complete blood count analysis and blood disease investigation

Complete blood count

1. How to read
a CBC?
Ahmad Darwish, MD
Assistant professor of Pediatric
Hematology/Oncology & BMT
Mansoura University

3. Agenda
Introduction
CBC Parameters
RBC Parameters & Histograms
Platelet Parameters & Histograms
WBC Parameters & Histograms

4. Introduction

5. Introduction
Automatedhematologyanalyzerisacost-effectivestrategyinresource-
limitedsettingsfordiagnosisofcommonblooddisorders.
Moreover,giventhedifficultyofbloodsamplinginthepediatricagegroup,
extractingthemaximumpossibleinformationfromeachinvestigationis
essential.
Modern-dayautomatedhematologyanalyzers,withtheirconstantly
expandingassessmentparametersprovideagood,quickoverviewofthe
patients’bloodpicture.
Xieet al, J Biophotonics. 2018; Gounariet al, Cytometry B Clin Cytom. 2016.
CBC byAhmad Darwish

7. CBC
A complete blood count is a seriesof tests used to evaluate the
composition of the various cellularcomponents of blood.
It is a basic test.
The most informative singleinvestigation.
It consists of:
1. RBC Parameters (Hb, RBCs, Hct, MCV, MCH, MCHC, RDW, etc.)
2. Platelet Parameters (PLT, MPV, PDW, P-LCR, Pct, etc.)
3. WBC Parameters
4. Histogram of RBC, PLT, WBC

8. Why CBC?
CBC is an inexpensivetool and powerfultool which provide
information about:
1.Blood
2.Marrow
3.Health or disease state of other body organs
CBC is the first investigationroutinely performed in both in-
patient and out-patient settings.

9. CBC uses
To diagnose:
1.Anemia
2.Haemoglobinopathies
3.Bone marrow aplasia
4.Nutritional deficiencies
5.Thrombocytopenia
6.Autoimmune conditions
7.Infections & parasitemia
8.Malignancies, response to drugs, chemotherapy etc.

10. INTERPRETATION OF CBC PARAMETERS
Mostautomatedhematologyanalyzersgeneratenumericalandgraphicaldata.
NumericaldataisintheformofmeasurementofvariousWBC,RBCandplatelet
parameters.
TheautomatedanalyzersalsoprovideRBC,WBC,andplatelethistograms
derivedbyplottingeachcell’ssizeontheX-axisandtheirrelativenumberonthe
Y-axis.
InterpretationoftheseCBCparametersandhistogramstogetherhelpsusassess
thepresentationandetiologyofanemiawithoutrequiringotherexpensive
investigations.
Xieet al, J Biophotonics. 2018; Gounariet al, Cytometry B Clin Cytom. 2016.
CBC byAhmad Darwish

11. RBC
Parameters

12. RBC Parameters
Automated hematology analyzers provide information on several RBC parameters
that are used to assess the typeof anemia, the treatment response& long-term
follow-upof patients like:
Hemoglobin (Hb)
Mean corpuscular volume (MCV)
Mean corpuscular hemoglobin (MCH)
Mean corpuscular hemoglobin concentration (MCHC)
Red cell distribution width (RDW)
RBCcount
Hematocrit (HCT)
Kujovich, ObstetGynecolClin North Am. 2016.
Nathan et al, Nathan and Oski’s hematology and oncology of infancy and childhood. Elsevier. 2015
CBC byAhmad Darwish

13. Increased RBCs
Polycythemia
High altitude
Pulmonary hypertension
Hypoventilation syndrome
Congestive heart failure
Obstructive sleep apnea
Poor blood flow to the kidneys

14. Decreased RBCs
Increased destructionImpaired productionBlood loss
Intra-corpuscular
▪Hereditary spherocytosis
▪Sickle cell anemia
▪G6PD
▪Pyruvate kinase deficiency
▪PNH
Extra-corpuscular
▪Autoimmune Haemolytic
disease
▪Mismatch transfusion
▪Microangiopatichemolytic
anemia TTP, HUS
▪DIC
▪Infection
▪Pure red cellaplasia
▪Pernicious anemia
▪Thalassemia
▪Anemia of prematurity
▪Anemia of chronic disorder
▪Trauma
▪surgery
▪Glbleed
▪Menorrhagia

