infections
•Allergic conditions and
hypersensitivity reaction

55. •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

56. •Lymphocytosis – may indicate
_ Viral infection
e.g. Infectious mononucleosis, CMV or pertussis.

_ Bacterial infection
e.g. TB
•Lymphopenia – caused by
_Stress.
_Steroid therapy
_ Irradiation

57. • (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.

58. •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.

59. •Infection of the mouth and throat.
•Painful skin ulceration.
•Recurrent infection.
•Septicemia.

60. •Small granular non-nucleated
discs.
•Diameter about 2-4 µm
•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

61. •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.

62. •Petechial hemorhage.
•Easy bruising.
•Mucosal bleeding
e.g. _ epistaxes.
_ gum bleeding