How to read Cbc

Prepared by
Dr.Hesham Abd Elaziz

1. CBC How to read Prepared by Dr. Hesham Abd Elaziz Elmahalla gen. hosp . Egypt [phone]

2. If you don't use it you lose it !

3. Contents 1- What is CBC 2- Why CBC 3- Parameters of CBC 4-What is normal ,what is abnormal 5-diagnostic possibilities 6-How CBC can direct management

4. CBC is an inexpensive maneuver Can help us in diagnosing 1-Blood diseases 2-Bone marrow conditions 3-Other organ abnormalities

5. CBC can diagnose 1-Anaemia 2- Bone marrow suppression 3-Nutritional deficiencies 4-Thrombocytopenia 5-Autoimmune conditions 6-Infections and infestations 7-Haemoglobinopathies 8- Response to treatment

6. Blood Components Blood is made of two major components plasma and cells

7. The plasma consists of water, plasma proteins (albumin , globulin and fibrinogen), and other constituents

8. Cells of the blood include the 1-Erythrocytes 2-Leukocytes 3-Platelets

9. What does CBC analyze ?

10. 1- RBCs 2- hemoglobin 3-reticulocytes 4-haematocrit 5- mean corpuscular volume 6- mean corpuscular hemoglobin 7-mean corpuscular hemoglobin concentration 8-Differential WCCs count 9- Platelets

11. The most important values is 1-Haemoglobin 2-MCV 3-Reticulocytes 4-Leukocytic count 5-Platelets

12. RBCs count in female 4.1-5.4 million/ cmm Decreased in Increased in 1-Iron deficiency 2-Chronic blood loss 3- Haemolysis 4-Bone marrow suppression 5-Chronic liver disease 6-Leukaemia malignancy 7-Hyperthyroidism 1-PE 2-OHSS 3-CHF , hypoxia smokers 4-Highlanders 5- Polycythemia vera

13. 1-Increased RBCs count & High Hb & haematocrit &High risk for pre- eclampsia investigate for PE 1-Albumine in urine 2-MCV 3-Uric acid 4-Liver function tests 5-Renal function tests

14. 1-Increased RBCs count & Hb haematocrit High risk for OHSS investigate for OHSS 1-Leukocytic count 2-Serum albumin 3-Kidney function tests 4-Coagulation profile

15. Normal Hb in female 12-16 gm/dl Decreased in Increased in 1- Iron deficiency anemia 2-Thalassemia 3-Chronic liver disease 4-Haemolysis 5-Hyperthyroidism 6-Malignancy 7-leukaemia 1- PE 2- OHSS 3- Hypoxia, smokers, CHF 4- Polycythemia vera

16. Haemoglobin 1-Pre-operative preparation >9.5g/dl 2-Before bloody operations : 11g/dl 3-Pre-operative for placenta praevia / accreta 12g/dl 4-Blood transfusion : if Hb is 7gms or less

17. Haematocrit (PCV) in women 37-47% in pregnant 33-44% Decrease in Increase in 1- Anaemia 2-Blood loss 3-Chronic liver disease 4- Hyperthyroidism 5-Haemolysis 6-Leukaemia 7- Malignancy 8-Thymus hypofunction 1-PE 2- OHSS 3-CHF 4-Smokers 5-Dehydration 6-Polycythaemia vera 7-Hyperspenism

18. Rule of 3 RBCs x 3 = Haemoglobin Haemoglobin x 3 = haematocrit If haematocrit >45 % severe OHSS (Patient should be hospitalized) >55% critical OHSS Leukocytic count > 25.000/ cmm ( Refere the patient to ICU)

19. Reticulocytes : These are the immature red cells If the cause of anaemia in the bone marrow , reticulocytes If the the cause of anaemia outside bone marrow , reticulocytes Normal levels are 0.5-1.5%

20. Reticulocytes Decreased in Increased in 1-Aplastic anaemia 2-Megaloplastic anaemia 3-Anaemia of chronic disease 4-Cirrhosis 5-Radiation 6-Decreased ACTH and pituitary hormones 1-Haemolytic anaemia 2-Pregnancy 3-Recent Hge 4-Response to treatment 5-Thalassaemia 6-Hypoxia 7-Leukaemia

21. Indices 1- (MCV) mean corpuscular volume 2- (MCH) mean corpuscular hemoglobin 3- (MCHC) the mean corpuscular haemoglobin concentration 4- (RDW) red cell distribution width

22. MCV means volume of red blood cells = cytic MCV = Hct / RBCs Normal values are 80 -100 fl. <80fl microcytic anaemia >100fl macrocytic anaemia MCV <72fl without heterogenecity is a sensitive and specific test for thalassaemia trait

