Globulos Rojos Nucleados, a travez de la identifiacion

NRBC case

1. NRBC Case Study
Run Across Four Cell-Dyn Instruments

2. CD4000CD4000
Laboratory WorksheetLaboratory Worksheet
CBC + RETC Test SelectionCBC + RETC Test Selection
1) rstRBC Flag- This flag 1) rstRBC Flag- This flag
indicates the indicates the
presence of red blood presence of red blood
cells which are cells which are
resistant to the lyse resistant to the lyse
reagent, therefore, reagent, therefore,
interfering with interfering with
various other CBC various other CBC
results (note the results (note the
asterisk next to the asterisk next to the
various parameters, various parameters,
invalidating these invalidating these
results). This flag results). This flag
requires the operator requires the operator
to rerun the sample to rerun the sample
in the resistant RBC in the resistant RBC
mode.mode.

3. CD4000CD4000
Laboratory WorksheetLaboratory Worksheet
CBC + RETC + Resistant CBC + RETC + Resistant
Test SelectionTest Selection
1) A directly reportable WBC, 1) A directly reportable WBC,
differential and NRBC. differential and NRBC.
Extended Lyse mode was Extended Lyse mode was
effective in removing effective in removing
interference by RRBC. Good interference by RRBC. Good
correlation with manual NRBC correlation with manual NRBC
which was 150 NRBC/100 WBC. which was 150 NRBC/100 WBC.
Notice the typical NRBC dual Notice the typical NRBC dual
population. The smaller population. The smaller
population to the right are the population to the right are the
more mature NRBC, staining more mature NRBC, staining
the DNA more brightly. The the DNA more brightly. The
larger population to the left is larger population to the left is
the newer, immature NRBC. the newer, immature NRBC.
They show a lesser degree ofThey show a lesser degree of
florescence due to the decreased uptake of the dye. This is due to the
less permeable membrane of the immature cells as opposed to the more
permeable membrane of the mature NRBC.

4. CD4000CD4000
Laboratory WorksheetLaboratory Worksheet
CBC + RETC +Resistant Test CBC + RETC +Resistant Test
SelectionSelection
2) PLTo and PLTi are still 2) PLTo and PLTi are still
invalidated due to a delta (the invalidated due to a delta (the
difference) in the results. This difference) in the results. This
would warrant a slide review would warrant a slide review
to estimate the correct to estimate the correct
platelet count. A CD61 platelet count. A CD61
immunoplatelet count could immunoplatelet count could
also be done as a viable also be done as a viable
alternative and would most alternative and would most
likely give are a reportable likely give are a reportable
platelet count.platelet count.
3) The black population below 3) The black population below
and to the left of the NRBC and to the left of the NRBC
population is due to the population is due to the
presence of inclusion bodies, presence of inclusion bodies,
in this case Pappenheimer in this case Pappenheimer
Bodies (4+). Bodies (4+).

5. CD3700CD3700
Patient CBC Test Patient CBC Test
Selection Selection
1) NRBC/RRBC flags- 1) NRBC/RRBC flags-
These flags These flags
indicate the indicate the
presence of NRBCs presence of NRBCs
and resistant RBC. and resistant RBC.
The presence of The presence of
this flag requires this flag requires
a repeat run in a repeat run in
the Resistant RBC the Resistant RBC
Mode (RRBC).Mode (RRBC).

6. CD3700CD3700
Patient CBC Test Patient CBC Test
Selection Selection
2) WBC flag- This flag 2) WBC flag- This flag
indicates the WBC indicates the WBC
count is invalid. In count is invalid. In
this case the this case the
instrument suspects instrument suspects
RRBCs or NRBCs may RRBCs or NRBCs may
be interfering with its be interfering with its
ability to accurately ability to accurately
count the WBC. The count the WBC. The
operator cannot operator cannot
report this value out. report this value out.
The specimen needs The specimen needs
to be repeated in the to be repeated in the
RRBC mode to RRBC mode to
eliminate the eliminate the
interference of these interference of these
cells from the WBC.cells from the WBC.