15. Blood indices
Mean corpuscular volume (MCV)
Mean corpuscular hemoglobin (MCH)
Mean corpuscular hemoglobin concentration (MCHC)
❖Anemias are classified based on MCV & morphology as:
normocytic, microcyticand macrocytic.
Kujovich, ObstetGynecolClin North Am. 2016.
Nathan et al, Nathan and Oski’s hematology and oncology of infancy and childhood. Elsevier. 2015
CBC byAhmad Darwish

17. Interference in MCV
Cold and warm antibodies
Marked hyperglycemia
Marked leukocytosis
Marked reticulocytosis
Methanol poisoning
Interference in MCH
Lipemia
Marked leukocytosis
Cold agglutinin
Monoclonal protein in blood
Interference in MCHC
Marked leukocytosis
Cold agglutinin
Rouleaux

19. Normalbloodsmear
Basophil (B)
Monocyte (M)
Platelet(P)
Redcells (R)
Neutrophil(N)
Lymphocyte(L)
Eosinophil(E)

20. CBC byAhmad Darwish
Anemia classification

21. Allmacrocyticanemiasareevaluated&treatedforvitB12&folatedeficiency.
Non-megaloblasticmacrocyticanemiarequiresfurtherevaluationof:
❖Reticulocytecount
❖Featuresofhemolysis
❖Interpretationofbonemarrowaspiratesmears
Reticulocytecountisnecessaryforevaluationofnormocyticnormochromic
anemias.
❑megaloblasticanemia,liverdiseaseandhypothyroidism,mustberuledout.
❑furtherevaluationofWBC&plateletparametersfollowedbyBMevaluationmayberequired.
CBC byAhmad Darwish
RBC Parameters

22. Reticulocyte
Normal value 0.5% -1.5% (Hence 0.5% -1.5% RBCs are replaced per day)
Uses
1.To evaluate anemia
They have a role in diagnosis& monitoringof aplastic anemia.
2.Response to treatment of anemia
They provide information regarding treatment-responsein conditions such as nutritional anemia.
If the disease causing the anemia is insidethe marrow, the RC is decreased
If the disease causing the anemia is outsidethe marrow, the RC is increased

23. Methods
Manualreticulocyte count using supravital stain
Automatedreticulocyte count by fluorescent method –gives immature reticulocyte
fraction (IRF) and removes errors like Howell-Jolly bodies, pappenheimerbodies
Reticulocyte production index or corrected reticulocyte count:
an index corrected according to level of anemia.
Reticulocyte index = reticulocyte count x patient’s haematocrit/ normal haematocrit

24. Reticulocyte proliferation index: index is used to determine if a person’s bone
marrow is property responding to the body’s need for red blood cells.
Shift correction factor: normal reticulocyte count survive 3.5 days in marrow and
1 day in peripheral circulation at normal PCV. In case of variation in PCV the
survival time is increased which is termed as shift correction factor
Reticulocyte proliferation index = reticulocyte
Shift correction factor
maturation’s days = shift correction factorPCV%
145
1.535
225
2.515

25. CBC byAhmad Darwish
RBC Parameters

26. Decreased Reticulocyte countIncreasedReticulocyte count
Aplastic anemiaHaemolytic anemia
Megaloblastic anemiaRecent hemorrhage
Anemia of chronicdiseaseThalassemia
CirrhosisRespond to treatment
RadiationLeukemia
Decrease ACTH and pituitary
hormones

27. Reticulocyte haemoglobin measurement
(RET –HE)
Reticulocyte haemoglobin measurement (RET –HE) is a direct assessment of
the incorporation of iron erythrocyte hemoglobin.
It is a direct estimate of the recent functional availability of iron (2-3)days.
Traditional chemistry tests used for iron assessment (serum iron, T sat, ferritin) are
indirect measurements.
As a direct measurement, Ret-He may identify iron deficiency earlier than
traditional parameters.
It is an established parameter used in KDOQI (kidney Disease Outcome Quality
initiative) guidelines for assessing iron status