23. The MCV can be normal with a low hemoglobin if the patient is hypovolemic or has had a recent blood loss

24. MCV <80 fl in microcytic cells as: 1-Iron deficiency 2-Thalassemia 3-Chronic disease 4- Lead poisoning 5- Porphyria

25. MCV < 80 fl ( microcytic ) 1- test ferritin 2- exclude haemoglobinopathies Iron supplementation if indicated oral or parenteral CBC after 2wks Iron is continued 3ms after Haemoglobin became normal

26. MCV 80-100 fl ( normocytic ) If Hb 8.5gm/dl or less *CBC/m and *test ferritin , folate , B12 and reticulocytes If normal : CBC /month If abnormal give supplementation

27. MCV >100 fl ( macrocytic ) caused by 1-Megaloblastic anaemia 2-Folate or Vitamin B12 deficiency 3-Liver disease 4-Post-splenectomy 5-Chemotherapy 6-Hypothyroidism

28. MCV > 100 fl ( macrocytic ) Investigate B12 , Folate Liver function tests Thyroid function tests CBC / month give folic acid 5 mg /d orally If low B12 give B12 supplementation If normal B12 Investigate reticulocytes ? referal

29. MCV<80fl ( microcytic ) If X is positive Iron deficiency anaemia is suggested If X is negative Thalassaemia is suggested X = MCV – ( Hb X5) - 3.5

30. MCH: is the average weight of hemoglobin per red cells Give the colour of the cells = chromic Most macrocytic are normochromic Most microcytic are hypochromic except chronic disease MCH = Hb / RBCs x100 Normal level is 27 -32pg Decreased in microcytic anaemia Increased in macrocytic anaemia .

31. MCHC: is the average concentration of hemoglobin per erythrocyte Normal levels =32-36% MCHC = Hb / Hct x10

32. MCHC in 1- Iron deficiency 2- Thalassaemias Normal levels of MCHC are 32 -36 %

33. RDW: Measures the variation of red blood cell volume It is used in conjunction with MCV to determine if anaemia is due to mixed cause or a single cause RDW = anisocytosis In microcytes RDW raised with Fe defeciency , in thalassaemia ,not Normal levels are 11.5-14.5%

34. Causes of anaemia by MCV Microcytic =<80fl = < 7micron Normocytic = 80-100fl= 7-8micron Macrocytic >100fl= >8.3micron 1- Sideroplastic 2- Fe deficiency 3- Thalassaemia 4-Haemoglobin opathies 5-Chronic infections 1- Acute blood loss 2- Haemolytic anaemia 3- Sickle cell disease 4-Haemoglobinopathies 1- Megaloplastic -B12 deficiency -Folic acid deficiency 2- Nonmegaloplastic Pregnancy Reticulocytosis Liver disease Alcohol 3-Hypothyriodism

35. MCV<80fl= <7micron Serum iron TIBC Bone marrow perls stain Iron deficiency anaemia Decreased Increased Chronic infections Decreased Decreased ++ Thalassaemia Increased Normal ++++ Haemoglobinopathies Normal Normal ++ Lead poisoning Normal Normal ++ Sideroplastic Increased Normal ++++ Microcytic anaemia

36. Iron related tests Normal Fe deficiency a S. Ferritin (p mol/L) 33-270 <33 TIBC( ug /dl) 300-340 >400 S. Iron ( ug /dl) 50-150 <30 Saturation % 30-50 <10 Bone marrow iron ++ Absent Iron deficiency anaemia

37. Iron deficiency anaemia 1-Microcytic MCV< 80fl RBC <7u 2-Hypochromic MCH <27pg MCHC <30% 3-Reticulocytes >2% 4-S.ferritin < 30pmol/l 5-TIBC >400 ug /dl 6-Serum iron <30ug/dl 7-Bone marrow stain Absent 8-Response to treatment Excellent

38. Macrocytic anaemia MCV>100fl 1-Megaloplastic anaemia Folic acid deficiency B12deficiency 2- Non megaloplastic Haemoglpbinopathies Hypothyroidism Drugs as immunosuppressant anticonvulsants

39. Treatment of IDA I-dietary iron( heme & non- heme ) II- Oral iron (tablets & syrups) III- Parenteral iron(IV&IM) IV- Erythropoietin V- Blood transfusion

40. II- Oral iron Elemental iron 100 to 200 mg/d until Hb becomes normal then prophylactic doses 30-120mg 3 months postpartum to replenish iron stores

41. It is permittible from the 2 nd trimester and postpartum period when : 1- Non-compliance with, or intolerance to oral iron therapy 2- Malabsorption Dose (mg) : Body wight (kg) X Hb deficit(in grm ) X 0.24 + 500mg to replinish iron store III- parenteral iron

