HEMOGRAM slides to help with health care

Very helpful

1. HEMOGRAM PRESENTER; HALWIINDI CLIVE MODERATOR; LANDILANI TEMBO

2. OBJECTIVES 1. What is hemogram 2.Common indications of hemogram 3. Blood composition 4. Carrying out FBC 5. Parameters of FBC 6. Effects of gender on FBC parameters 7. Parameters of FBC in details

3. THE HEMOGRAM AKA- full blood count (FBC), complete blood count (CBC) It is one of the most frequently ordered hematological investigation in the diagnosis and management of various clinical conditions. It comprises of 13-19 parameters The FBC measures many cellular components and features of the blood RBC; play a role in tissue perfusion WBC; play a role in host immunity PLT; play a role in hemostasis and coagulation

4. COMMON INDICATIONS FOR FBC Suspected clinical disorder; Anemia, thrombocytonia, infection, leukemia, bleeding disorders, cancer, allergies, immuno deficiencies, hemoglobinopathies. Pre and post-operatively Pre and post-tranfusion Supportive and management of some conditions Monitoring treatment and side-effect of the certain drugs

5. BLOOD COMPOSITION

6. CARRYING OUT FBC

7. PARAMETERS OF THE FBC White blood cells (WBC) Red blood cells (RBC) Hematocrit ( HCT) Mean corpuscular hemoglobin (MCH) Mean corpuscular volume ( MCV) Mean corpuscular hemoglobin concetration (MCHC) Hemoglobin (Hgb/Hb) Red cell distribution width ( RDW) Differential (%) and absolute value: neurophils, lymphocytes, monocytes, eosinophils, basophils.

8. FBC PARAMETERS CONT.... Reticulocyte count (% and absolute values) Platelets Platelets distribution width (PDW) Mean plts volume (MPV) Platelet large cell ratio (PLCR) Immature granulocytes (IG)

9. EFFECTS OF GENDER ON FBC PARAMETERS. Prepubertal humans:no major differences in RBC or hemoglobin. Gender difference revert back to normal 10years after menopause when Hb becomes similar to that of aged matched men. adults men and women have different Hb, RBC and PCV in health. The gender difference is independent of iron status-iron replete premenopausal women have mean Hb levels approximately12% lower than age and race matched men

10. WBC normal value men; 5,000 to 10,000 blood cells per microliter of blood For women 4,500 and 11,000 per microliter of blood Children 5,000 and 10, 000. Thresholds common used in our setting 4,000-11,000 An increase in WBC is termed leukocytosis and a decrease in WBC is called leukopenia

11. CAUSE OF LEUKOCYTOSIS Bacterial or viral infection autoimmune disease( lupus) inflammatory disease(rheumatoid arthritis) cancer such as leukemia Hodgkin disease allergic reaction tissue damage burns kidney failure pregnancy

12. CAUSES OF LEUKOPENIA Immune suppression-HIV/AIDS, malnutrition, chemotherapy and radiotherapy lymphoma diseases of the liver or spleen Splenomegaly Effect of drugs(antibiotic) alcohol abuse

13. RBC AND HEMOGLOBIN NORMAL VALUES MEN; 4.5-6.5 million cells per microliter WOMEN; 3.8-5.8 million cells per microliter

14. HEMATOCRIT OR PACKED CELL VOLUME Male; 40.7-50.3% Female;36.1-44.3% 444444444444444444444444444 44

15. Normal Ranges  Cord blood: - Hb - 16.5 ± 3 g/dl - Hct - 51 ± 9 %  0.5-2 years: - Hb: 12.0 ± 1.5g /dl - Hct - 36 ± 3 %  12-16 yrs: Female: -Hb 14.0 ± 2 g/dl -Hct 41 ± 4% Male: -Hb 14.5 ± 1 g/dl - Hct 43 ± 6%

16. CONDITIONS WITH LOW HCT Anemia Associated long term illness, infections or WBC disorder e.g leukemia orn lymphoma vitamin or mineral deficiences recent or long-term hemorrhage

17. CONDITONS ASSOCIATED WITH HIGH HCT Dehydration polycythemia vera (a myeloproferative disorder associated with producton of the excessive number of red cells) Lung or heart disease Administering of the testosterone supplement therapy Dengue fever ( high HCT is a danger sigh of an increased risk of dengue shock sydrome COPDs and other pulmonary conditions associated with hypoxia

18. HCT CONT..... Doping or EPO Use of anabolic androgenic steroids Capillary leak syndrome

19. MEAN CELL VOLUME It is the average size of RBC MCV is equal to PCV *10/RBC

20. MCV CONT...... Normal MCV is equal to 80-96 femtoliters per cell (fL) Cell <80 microcytes Cell 80-96 normocytes Cells >96 macrocytes