28. The conventional parameters are generated in all automated cell counters, while
the newer parameters are available in specific counters and need to be
customized to be generated as printouts.
Additionally, there are several indicators that can be derived from the parameters
reported in the automated analyzers such as the Mentzer index (MCV/RBC) that
can also help differentiate between IDA and â-thalassemia.
CBC byAhmad Darwish
RBC Parameters

29. WhatistheMentzer index?
•MCV/RBC.
-This is one ofthe formulasthatis used to distinguish the
hypochromic,microcyticanemiasofthethalassemia
fromirondeficiency.
-Asageneralrule,irondeficiencycausesalterations
RBCsthattendtobevariable,whereasthalassemia
generallyresultsinmoreuniformlysmallercells.
trait
in
-In patients withtheb-thalassemia trait, theMentzerindex
usuallyless than 13.
is
-inpatients with iron deficiency, it isusually greaterthan 13.

30. Calculation of the Mentzerindex

31. Sometimes both conditions coexist
Thalassemia minor associated with IDA
A trial of oral iron is necessary
DD of Iron Deficiency Anemia

33. Normal
Values

35. Newer parameters, additionally, provide information that has made the detection
of typeand causeof anemias easierand may, over time, reduce the dependence
on peripheral blood smear examination for all cases.
They also help distinguishbetween the various etiologies of anemia such as:
❑Iron deficiency anemia (IDA)
❑Anemia of chronic disease (ACD)
❑Anemia of inflammation (AI)
❑Anemias due to inherited conditions such as thalassemia
Briggs ae al. Int J Lab Hemat.2009.
Kujovichet al. ObstetGynecolClin North Am. 2016.
Pivaet al. Clin Lab Med. 2015.
Markoviæet al. ScandJ Clin Lab Invest. 2005.
Thomas et al. J Clin DiagnRes. 2017.
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RBC Parameters

36. CBC byAhmad Darwish
Newer RBC and Reticulocyte Parameters on Automated Analyzer
Significance in anemiaRBC parameter
•Along with RET-He helps in detecting onset of anemia
and also improvement in erythropoiesis
RBC hemoglobin equivalent (RBC-He): Hemoglobin
content of all mature RBCs
In detection of microangiopathies, DIC, infections, sepsis,
immune disorders, etc.
Fragmented red cell count (FRC): Fragmented
RBCs
•Low in IDA
•Can be used for IDA screening in pediatric population
Red cell size factor (RSf): Cellular hemoglobin
content of RBCs and reticulocytes
•Low in IDA
•Can be used for IDA screening in pediatric population
•Iron restricted erythropoiesis marker
Percentage hypochromic cells (%HC) or equivalent
low hemoglobin density (LHD%): hypochromic
RBCs (%)
Screening of thalassemiaPercentage unghostedcells: Target cells in
peripheral blood
ACD: anemia of chronic disease, AI: anemia of inflammation, DIC: disseminated intravascular
coagulation, EPO: erythropoietin, FID: functional iron deficiency, IDA: iron deficiency anemia.
Nathan et al. Nathan and Oski’s hematology and oncology of infancy and childhood. Elsevier. 2015.