42. Indications: 1-Chronic renal failure 2-Religion indications 3-Ertthropoietin

43. No cut of levels The indications should consider clinical and haematological points Transfusion is rarely indicated in the stable patient when Hb is >10 g/dl and is almost always indicated when <6 g/dl IV-Blood transfusion

44. MCV>110fl Consider folic acid and B12 deficiency MCV=100-110fl Consider other causes of Megaloplastic anaemia

45. 1- Prophylactic of NTD and some congenital anomalies(?heart) started 4-8 wks before &first12 wks after pregnancy Dose: 400-500µg/d 5mg/d is recommended in 1- History of NTD 2- Epileptic drugs 3- Obesity & DM 4- Multiple pregnancy 2-folic acid deficiency anemia (5%) Prevention : 400-500µg/d Treatment: 1-5mg/d up to 3times /d 12wks before pregnancy and 1 st trimester Folic acid supplementation

46. Normocytic anaemia 1-Chronic disease 2-Early iron deficiency anaemia 3-Heamoglobinopathies 4-1ry bone marrow disorder 5-Combined deficiencies 6-Haemolysis 7-Anaemia of investigations (ICU)

47. Anaemia of chronic disease 1-Thyroid disease 2-Malignancy 3-Collagen vascular disease *Rheumatoid arthritis *SLE *Poly arteritis nodosa *Chronic infections as HIV , Osteomylitis,TB *Renal failure

48. Dimorphic anaemia 1-Folic acid deficiency combined with Fe deficiency as pregnancy 2-B12and Fe deficiency 3- Iron deficiency and haemolysis RDW is increased very much

49. Leukocytic count: 1- Neutrophils 2- Bands 3- Eosinophils 4-Monocytes 5- Lymphocytes

50. Two types of WBCs A- Granuloctes 1-Neutrophils 50-70% 2-Eosinophils 1-5% 3-Basophils up to 1% B- Agranulocytes 1-Lymphocytes 20-40% 2-Monocytes 1-6%

51. The change of a number of cells depends on the function 1-In bacterial infections , Neutrophils are mostly affected 2-In viral infections ,Lymphocytes are mostly affected 3-In parasitic infestations , Eosinophils are mostly affected

52. Leukocytic count 1- Normal level 4.000-11.000/ cmm 2- In pregnancy 6.000-15.000 / cmm 3- Leukocytosis in pregnancy > 15.000/ cmm 4-Chorio-amnionitis WCC > 15.000 / cmm 5-Critical OHSS WCC >25.000 / cmm

53. Bands: Immature neutrophils which are released after injury or inflammation An increase in the release of immature cells is known as a shift to the left Normal level ranges from 0 – 4%

54. Neutrophils : The function of neutrophils is to destroy and ingest bacteria Neutrophils arrive first at the site of inflammation , their numbers will greatly immediately after an injury or during the inflammatory process

55. Neutrophils life span is 10hrs (n:45-74%) Increase in Decrease in 1-Inflammation 2- Bacterial infections 3Corticosteriod 4-Necrosis from burns and MI 5-Stress 1-Viral infections 2-Hypersplenism 3-Agranulocytosis causing drugs as: Carbamazipine Clozapine Colchicine Carbimazole 4-Bone marrow failure

56. Eosinophils : found in skin ,the airway and blood stream Increase in allergic , inflammatory reactions and parasite infestations Normal blood levels range from 0 -7 % .

57. Basophils : Called basophils when found in the blood Called Mast cells when found in the tissues ( GIT , RT and the skin) They contain heparin and histamine Basophils may contribute to preventing clotting in microcirculation

58. Basophils Normal level is 0-2% Increase in 1-Allergy 2-Viral infections 3-Inflammatory disorders 4-Lymphoma 5-Radiation exposure 6-Leukaemia

59. Monocyte counts 2-10% Increase in Decrease in 1- Bacterial infections (TB) 2-Auto-immune disease 3-Leukaemia 4-Hodgkin’s disease 1-Acute infection 2-Corticosteroids 3-Leukaemia

60. Lymphocytes : normal range20-40% Increase in Decrease in 1-Viral infection 2-Chronic bacterial infection 3-Lymphoma 1- Viral infection 2- HIV 3- Post- chemotherapy 4- Whole body radiation 5- Bone marrow failure

61. Three types of lymphocytes 1- B lymphocytes ( humoral immunity) antibody formation 2- T lymphocytes ( cellolar immunity) For viral infections 3- Natural killer cells

