Complete Blood Count, Interpretations

A presentation made by Dr Gauhar Mahmood Azeem on the interpretations of a simple CBC and the information it can give us, Various conditions which may cause derangement are mentioned,

1. Complete Blood Count Interpretations Dr. Gauhar Mahmood Azeem House Officer, Medical Unit 4 Services Hospital Lahore

2. ‘COMPLETE’ BLOOD COUNT

3. Complete Blood Count A complete blood count (CBC) is an important and readily available investigation that focuses on Red Blood Cells, White Blood Cells and Platelets, and their various parameters. It can help to serve as a screening test for many disorders and as a prognostic or follow up tool.

4. Components WBC RBC Hemoglobin Hematocrit MCV MCH MCHC RDW Platelets Neutrophils Lymphocytes Monocytes Basophils Immature Granulocytes Reticulocyte count

5. RBC Normal Values Males 4.7 to 6.1 million cells per microliter Females 4.2 to 5.4 million cells per microliter

6. Low RBC Count Known as anemia Acute or chronic bleeding RBC destruction (e.g.,  hemolytic anemia, etc.) Nutritional deficiency (e.g., iron deficiency, vitamin B12 or folate deficiency) Bone marrow disorders or damage Chronic inflammatory disease Kidney failure

7. High RBC Count Known as  polycythemia Dehydration Pulmonary disease Kidney or other tumor that produces excess erythropoietin Smoking Genetic causes (altered oxygen sensing, abnormality in hemoglobin oxygen release) Polycythemia vera

8. Hemoglobin Is the protein molecule that carries oxygen in the Red Blood Cells. 13.0-18.0 g/dl in males 11.5-16.5 g/dl in females We can have N HB in N RBC We can have N HB in D RBC We can have D HB in D RBC Thus the other indices MCH and MCHC come into play.

9. Hematocrit or PCV Males normal 45% Females normal 40% High Hct Increased risk of Dengue Shock Syndrome Polycythemia Vera COPD EPO or Erythropioten use Dehydration Capillary leak syndrome Sleep apnea Anabolic Steroid use Low Hct Due to anemia Anemia can be characterised by using the indices

10. Mean Corpuscular Volume Normal 77-95fL Low MCV indicates RBCs are smaller than normal ( microcytic ); caused by iron deficiency anemia, or   thalassemias , Congenital sideroblastic Anemia, Lead Poisoning, pyridoxine deficiency, anemia of chronic disease High MCV indicates RBCs are larger than normal (macrocytic )

11. Megaloblastic Macrocytic Anemia Macrocytes in bone marrow smear Medications affecting folate metabolism Vit B12 deficiency (Pernicious Anemia) Folate deficiency (Alcohol related often) Atrophic  Gastitis Gastrointestinal malabsorption Nitrous oxide abuse Primary  Bone marrow  disorders

12. Non Megaloblastic Macrocytic Anemias Alcohol Abuse Emphysema Hypothyroidism Accelerated Erythropoiesis (High Reticulocyte Index) Hemolytic Anemia Post-hemorrhagic Anemia Increased RBC membrane surface area Obstructive Jaundice Hepatic disease Post- splenectomy Bone Marrow disorders Myelophthisic Anemia Myelodysplastic Anemia ( Myelodysplastic Syndrome) Aplastic Anemia Acquired Sideroblastic Anemia

13. Couldn’t get past the spleen!

14. MCH and MCHC Mean corpuscular hemoglobin (MCH) measures the amount, or the mass, of hemoglobin present in one RBC. The weight of hemoglobin in an average cell is obtained by dividing the hemoglobin by the total RBC count. The result is reported by a very small weight called a picogram ( pg ).  Mean corpuscular hemoglobin concentration (MCHC) measures the proportion of each cell taken up by hemoglobin. The results are reported in percentages, reflecting the proportion of hemoglobin in the RBC. The hemoglobin is divided by the hematocrit and multiplied by 100 to obtain the MCHC

15. MCH and MCHC Less in Microcytic Anemias Normal in Macrocytic Anemias Elevated in hereditary spherocytosis,   sickle cell disease  and  Honozygous Hemoglobin C disease