37. CBC byAhmad Darwish
Newer RBC and Reticulocyte Parameters on Automated Analyzer
Significance in anemiaRBC parameter
Can help distinguish between hemoglobinopathies & IDA.RBC-Y: Size and contents of the RBCs
•Differentiate between IDA and FID
•Iron restricted erythropoiesis marker
Reticulocyte hemoglobin equivalent (Ret-He) or Mean
Reticulocyte Hemoglobin Content (CHr): Mean content
of hemoglobin within reticulocytes
•Differentiate between IDA and FID
•Iron restricted erythropoiesis marker
Low fluorescence reticulocyte (LFR), Medium
fluorescence reticulocyte (MFR), High fluorescence
reticulocyte (HFR): Maturity stages of reticulocytes
•Assesses effectiveness of erythropoiesis
•Assessment of response to iron or vitamin-B12/folate
supplementation in nutritional anemias
•Monitoring EPO therapy response
Immature reticulocyte fraction (IRF): Sum of HFR and
MFR
•Low in IDA and AIReticulocyte-Y (RET-Y): Size and contents of the
reticulocyte
ACD: anemia of chronic disease, AI: anemia of inflammation, DIC: disseminated intravascular
coagulation, EPO: erythropoietin, FID: functional iron deficiency, IDA: iron deficiency anemia.
Nathan et al. Nathan and Oski’s hematology and oncology of infancy and childhood. Elsevier. 2015.

38. RBC
Histograms

39. In RBC histograms, the cell-counters count RBCs between 25and 250femtoliter (fL).
The histograms have two flexible discriminatorsthat help differentiate RBC curves from
others:
❖RBC lower discriminator (RL) that fluctuates between 25and 75fLand
❖RBC upper discriminator (RU) that fluctuates between 200and 250fL.
When the cell population is homogeneous, the curve shows a symmetrical bell-shaped
or Gaussian distribution.
The area of the histogram’s peak (60 to 125 fL) helps to calculate MCV& RDW.
CBC byAhmad Darwish
RBC Histograms

40. Interpretation of RBC Histograms:
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(A) Normal RBC curve (B) Calculation of MCV
(C) Calculation of RDW

41. Interpretation of RBC Histograms:
CBC byAhmad Darwish
(C) Rightward shift of curve as seen in the presence of macrocytic RBCs
(B) Leftward shift of curve as seen in the presence of microcytic RBCs(A) Extension of lower end of curve as in case of normal MCV with flagging

42. In a normal RBC histogram, RBCs are located between 55-125fL.
MCVis calculated using a perpendicular line between the base of the curve and its peak.
RDWhelps calculate the variation in RBC size & can be of 2 forms: RDW-SD & RDW-CV.
RDW-SDis the standard deviation expressed as fLobtained by drawing a line of 20% on the y-axis.
Its normal range is between 35-45 fL.
RDW-CVis the coefficient of variation percentage and lies within the range of 11.5% to 14.5%.
It is calculated as: RDW-CV = SD/MCV ×100.
CBC byAhmad Darwish
RBC Histograms

43. CBC byAhmad Darwish
RBC Histograms

44. CBC byAhmad Darwish
RBC Parameters
It helps differentiate between puremicro/normocytic & mixedred cell populations.

45. To avoid interference of aperture artifacts, giant platelets, RBC agglutinates, the
information <20% of the scale on the histogram is excluded.
When RBCs are smallerthan normal in size, as in microcyticanemia, the curve shifts
to the left
When RBCs are largerthan normal in size, as in macrocytic anemia, the curve shifts
to the right.
The extension of the lower end of the scale helps in the detection of RBC fragments,
WBC fragmentsand platelets.
CBC byAhmad Darwish
RBC Histograms

46. RBC Histograms Flags in Childhood Anemia
Flagsare signals that occur when automated hematology analyzers
detect an abnormalresult.
Any abnormal flagshould always be correlated with the peripheral smear
findings.
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47. Flags encountered in RBC histograms:
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48. RL Flag: This occurs due to abnormal height at lower discriminator
when it exceeds the preset height by >10%.
This is seen in the presence of:
Platelet clumps
RBC fragments
Extreme micro-erythrocytosis
Giant platelets
Micro-RBCs
CBC byAhmad Darwish

49. RU Flag: This occurs due to abnormal height at upper discriminator
when it exceeds the preset height by >5%.
This is seen in the presence of:
Nucleated RBCs
RBC agglutination
Cold agglutinins
(the flag disappears when the sample is incubated at 37ºC)
CBC byAhmad Darwish

50. Variations in size and shape of red cells:-
•(A) Microcytichypochromic red cells in iron deficiency
anemia;
(B) Oval macrocytes and a hypersegmented neutrophilin
megaloblastic anemia;
(C) Sickle cells in sickle cell anemia;
•
•