21. CONDITIONS WITH LOW MCV Iron deficiency with its numerous causes Thalassemia with its several types Anemia of the chronic diease Sideroblastic anemia Lead poisoning HbC and other hemoglobin hybrids Spherocytosis

22. CONDITIONS WITH HIGH MCV Vitamin b12 and folate deficiency Liver disease Alcoholism Hypothyroidism Some hemolytic anemia Mylodysplatic syndrome/preleukemia Aplastic anemia Benign familial macrocytosis Some chemotherapy

23. ANEMIA ASSOCIATED WITH NORMAL MCV Kidney disease anemia of the chronic diasese /inflammation (early stage) acute blood lose endocrine disease some hemolytic anemias

24. MEAN CELL HEMOGLOBIN CONCENTRATION This is the average concetration of HB in a given volume of packed the RBCs (INDIVIDUALLY) expressed in % or g/dl It is the ratio of the Hb to Hct and measure how much Hb is packed into average cell In conjuction with MCV and RDW it is the single most important blood index in diagnosis of anemia. MCHC is equal to Hb ( Hct by 10) in g/dL MCHC is equal to MCH/MCV Normal MCHC is equal to 32-37g/dL

25. MCHC CONT.... Low MCHC (HYPOCHROMIA) means there is is low contration of Hb in a given volume of RBC (Reduce oxygen carrying capacity) A normal MCHC (normochromia) or high (hyperchromia) means that oxygen carrying capacity of the RBC is normal

26. MCHC CONT.... ANEMIA ASSOCIATED WITH NORMAL MCHC ANAEMIA ASSOCIATED WITH LOW MCHC CAUSES OF HIGH MCHC BLOOD LOSS ANEMIA IRON DEFICIENCY (WITH OR WITHOUT ANAEMIA) AUTOIMMUNE HAEMOLYTIC ANEMIA ANEAMIA DUE TO KIDNEY DISEASE LEAD POISONING COLD AGGLUTIN (CHAD) (FALSELY) MIXED ANEAMIAS THALASSEAMIA (BETA ALPHA THALASSEMIA AND THALASEEMIA INTERMEDIA SMOKERS BONE MARROW FAILURE SIDEROBLASTIC ANEMIA HEREDITARY SPHEROCYTOSIS HAEMOLYTIC ANAEMIAS ANEMIA OF CHRONIC DISEASE SEVERE BURNS, LIVER DISEASE, HYPERTHYROIDISM SICKLE CELL DISEASE HAEMOGLOBIN C DISEASE

27. MCV AND MCHC IN ANEMIA MCV MCHC EXAMPLES OF CONDITIONS LOW (MICROCYTIC) LOW (HYPOCHROMIC) IRON DEFICIENCY ANEMIA LOW (MICROCYTIC) NORMAL (NORMOCHROMIC) THALASSAEMIA NORMAL (NORMATIC) NORMAL (NORMOCHROMIC ) ANEMIA OF CHRONIC DISEASE HIGH (MACROCYTIC) NORMAL (NORMOCHROMIC) VITAMIN B12 DEFICIENCY

28. MEAN CORPUSCULAR HEMOGLOBIN This is the average weight of the Hb in a person red cells. (individually red cells) Normal MCH levels are around 28 to 32 picograms (pg) per cell in adults or micromicrogram MCH is equal to (Hb by 10 )/RBC. MCH is low in hypochromic anemia and iron deficiency anemia.

29. RED CELL DISTRIBUTION WIDTH (RDW) The RDW is a measure of variation in RBC size (ANISOCYTOSIS) The RWD can be reported statistically as coefficient variation (RDW-CD) or standard deviation (RDW-SD) RDW-SD (expressed in fL) is an actual measurement of the width of the RBC size distribution histogram and is measured by calculating the witdth (in fL) at the the 20% height level of the RBC size distribution histogram. This parameter is not influenced byn average RBC size ( MCV)

30. RDW CONT........ RDW-CV (expressed in %) is calculated from SD and MCV is equal to 1 SD of RBC volume /MCV by 100 Normal values RDW-SD 39-49 RDW-CV 11-16% An increased in the RDW is the presence of an otherwise normal count should warrant a smear

31. CONDITIONS WHERE RDW MAY BE CLINICALLY SIGNIFICANT Chronic liver diseases Iron deficiency anemia Kidney disease Sickle cell disease Thalassemia Polycythemia vera Ischemic stroke