16. Red Cell Distribution Width Low value indicates uniformity in size of RBCs High value i ndicates mixed population of small and large RBCs; immature RBCs tend to be larger. For example, 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 RDW

17. Reticulocyte Count Absolute reticulocyte count = # or % retics X ( pt’s Hct / Normal Hct ) Can be absolute or % In the setting of anemia, a low reticulocyte count indicates a condition is affecting the production of red blood cells, such as bone marrow disorder or damage, or a nutritional deficiency (iron, B12 or folate ) In the setting of anemia, a high reticulocyte count generally indicates peripheral cause, such as bleeding or  hemolysis, or response to treatment (e.g., iron supplementation for iron deficiency anemia)

18. Reticulocyte index Reticulocyte Index= Absolute Retic Count/ Maturition Factor Maturation Factor Hct > 35% : 1.o Hct 25-35% : 1.5 Hct 20-25% : 2.0 Hct <20% : 2.5

19. White Blood Cell Count The  normal number  of  WBCs  in the  blood  is 4,500-11,000   white blood cells  per microliter ( mcL ).  Normal value ranges  may vary slightly among different labs.

20. Leukopenia Low white cell count may be due to acute viral infections, such as with a cold or influenza. It can be associated with  chemotherapy ,  radiation therapy ,  myelofibrosis  and  aplastic anemia  (failure of white cell, red cell and platelet production).  HIV  and  AIDS  are also a threat to white cells. Other causes of low white blood cell count include  systemic lupus erythematosus ,  Hodgkin's lymphoma , some types of  cancer ,  typhoid ,  malaria ,  tuberculosis ,  dengue ,  rickettsial infections , enlargement of the  spleen ,  folate  deficiencies,  psittacosis ,  sepsis  and  Lyme disease . Many other causes exist, such as deficiency in  certain minerals , such as  copper and   zinc .

21. Pseudoleukopenia Pseudoleukopenia can develop upon the onset of infection. The leukocytes (predominately neutrophils, responding to injury first) start migrating towards the site of infection and can be scanned at the site of infection. Their migration causes bone marrow to produce more WBCs to combat infection as well as to restore the 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 ".

22. Drugs causing Leukopenia LOADS!!! Clozapine, buproprion , valproic acid, minocycline, lamotrigine . Immunosuppressive  drugs, such as  sirolimus ,  mycophenolate mofetil ,  tacrolimus ,  cyclosporine ,  Leflunomide ( Arava )  and  TNF inhibitors . [2]   Interferons used to treat  multiple sclerosis , such as  Rebif ,  Avonex , and  Betaseron , can also cause leukopenia . Chemotherapeutic drugs. Lots of others.

23. Give Augmentin!!!

24. Leukocytosis Known as leukocytosis Infection , most commonly  bacterial   or viral Inflammation Leukemia ,  myeloproliferative disorders Allergies ,  asthma Tissue death (trauma, burns,  heart attack ) Intense exercise or severe stress Will mention in detail in respective cell line.

25. Differential Counts

26. Absolute Neutrophil Count {(% of Neutrophils+ % of Bands) X WBC}/100

27. Neutropenia Decreased production in the bone marrow due to: aplastic anemia arsenic poisoning cancer, particularly blood cancers certain medications hereditary disorders (e.g. congenital neutropenia, cyclic neutropenia) radiation Vitamin B 12 , folate or copper deficiency Increased destruction: autoimmune neutropenia chemotherapy treatments, such as for cancer and autoimmune diseases Marginalisation and sequestration: Hemodialysis Medications Flecainide  (a class 1C cardiac antiarrhythmic drug) Phenytoin Indomethacin Propylthiouracil Carbimazole Chlorpromazine Trimethoprim/ sulfamethoxazole  ( cotrimoxazole ) Clozapine Ticlodipine Often, a mild neutropenia is seen in viral infections. Additionally, a condition called morning pseudoneutropenia  might be a side effect of certain antipsychotic medications.