51. Variations in size and shape of red cells:-
(D) Spherocytesinhereditaryspherocytosis
(E) schistocytes (Helmet cell) asin HUS
(F) Targetcellsiniron deficiencyor thalassemia trait

52. (G) Burr cellsin chronic renal failure
(H) Teardrop red cells in myelofibrosis
(I) Bite cells&(J)Blistercellin G6PD def

53. PLT
Parameters

54. Myeloproliferative Disorders
• Essentialthrombocytosis
• IdiopathicMyelofibrosis
• Polycythaemia Vera
Transferfromextravascular pools intocirculation
• Splenectomy(Over 70% of platelets storedinspleen)
Thrombocytosis
• Exercise
• Epinephrine
ThrombocytosisSecondaryto
• Irondeficiency anemia
• Acute blood loss
• Hemolysis
• Recoveryfrom thrombocytopenia

55. Platelet Parameters
Platelets may be abnormal in sizeor numberin various anemiasand may help
determine the etiology of anemia.
Platelets are counted and represented between 2 and 20 fLin platelet histograms.
At 20 fL, there may be interference in counting due to RBC & WBC fragments.
At 2 fL, there may be interference in counting due to EDTA particles& air bubbles.
Here, two flexible discriminators:
CBC byAhmad Darwish
Lower discriminator (LD) or platelet lower discriminator (PL)
Upper discriminator (UD) or platelet upper discriminator (PU)
and a fixed discriminator at 12 fL

56. The platelet histogram curve
should lie between LD& UD
It starts & ends at the
baseline.
The platelet curve is
normally left skewed.
CBC byAhmad Darwish

57. In thrombocytosis, the curve shifts upwards
CBC byAhmad Darwish
In thrombocytopenia, the curve shifts downwards

58. Platelet histogram is used to calculate:
CBC byAhmad Darwish
Mean platelet volume (MPV)
Platelet distribution width (PDW)
Platelet large cell ratio (P-LCR)

59. It is analogous to the MCV of RBCs.
It represents the average volume of the counted platelets.
It lies between 8 & 12 fL normally.
MPV (fL) = Plateletcrit (%) / platelet count (x 10
3
/μL)
MPV, i.e., the range of platelet size, varies with platelet count.
In physiological conditions, MPV is inversely related to platelet count and is raised in
thrombocytopenia.
Dastjerdiet al. Hematology. 2006.
Korniluket al. Mediators of Inflammation. 2019.
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MPV

60. IT is used to discriminate between
reactive(MPV normal) & malignantthrombocytosis (MPV raised).
It is increased in: splenectomy, CML, myelofibrosis, Bernard Souliersyndrome & ITP.
It is decreased in: hypersplenism, aplastic anemia, megaloblastic anemia, Wiskott
Aldrich syndrome & chemotherapy
Korniluket al. Mediators of Inflammation. 2019. CBC byAhmad Darwish
MPV

62. It is a measure of the variation of platelet size.
It is a coefficient of variation calculated as SD /MPV×100
It has a reference range of 9 to 14%.
It is expressed in the histogram by drawing an arbitrary line at the height of 20%.
It is highin aplastic anemia, megaloblastic anemia, CML, chemotherapy.
It is falsely highin the presence of platelet clumps, microcytic RBCs& fragments.
CBC byAhmad Darwish
PDW

63. It is the percentageof platelets that exceedthe normal
value of platelet volume of 12 fLin the total platelet count.
It is calculated as:
platelet cell concentration (PLCC) / platelet count
(where P-LCC refers to the platelets in the volume range of 12 to 30 fL).
It is raisedin the presence of platelet clumps, microcytic RBCs& giant platelets.
CBC byAhmad Darwish
P-LCR

64. Platelet Histogram Flags
LD Flag (PL Flag):
This occurs when LD exceeds preset height by 10%.
This can occur due to the presence of:
1.A high blank value
2.Platelet aggregation
3.Cell fragments
4.Contaminated reagents
5.High numbers of bacteria
CBC byAhmad Darwish