32. MCV AND RDW IN DIFFERENT ANEMIA ANEMIA TYPE NORMAL RDW HIGH RDW MICROCYTIC THALASSEMIA IRON DEFICIENCY ANEMIA, SOME HEMOLYTIC ANEMIA NORMOCYTIC ACUTE BLOOD LOSS ANEMIA, ANEMIA OF CHRONIC DISEASE, SPHEROCYTOSIS COMBINED ANEMIAS, SICKLE CELL ANAEMIA, SIDEROBLASTIC ANAEMIA, MACROCYTIC APLASTIC ANEMIA , PRELEUKEMIA, LIVER DISEASE VITAMIN B12 DECIFIENCY/FOLATE, COLD AGGLUTINI DISEASE

33. PLATELETS Measures the average number of platelets normal range is 150-500 by 10^9/l platelets are circulating 3 to 4 micro meter diameter anuclera fragments of th eborn marrow megakaryocyte Thy are essential in formation of the initially platelets plug in the first production of platelets factor 3 an essential component of the coagualation cascade. platelets are rapidly deployed to sites of injury or infection and potentially mocules inflammatory process by interating with leukocytes and secreting cytokine, chemokines and other inflammatory mediators

34. PLATELETS CONT.... An increase in platelets count is called thrombocytosis A decrease in platelet count is called thrombocytopenia

35. COMMON CAUSE OF THROMBOCYTOSIS REACTIVE MYLOPROLIFERATIVE NEOPLASMS OTHER CAUSE CHRONIC INFECTION ESSENTIAL THROMBOCYTOSIS ASSOC IATED WITH OTHER MYLOID NEOPLAMS CHRONIC INFLAMMATION MALIGNANCY HYPOSPLENISM (POST SPLENECTOMY) IRON DEFIECIENCY ACUTE BLOOD LOSS POLYCYTHEMIA VERA

36. COMMON CAUSES OF THROMBOCYTOPENIA Aplastic anemia Babesiosis Chemotherapy Drug induced thrombocytopenic purpura (HIT) Familial thrombocytopenia HELLP syndrome Pregnancy Splenomegaly Girberts syndrome

37. RETICULOCYTE COUNT (% AND ABSOLUTE VALUES) Reticulocyte are immature RBCs produced in the bone marrow and released into the peripheral blood count can be an index to measure erythropoietic activity or failure following anemia, hemorrhage and bone marrow failure retic count ( percentage of reticulocytes/total RBC) by 100 normal is equal to 0.5 to 2.5 inadults and 2 to 6% in infants

38. VARIATIONS IN THE RETICULOCYTE COUNT CONDITIONS ASSOCIATED WITH A LOW RETICULOCYTE COUNT CONDITIONS ASSOCIATED WITH A HIGH RETICULOCYTE COUNT IRON DEFICIENCY ANEMIA INCREASED PREMATURE DESTRUCTION NUTRITIONAL DEFICIENCY FOLIC AND VITAMIN B12 DEFICIENCY AT HIGH ALTITUDES DUE TO HYPOXIA BONE MARROW FAILURE DUE TO EFFECT DRUG TOXICITY, INFECTION OR CANCER,APLASTIC ANEMIA HAEMOLYTIC DISEASE OF THE FOETUS AND NEWBORN (HDFN) KIDNEY DISEASE CHRONIC BLOOD LOSS LIVER DISEASE SIDES EFFECTS FROM CHEMOTHERAPY AND AND RADIOTHERAPY HYPO PROFELIFERATIVE DISORDERS

39. PLATELETS DISTRIBUTION WIDTH (PDW) It reflects the variations in size distribution (platelets anisocytosis) Normal range is 9.6 to 15.3 femtoliters PDW tends to increase in inflammatory reactions and clinical disease. platelets activation increase PDW. Inflammatory cytokines (IL6, CSF-G, CSF-M) regulate megakaryocyte maturation, platelets producation and platelets size. PDW can be used in the diagnosis of immune thrombocypenia Increased PDW has been seen DM cancer cardio cerebrovascular and respiratory.

40. MEAN PLATELET VOLUME This is the average size of platelets MPV depends on the degree of stimulation of megakaryocte depend on thrombopoietic stress Normal MPV 8.9 to 11.8 fL A high MPV with low platelets count is seen when platelets are destroyed, usually by antibodies an infection or toxin. for example in ITP platelets deficiency caused by destruction of platelets without a known cause A high MPV and platelet count occurs when the bone marrow produce too many platelets due to genetic mutation of the cancer.