28. Neutrophilia Post splenectomy Cigarette smoking Hypoxia Epinephrine Exercise Acute or Chronic Infection Myeloprofilerative disorders Acute stress Lukemoid reactions Drugs (steroids) Chronic Inflammation Tumors Myelophthisis Hyperactive marrow

29. Lymphocytopenia Autoimmune disorders (e.g.,  lupus, Rheumatic Arthritis) Infections (e.g., HIV,  viral hepatitis, typhoid fever,  inluenza ) Bone marrow damage (e.g., chemotherapy, radiation therapy) Corticosteroids

30. Lymphocytosis Acute viral infections (e.g., chicken pox, cytomegalovirus (CMV),Epstein-Barr virus (EBV),  herpes,rubella ) Certain bacterial infections (e.g . pertussis, whooping cough, tuberculosis (TB)) Toxoplasmosis Chronic  inflammatory disorder (e.g., ulcerative colitis) Lymphocytic leukemia, lymphoma Stress (acute)

31. Low monocytes Usually, one low count is not medically significant.Repeated low counts can indicate: Bone marrow damage or failure Hairy cell leukemia

32. Monocytosis Chronic infections (e.g., TB, Fungal Infections) Infection within the heart (bacterial endocarditis) Collagen vascular diseases (e.g., lupus, scleroderma, rheumatoid arthritis,  vasculitis ) Monocytic or myelomonocytic leukemia (acute or chronic)

33. Low Eosinophils Numbers are normally low in the blood. One or an occasional low number is usually not medically significant

34. Eosinophilia Asthma, allergies such as hay fever Drug reactions Parasitic infections Inflammatory disorders (celiac disease, inflammatory bowel disease) Some cancers, leukemias or lymphomas

35. Basopenia :D As with eosinophils , numbers are normally low in the blood; usually not medically significant

36. Basophilia Rare allergic reactions (hives, food allergy) Inflammation (rheumatoid arthritis, ulcerative colitis) Some leukemias

37. Platelet Count Normal platelet counts are in the range of 150,000 to 400,000 per microliter (or  150 - 400  x 109 per liter), but the normal rangefor the platelet count varies slightly among different laboratories.

38. Thrombocytopenia Immune Thrombocytopenias  (ITP) – formerly known as immune thrombocytopenia purpura and idiopathic thrombocytopenic purpura Cirrhosis Splenomegaly Gaucher’s disease Familial thrombocytopenia Chemotherapy, radiotherapy Babesiosis , Dengue, Onyalai , Rocky mountain spotted fever Thrombotic Thrombocytopenic Purpura HELLP Syndrome Hemolytic Uremic Syndrome Drug Induced Thrombocytopenia   (Heparin Induced Thrombocytopenia, acetaminophen, quinidine, sulfa drugs) Pregnancy associated Neonatal alloimmune associated Aplastic Anemia, leukemia, lymphoma Transfusion associated

39. Thrombocytosis Reactive Chronic infection Chronic inflammation Malignancy Hyposplenism (post- splenectomy ) Iron deficiency Acute blood loss Myeloprofirative disorders  – platelets are both elevated and activated Essential Thrombocytosis Polycythemia Vera Associated with other myeloid neoplasms Congenital Cancer (lung, gastrointestinal,  breast , ovarian , lymphoma) Kawasaki disease Soft tissue sarcoma Osteosarcoma Dermatitis  (rarely) Inflammatory bowel disease Rheumatoid arthritis Nephritis Nephrotic syndrome Bacterial diseases , including  pneumonia ,  sepsis ,  meningitis ,  urinary tract infections , and septic arthritis

40. Mean Platelet Volume Typical range of platelet volumes is 9.7–12.8  fL Low value indicates average size of platelets is small; older platelets are generally smaller than younger ones and a low MPV may mean that a condition is affecting the production of platelets by the bone marrow . High volume indicates a high number of larger, younger platelets in the blood; this may be due to the bone marrow producing and releasing platelets rapidly into circulation.

41. Platelet Distribution Width A high PDW means increased variation in the size of the platelets, which may mean that a condition is present that is affecting platelets

42. Low Blood Counts All three lines depressed in Aplastic Anemia, Myelodysplastic Syndrome, Chemotherapy

43. High Blood Counts Polycythemia Vera (Secondary)

44. Thank You