7. CD3700CD3700
Patient CBC Test Patient CBC Test
SelectionSelection
3) DFLT (NLMEB)- When 3) DFLT (NLMEB)- When
the instrument’s the instrument’s
algorithm is not algorithm is not
able to see a clear able to see a clear
separation between separation between
the WBC the WBC
populations, it will populations, it will
set default set default
discriminator lines discriminator lines
to generate a to generate a
reading where the reading where the
populations would populations would
normally be found. normally be found.
A smear review of A smear review of
the differential is the differential is
required.required.

8. CD3700CD3700
Patient CBC Test Patient CBC Test
SelectionSelection
4) VAR LYM flag- This 4) VAR LYM flag- This
flag occurs as a flag occurs as a
result of the result of the
elongation and elongation and
density of the density of the
lymphocyte lymphocyte
population into population into
the region where the region where
variant lymphs variant lymphs
are found.are found.
5) RBC MORPH- This 5) RBC MORPH- This
flag is triggered flag is triggered
by the elevated by the elevated
RDW.RDW.

9. CD3700CD3700
CBC + Resistant RBC CBC + Resistant RBC
Test SelectionTest Selection
1) By repeating the 1) By repeating the
specimen in the specimen in the
RRBC mode, the RRBC mode, the
resistant RBCs and resistant RBCs and
the majority of the the majority of the
NRBCs are exposed NRBCs are exposed
to lyse for an to lyse for an
extended period of extended period of
time, eliminating time, eliminating
their interference their interference
with the WBC. Note with the WBC. Note
that the WBC flag is that the WBC flag is
gone, indicating this gone, indicating this
is a fully reportableis a fully reportable
WBC. The NRBC flag remains indicating that NRBCs are present, but are WBC. The NRBC flag remains indicating that NRBCs are present, but are
NOT included in the WBC and therefore no correction of the WBC is needed. NOT included in the WBC and therefore no correction of the WBC is needed.
A smear review would be needed to get a quantitative NRBC.A smear review would be needed to get a quantitative NRBC.

10. CD3700 CD3700 CBC + Resistant RBC Test SelectionCBC + Resistant RBC Test Selection

This is the Flagging Diagnostics screen, accessed by pressing [PAGE DOWN] This is the Flagging Diagnostics screen, accessed by pressing [PAGE DOWN]
from the RUN screen. It gives an estimation of the number of NRBC seen per from the RUN screen. It gives an estimation of the number of NRBC seen per
100 WBC. This is for Laboratory Use Only and is not a reportable result. Notice 100 WBC. This is for Laboratory Use Only and is not a reportable result. Notice
how close the estimate (89) matches the CD4000 reportable NRBC (90).how close the estimate (89) matches the CD4000 reportable NRBC (90).

11. CD3200CD3200
Patient CBC Test Patient CBC Test
SelectionSelection
1) NRBC/RRBC Flags- 1) NRBC/RRBC Flags-
These flags These flags
indicate the indicate the
presence of presence of
nucleated red nucleated red
blood cells (NRBC) blood cells (NRBC)
and resistant red and resistant red
blood cells (RRBC) blood cells (RRBC)
and requires a and requires a
repeat run in the repeat run in the
RBC mode.RBC mode.

12. CD3200CD3200
Patient CBC Test Patient CBC Test
SelectionSelection
2) WBC flag- This flag 2) WBC flag- This flag
indicates that the indicates that the
WBC count is WBC count is
invalid. In this invalid. In this
case the case the
instrument instrument
suspects RRBCs or suspects RRBCs or
NRBC may be NRBC may be
interfering with interfering with
its ability to its ability to
accurately count accurately count
the WBC. The the WBC. The
operator cannot operator cannot
report this value report this value
out. Theout. The
separation needs to be repeated in the RRBC test selection to eliminate theseparation needs to be repeated in the RRBC test selection to eliminate the
interference of these cells from the WBC.interference of these cells from the WBC.

13. CD3200CD3200
Patient CBC Test SelectionPatient CBC Test Selection
3) DFLT (NLMEB)- 3) DFLT (NLMEB)-
When the When the
instrument’s instrument’s
algorithm is not algorithm is not
able to see a clear able to see a clear
separation between separation between
the WBC the WBC
populations, and it populations, and it
will set a default will set a default
reading where the reading where the
populations would populations would
normally be found. normally be found.
A smear review of A smear review of
the differential is the differential is
required to confirm required to confirm
the automated the automated
differential results.differential results.