41. FACTORS AFFECTING PLATELETS COUNT AND VOLUME PEOPLE WHO LIVE AT LOW ALTITUDES AND MAY HAVE HIGHER THAN AVERAGE PLALETES COUNT. THOSE WHO LiVE AT HIGH ALTITUDE MAY HAVE A HIGH MPV WHICH HAS BEEN CONSIDERED TO POSSIBLE RISK FACTOR FOR HEART FAILUE SMOKING, HIGH BLOOD PRESSURE AND GLUCOSE LEVELS WITHOUT A DIAGNOSIS HAVE ALL BEEN ASSOCITED WITH A HIGH MPV IN MEN MENSTRUATION AND ORAL CONTRACEPTIVES ARE ASSOCIATED WITH HIGH MPV IN WOMEN STRENOUS EXERCISE HAS ALSO BEEN ASSOCIATED WITH AN INCREAASE IN PLATELETS COUNT IF IT IS SEVERE ENOUGHTO CAUSE TISSUE DAMAGE.

42. VARIATIONS WITH MPV CONDITIONS ASSOCIATED WITH HIGH MPV CONDITIONS ASSOCIATED LOW MPV BERNARD SOULIER DISEASE LOW PLTS COUNT ALONG WITH LOW MPV POINTS TOWARDS BONE MARROW DISORDERS THAT LOW DOWN OR DECREASE THE PRODUCTION OF PLATELETS SUCH AS APLASTIC ANEMIA BONE MARROW STIMIULATING DRUGS SUCH AS ERYTHROPOITIN OR THROMBOPOIETIN HIGH PLATELET COUNT ALONG WITH LOW MPV OFTEN SIGNIFIES AN INFECTION, INFLAMMATION OR CANCER DM NORMAL PLATELET COUNT ALONG WITH LOW MPV IS COMMON WITH CHRONIC KIDNEYFAILURE GENETIC ABNORMALITIES SEPSIS HEART DISEASE OR ARTIFICIAL HEART VALVES HYPERTHYROIDISM NON ALCOHOLIC LIVER DISEASE RESPIRATORY DISEASE

43. PLATELETS LARGE CELL RATIO This is the proportion of platelets greater than 12fL (NORMAL P-LCR<30% IN THE TOTAL PLATELETS COUNT) P-LCR is also considerd an indicator for risk factor associated with thromboembolic ischemic events P-LCR is inversely related to platelets count and directly related to PDW and MPV Large platelets are usually relatively young contains more intracellular granules and more thrombogenic potential platelets turnover play a sighificant role in platelets size Increased PDW has been seen DM cancer cardio cerebrovascular and respiratory.

44. IMMATUE GRANULOCYTES These are WBC that are fully developed at the time of release from the bone marrow into the peripheral tThy include;promyelocytes, myelocytes and metamyelocytes Thy are prercusor neutrophils With exception of neonates or pregnant women and post delivery the presence of IG indicates early stage of infection inflammation tissue damage or presence of hematological malignancy The presence of IG in the peripheral blood is described as left shift.it is often a reflection of the bone marrow response to bacterial infection and sepsis in adults IG may predict severe acute pancreatitis independently of SIRS

45. DIFFERENTIAL COUNT There are 5 types of WBC divides into 2 main groups GRANULOCYTES; have visible granules in their cytoplasm Neurophils Esonophils Basophils AGRANULOCYTES; Monocytes lymphocytes changes in each cell type has different significance

46. NEUROPHILS AND NEUTROPHILIA Normal absolute neurophils count is 2.0-7.5 by 10^9/l Neutrophilia is an absolute count > 7.5 by 10^9/l Neutrophilia is common seen in pts with bacterial infection The most severe infection are associated with more marked neutrophilia and often a degree of myleiods left shift the presence of immature myleoids cells in peripheral blood with toxic neutrophils granulation

47. NEUTROPHILIA Neutrophilia may also be seen in non infective disorder It is common response to steroids therapy, severe exercise and following surgery or splenectomy but can also occur in systemic vasculitis.Neutropenia can be seen in connective tissue disorder particulary rheumatoid and sjogren disease. It can be as results of the drugs therapy (clozipine, azathioprine, carbimazole and cytotoxic chemotherapy) viral infection (EBV) Physiological neutrophilia can occur as a normal physological process