65. UD Flag (PU Flag):
This occurs when there is abnormal height at UD
and it exceeds the preset height by >40 %.
It can be seen in the presence of platelet clumps, giant platelets and
microcytic RBCs.
CBC byAhmad Darwish
Platelet Histogram Flags

66. MP Flag:
This occurs when there are multiple peakspresent.
It can be seen in cases of:
1.Platelet transfusion
2.Recovery from chemotherapy
3.Platelet aggregation
CBC byAhmad Darwish
Platelet Histogram Flags

67. CBC byAhmad Darwish
Platelet Parameters on Automated Analyzer
Significance in AnemiaPlatelet parameters
❑Raised when platelet anisocytosispresent
Platelet volume distribution width (PDW):
Variation in platelet size
❑Act as acute phase reactant;
(High in anemias associated with
myeloproliferative neoplasms & chronic disease,
e.g., type I diabetes mellitus)
Mean platelet volume (MPV):
Thrombocyte volume
❑High in active stages of certain chronic diseases
(e.g., Crohn disease)
Plateletcrit(Pct):
Volume of circulating platelets in unit volume of blood
IDA: iron deficiency anemia
Nathan et al. Nathan and Oski’s hematology and oncology of infancy and childhood. Elsevier. 2015.

68. CBC byAhmad Darwish
Platelet Parameters on Automated Analyzer
Significance in AnemiaPlatelet parameters
❑Peripheral destruction of platelets (autoimmune
conditions)
Reticulated platelets or immature platelet fraction (IPF):
Immature platelets
❑Reactive thrombocytosis (IDA, viral infections)
❑Peripheral destruction of platelets
Platelet large cell ratio (P-LCR):
Large circulating platelets
❑Raised when variation in platelet shape is present
(e.g., giant platelets in reactive thrombocytosis)
Platelet component distribution width (PCDW)
❑Raised in reactive thrombocytosis (IDA,
thalassemia)
Mean platelet mass (MPM) or
Mean platelet component (MPC)
IDA: iron deficiency anemia
Nathan et al. Nathan and Oski’s hematology and oncology of infancy and childhood. Elsevier. 2015.

69. WBC
Parameters

70. WBC Parameters
WBC differentialindicates the chronicityof the disease and very high counts
may indicate severe infectionsand malignancies.
The presence of leucopeniaalong with anemia, can point towards more specific
etiologies.
CBC byAhmad Darwish

72. Total WBC count: 4000 to11,000/μL
Neutrophils(50-70%)
Monocytes(2-6%)
Lymphocytes
(20-40%)
Basophills(0-1%)
Eosinophils
(0-3%)

73. •Acute andchronic bacterialinfections
•Viralinfections
•
•
•
Allergy,especially severeallergic reactions
•Acute lymphocyticleukemia
Leucocytosis
•Acute myeloid leukemia (AML)
•
•
•Chronicmyelogenousleukemia
•
•
•
•

74. leukemoid reaction
Acuteleukaemia →(↑total leucocyticcountmostlyexceed
100,000+ Blastcellsin peripheral blood +↓platelets+↓RBCs )
•
•leukemoidreaction (like=oid ) → ↑totalleucocytic countmore
than 50,000 (rarelyexceed 50,000+ no blast cells + Bandeamia
+normalplatelets+ normalRBCs ).
Normalleucocytessecreteleucocytic alkaline phosphatasebut in
leukemicleucocytes neversecreteso in leukemoid reaction
alkalinephosphataseis very↑ ↑↑.
leukoerythroblasticreaction:-leucocytes&RBCs blastsappear
on Peripheral blooddue to bone marrowinfiltration(lymphoma-
leukaemia) .
•
•

75. •Chemotherapyandradiation therapy
•Sepsis
•Typhoid
•
•
Tuberculosis
•
Leucopenia
Enlargementof thespleen
•
Leukemia(as malignantcellsoverwhelmthe bonemarrow)
•
Folate deficiencies
•
•
Aplasticanemia (failure ofbonemarrowproduction)
•
HIV andAIDS
•
Influenza
•Systemiclupus erythematosus