14. CD3200CD3200
Patient CBC Test Patient CBC Test
SelectionSelection
4) VAR LYM flag- This 4) VAR LYM flag- This
flag occurs as a flag occurs as a
result of the result of the
elongation and elongation and
density of the density of the
lymphocyte lymphocyte
population into the population into the
region where region where
variant lymphs may variant lymphs may
be found.be found.
5) RBC MORPH flag- 5) RBC MORPH flag-
This flag is triggered This flag is triggered
by the elevated by the elevated
RDW.RDW.

15. CD3200CD3200
CBC+Resistant RBC Test CBC+Resistant RBC Test
SelectionSelection
1) WOC (WBC) flag- The 1) WOC (WBC) flag- The
instrument reported instrument reported
the WOC (White the WOC (White
Optical Count), but Optical Count), but
this value is not this value is not
reportable due to the reportable due to the
presence of the WBC presence of the WBC
flag, which invalidates flag, which invalidates
the count. Although the count. Although
the extended lysing the extended lysing
time has likely time has likely
removed most of the removed most of the
RRBCs, there is still RRBCs, there is still
something interferingsomething interfering
with the instrument’s ability to accurately determine a WBC count. The with the instrument’s ability to accurately determine a WBC count. The
WBC in this case would need to be verified by an alternative method WBC in this case would need to be verified by an alternative method
(i.e. Manual WBC) and is not reportable. (i.e. Manual WBC) and is not reportable.

16. CD3200CD3200
CBC+Resistant RBC CBC+Resistant RBC
Test SelectionTest Selection
2) NRBC flag- 2) NRBC flag-
Indicating there Indicating there
are NRBC present. are NRBC present.
A blood smear A blood smear
review is required review is required
in order to in order to
determine the determine the
number of number of
nucleated RBC nucleated RBC
present and aid in present and aid in
the correction of the correction of
the WBC count.the WBC count.

17. CD3200CD3200
CBC+RRBC Test SelectionCBC+RRBC Test Selection

This is the laboratory This is the laboratory
worksheet for the worksheet for the
CD3200. Press the CD3200. Press the
[PAGE DOWN] key on [PAGE DOWN] key on
the RUN menu to the RUN menu to
access it. The access it. The
instrument displays instrument displays
the expanded the expanded
differential,including differential,including
an estimation of the an estimation of the
number of NRBCs number of NRBCs
present. This is to be present. This is to be
used as a reference used as a reference
and is notand is not
meant to replace the manual NRBC count. Note the nice correlation of the meant to replace the manual NRBC count. Note the nice correlation of the
CD3200 estimate (76) to the fully reportable CD4000 NRBC (90).CD3200 estimate (76) to the fully reportable CD4000 NRBC (90).

18. CD1700CD1700
CBC Test SelectionCBC Test Selection
1) RM flag- This flag 1) RM flag- This flag
indicates that there indicates that there
are cells in the are cells in the
multiple regions multiple regions
around the around the
lymphocyte lymphocyte
population. This population. This
alert can be tripped alert can be tripped
by the presence of by the presence of
NRBCs and Resistant NRBCs and Resistant
RBCs. This flag RBCs. This flag
invalidates the WBC invalidates the WBC
and requires the and requires the
operator to review a operator to review a
blood smear to blood smear to
accurately assess the accurately assess the
cells present.cells present.

19. CD1700CD1700
CBC Test SelectionCBC Test Selection

If NRBCs are found to be If NRBCs are found to be
present, the WBC count present, the WBC count
will need to be corrected. will need to be corrected.
The manual NRBC= The manual NRBC=
150/100 WBC, therefore 150/100 WBC, therefore
the corrected WBC would the corrected WBC would
be calculated as follows:be calculated as follows:
WBC Count x 100____ WBC Count x 100____
100 + NRBC/100 WBC100 + NRBC/100 WBC
58 x 100___58 x 100___ = 23.2 = 23.2
100 + 150 corrected100 + 150 corrected
WBCWBC