48. CONDITIONS ASSOCIATED WITH NEUROPHILIA AND PHYSIOLOGICAL NEUTROPHILIA CONDITIONS ASSOCIATED WITH NEUTROPHILIA CONDITIONS ASSOCIATED PHYSIOLOGICAL NEUTROPHILIA SOME FUNGAL INFECTIONS NEONATES HAVE A HIGHER NEUROPHIL SOME PARASITIC INFECTIONS (PNEUMOCYSTIS CARINII) WOMEN OF CHILDBEARING AGE HAVE HIGHER NEUROPHILS COUNTS THAN MEN ACUTE AND CHRONIC BACTERIAL INFECTION ( PYOGENIC BACTERIA INCLUDING MILLIARY TB) PREGNANCY CAUSE A MARKED RISE IN THE NEUTROPHIL COUNT ACUTE HYPOXIA CHILD BIRTH OR LABOUR IS ASSOCIATED WITH NEUTROPHILS BURNS VIGOROUS EXERCISE CAN DOUBLE THE NEUTROPHILS COUNT. INFARCTION DRUGS ESPECIALLY CORTICOSTEROIDS VIRAL INFECTIONS (CHICKENPOX, HERPES SIMPLEX) IN PATIENT WITH SICKLE CELL CRISES

49. NEUTROPENIA Neutropenia is defined as as absolute neutrophils count less than 1.0 by 10^9/l Neutropenic patients are more susceptible to bacterial infection and without prompt treatment with broad spectrum antibiotic can develop life threatening neuropenic sepsis Neuropenia is commonly associted with deficiencies of vitamin B12, folate, aplastic anemia, tumors, effect of certain drug, metabolic diseases. A sudden onset neutropenia can be seen in patients with overwhelming bacterial infection and appear to be poor prognotic sign. A significant persisting neutropenia requires the opinion of the a hematologist particularly in patients with cytopenia in other lineages. Mild chronic neutropenia not associated with infection are reasonably common and are sometimes referred as benin idiopathic neutropenia.

50. LYMPHOCYTES Normal range is 1.5-4.5 by 10^9/L(20-40%) Lymphocytes is higher than normal number if lymphocytes (>4.5 by10^9L) If there is persistent lymphocytosis with smear cells it maybe neccessary to request for the lymphocyte markers (flow immunophenotype) to rule out a lymphoproliferative disorder. If there are atypical or reactive lymphocytosis it may be necessary to rule out viral infections (infectious mononucleosis, EBV)

51. COMMON CAUSE OF LYMPHOCYTOSIS Acute lymphocytic leukemia( rapidly rising lymphocyte count and blast cells present) Chronic lymphocytic leukemia (lymphodenopathy, hepatosplenomegaly) Viral infections Pharyngitis Tuberculosis Whooping cough Mononucleosis Hypothyidism

52. COMMON CAUSE OF EOSINOPHILIA Acute myelogeous leukemia Allergic, ascariasis Asthma Drug allergy Hay fever Ovarian cancer Parasitic infection Hodgkins lymphoma Eosinophilic esophagitis

53. BASOPHILS Basophils are the least numerous of the myelonous cells with large blue granules. Basophilia is the presence of the numerous circulating blasts suggest the possbility of acute myeloids leukemia. Elevetion of the basophils may also be representative of the multiple other underlying neoplasms such as polycythemia vera, myelofibrosi, thrombocythemia or in rare cases solid tumors, allergic reactions or chronic inflammation related to infections such as tuberculosis, influenza, inflammatory bowel disorder or an inflammatory autoimmune diseases.

54. MONOCYTES Normal monocyte number is 2.0-0.8 by 10^9L. Monocytosis is an increase in the number of monocytes circulating in the blood. Monocytosis can be feature in chronic infection with tuberculosis and syphilis as part of the inflammatory reaction in crohn disease and ulcerative colitis and as a response to certain carcinomas. A persistent monocytosis that is unexplained, particularly if associtaed with anemia or thrombocypenia, may be a feature of myoledysplastic and myloproliferative disorder, so a hematology assesment is advised in these case.

55. CONDITIONS ASSOCIATED WITH MONOCYTOSIS Pregnancy Infections;tuberculosis, brucellosis, subacute endocarditis,, syphilis and other viral infection Blood and immune cause chronic neutropenia and myeloproliferative disorder Autoimmune disease and vasculitis; systemic lupus erythematous, rhematoid arthritis. Malignancy;Hodgkins disease and certains leukemia such as chronic myelomonocytic leukemia and monocytic leukemia

56. EOSINOPHILS Eosinophilia is much less common finding in clinical pratice but the search for likely cause is often rewarding normal absolute eosinophilsm count is 0-0.4 by 10^9L Mild eosinophilia is common in patients with asthma, hay fever, and eczema but rarely exceed 1.0 by 10^9/L A few cases remain unexplained and were previouly known as hyper eosinophilic syndrome but these patients are increasing rare now that molecular diagnostic are able to characterise many of the these as clonal eosinophilic leukemia

57. REFERENCES 1.https://emedicine.medscape.com/hematology

58. THANK YOU .