76. Neutrophilia
Physiological:Stress,anxiety,seizure,exercise
Acute bacterialinfection
Tissue injuryand inflammation
Metabolic:DKA/Acuterenal failure
Myeloproliferativedisorders
Misc:Splenectomy,Hemolyticanemia

77. fromcirculation
Increasedremoval
•Immunological likeSLE
•Hypersplenism
•Sepsis
Decreasedor
ineffective
production
• Aplasticanemia
• VitB12 &Folatedeficiency
• MDS
Neutropenia

78. Mild(700–1500permicroliter)
•Allergicrhinitis,extrinsic asthma,milddrugreaction,long-termdialysis,immunodeficiency
Moderate(1500–5000permicroliter)
•Parasiticdisease,intrinsicasthma,pulmonaryeosinophiliasyndrome
Marked(>5000permicroliter)
Trichinella,hookworm,Toxocaracanis,eosinophilicleukemia,severedrugreaction
Eosinophilia

79. •Usuallyrelatedtoincreasedcirculatingsteroids
•Cushing’ssyndrome
Eosinopenia •Drugs
•ACTH,epinephrine,thyroxine,exogenoussteroids
•Acutebacterialinfection
•Normal diurnalpattern.

80. •Hypothyroidism, myxedema
•Chronicmyeloidleukemia
•Ulcerativecolitis
Basophilia
•Polycythemiavera
•Urticaria
•Hodgkin’slymphoma/disease
•Splenectomy

81. •Viral infections
•Tuberculosis
•Subacutebacterialendocarditis
•Collagendiseases
Monocytosis
•Infectiousmononucleosis
•Sarcoidosis
•Crohn’s disease
•Rheumatoiddisease
•Ulcerativecolitis.

82. • Infectiousmononucleosis
• Mycobacteriumtuberculosis
• Acutelymphoblasticleukaemia
• Brucellosis
• Burkitt’slymphoma
• Cytomegalovirus
Lymphocytosis
• Epstein-Barrvirus
• Whoopingcough
• Non-Hodgkin’slymphoma
• Syphilis
•Toxoplasma

83. •Viralinfection
•HIV
Lymphocytopenia
•Drugs(vinblastine,chloramphenicol,
Doxorubicin)
•Marrowsuppression

84. WBC Histograms
WBChistogramsgeneratedbyautomatedhematology
analyzersplotthesizeofcells(infL)ontheX-axisand
thefrequencyofthecellsonY-axis.
Thecounterherealsosetsalowerdiscriminator(LDor
WL)thatfluctuatesbetween30and60fLandanupper
discriminator(UDorWU)thatisfixedat300fL.
Thenumberofcellsbetweenthesetwodiscriminators
isthetotalWBCcount.
CBC byAhmad Darwish

85. WBC Histograms
AnormalWBChistogramcurveshouldbewithinthe
discriminatorsandstartandendatthebaseline.
WBChistogramsconsistoftwotroughsorvalleys;
T1liesbetween78&114fLandT2<150fL.
These2troughsaredetectedby2innerdiscriminators
thatseparatetheWBCpopulationsinto3groups,
basedonthesizeofcells.
CBC byAhmad Darwish

86. WBC Histograms
ThepeakbetweenLDandT1representsasmallcell
population,i.e.,lymphocyteswiththeirvolumeranging
from35to90fL.
ThepeakbetweenT1andT2representsmediumcell
populationcomprisingofeosinophils,basophils,
monocytes,promyelocytesandblastswiththeir
volumerangingbetween90and160fL.
ThepeakbetweenT2andUDdenotesneutrophils
withtheirsizerangingfrom160to300fL.
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87. Histograms showing abnormaldistribution of neutrophils& lymphocytes
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WBC Histograms

88. WBC Histogram Flags
WL flag (LD flag):
ThisisanabnormalcurveattheLDthatoccurswhentheheightofLDexceedsthe
present2%oftheY-axis.
ThismaybeseeninthepresenceofnucleatedRBCs,clottedsample&coldagglutinins.
CBC byAhmad Darwish

89. WBC Histogram Flags
WU flag (UD flag):
ThisisanabnormalcurveattheUDthatoccurswhentheheightofUDexceedsthe
preset10%oftheY-axis.
ThismaybeseeninthepresenceofinadequateWBClysing,WBCaggregation&extreme
leukocytosis.
CBC byAhmad Darwish

90. WBC Histogram Flags
T1 flag (LD flag):
This is an abnormal curve at T1 level.
T1 and T2 flags appear when discrimination between 3 populations is not possible.
A T1 flag appears when differentiationbetween lymphocytesand medium-sized cell populationsis
not possible, for example, in cases of CML& leukocytosis.
CBC byAhmad Darwish

91. WBC Histogram Flags
T2 flag:
This is an abnormal curve at T2 level.
T2 flags appear when discrimination between 3 populations is not possible.
A T2 flag appears when differentiationbetween mixed cellsand neutrophilsis not
possible,
CBC byAhmad Darwish

92. This occurs when the height of T1 surpasses the present limit of 40%.
The F1 flag denotes that the discrimination between small cell and middle
cell populations is not an accurate example in ALL.
An F2 flag occurs when the middle cell data is inaccurate.
The T1 and T2 exceed the preset limits of 40% and 50%, respectively.
Examples of F2 flags are eosinophilia, acute myeloid leukemia and
monocytosis.
F3 flag occurs when the T2 exceeds the preset limit of 50%, denoting that
the large cells data is inaccurate.
WBC Histogram Flags
F1, F2 & F3 flags:

93. CBC byAhmad Darwish
Significance in anemiaWBC parameters
Systemic inflammation, sepsis, hematological
disorders (MPN,
AML, bone marrow infiltrative disorder).
Immature granulocyte count (IMG): Immature
myeloid cells
Reactive lymphocytes, lymphoma cells, blasts;
Helps in sepsis monitoring.
High fluorescent lymphocytes (HFL) or Atypical
lymphocytes,ALY% or Large unstained cells,
%LUC
Raised in sepsis; Low in MDS or MDS/MPN.Neutrophil granulation (NEUT-X/NEUT-Y):
Granularity/nucleicacid and protein content
More than 3.7 in the absence of a WBC peak in
malaria.
Malaria factor (Mf)
AML: acute myeloid leukemia, MDS: myelodysplastic syndrome, MDS/MPN: myelodysplastic
syndrome/myeloproliferative neoplasm.
1. Nathan D, OrkinS, OskiF. Nathan and Oski’shematology and oncology of infancy and childhood. Elsevier. 2015.
White Blood Cell Parameters on Automated
Analyzer

94. Abnormal
Values

95. Abnormal values in CBC reports
CBC byAhmad Darwish

96. Abnormal values in CBC reports
CBC byAhmad Darwish

97. Abnormal values in CBC reports
CBC byAhmad Darwish

98. Home
Message

99. Quality control in
performance of a CBC
Pre-analyticalfactors
Samplesshouldnotbelefttostandfora longtime
beforeprocessing
Samplesshouldbekeptawayfromdirectsunlight
Insufficientsamples shouldbe rejectedspecially to
deter theeffectsofanticoagulantconcentrations on
CBCresults
Sample collectionshouldfollowpropercollection
procedures
Properlabeling
Rightanticoagulantshouldbeused(EDTA)

100. SampleCollection
EDTATrisodium citrate Heparin

101. Automatedhematologyanalyzersdonotprovideacompleteanswerregardingthe
underlyingetiologyofanemiaandmayleaveroomformisinterpretation.
Thus,furthertestingisrequiredtomakeaconfirmatorydiagnosis.
However,despitethesepitfalls,itplaysaroleinearlydecision-makingandcan
helpinreducingthetimelagbetweenclinicalpresentationandinstitutionof
appropriatetherapy.
Do not Forget

102. [email protected]
002 01001179115