62. Platelets counts 150.000-400.000/ cmm Thrombocytosis >400.000/ cmm Thrombocytopenia <150.000/ cmm 1-Pregnancy 2-Infections 3-Inflammation 4-Trauma 5-Arthritis 6-Atheletics 7-Malignancy 8-Postsplenectomy 1-Menstruation 2-Gestational thrombocytopenia 3- PE 4-HELLP syndrome 5-Severe haemorrhage 6-DIC 7 - ITP 8-Aplastic anemia 9-Drug-induced 10-Leukaemia The values have to fit the clinical situation

63. Life span of platelets is 7-10ds Consider in Low dose aspirin therapy NSAIDs therapy And in platelets therapy

64. Thrombocytopaenia in pregnancy 1-Gestational thrombocytopaenia Mild , seen in 2 nd and 3 rd trimester 2-Associated with PIH syndromes as HELLP , PIH , PE And super imposed PE 3-Auto-immune (ITP) mostly seen in 1 st trimester 4-HIV

65. I-Pregnancy specific Gestational thrombocytopenia 75% (7% of pregnancies) Preeclampsia/ Eclampsia &HELLP syndrome 20% Acute fatty liver Autoimmune Disseminated Intravascular Coagulopathy (DIC): Placental abruption ,IUFD & Septicemia Severe obstetrical hemorrhage with excessive fluid infusion( dilutional coagulopathy )

66. II-Pregnancy-associated 1-Spurious result (EDTA)  Blood smear± Citrate 2-Autoimmune Disease Immune Thrombocytopenia Purpura (ITP) 4% Antiphospholipid antibodies (APS &SLE ) Acquired Glanzman's disease(↓ function) rare 3- Thrombotic microangiopathies (TTP) 4- Viral infection :( Hep C, CMV, EBV, AIDS) 5- Aplastic anemia & Megaloblastic anaemia 6-Drug exposure 7-Allergic reaction 8- Irradiation 9- Inherited thrombocytopenia

67. 5 criteria 1- Mild thrombocytopenia 2- Mostly >100,000/ mL , rarely <70,000/ml) 3- No history of thrombocytopenia outwith pregnancy 4- Occurs late in gestation (normal ) 5- No fetal/neonatal thrombocytopenia Postpartum resolution (6 weeks) (No Treatment is Required) Gestational thrombocytopoaenia 7% of all pregnancies

68. Idiopathic Thrombocytopenic Purpura : Probably autoimmune ↓platelet lifespan No pathognomonic signs, symptoms, or tests Diagnosis by exclusion ,however 4 associations: Persisten€t thrombocytopenia (<100,000/ml ) Normal €or ↑ bone marrow megakaryocytes Exclusion of other systemic disorders or drugs causing thrombocytopenia Absence of splenomegaly May be indistinguishable from mild form gestational thrombocytopenia at late pregnancy ITP (Immune thrombocytopaenic purpura

69. It is considerable at platelet count <50,000/ml. Pridnisonlone ( Hostacortin H 5mg , Suluprid 5& 20mg ) from 5mgX2/d up to 1 mg/kg/day Most likely continued throughout pregnancy. In refractory disease, high-dose intravenous immunoglobulin is given If still no response Splenectomy with CS (technically difficult) to increase platelets Treatment of ITP in pregnancy

70. Dexametasone : ( Epidrone ) Before delivery : 8-24 mg iv /day during a period of 4-6 days. During labor :high doses of cortisone may be used: 16 mg iv Dexametasone or 200 mg hydrocortisone hemisuccinate Treatment of ITP in pregnancy

71. Fetal & neonatal thrombocytopenia are common in the following situations: 1-The mother has had a splenectomy and/or has ITP refractory to splenectomy II-The mother's platelet count has been <50,000/ml at some time during the pregnancy and/or had a platelet count <100,000/ml at the time of delivery . III-An older sibling has had neonatal thrombocytopenia ITP in pregnancy

72. Effect on the foetus and neonate Platelet-associated IgG antibodies can cross the placenta and cause severe fetal-neonatal thrombocytopenia (<50,000/ml ) in 12% Intracranial hemorrhage as the consequence of labor and delivery 1%.. There is no clinical characteristic or laboratory test that will accurately predict fetal platelet count, and there is no instantanious correlation between fetal and maternal platelet counts ITP in pregnancy

73. In HELLP Low platelets *Class 1 (at higher risk)<50.000/ cmm *Class II 50.000-100.000/ cmm *Class III 100.000-150.000/ cmm

74. In thrombocytopaenia 1- Platelets below 75.000 contra-indicate spinal prick 2-CS can be embarked at the level of 50.000/ cmm 3-25.000/ cmm or more , permits vaginal delivery 4-Platelet transfusion at 40.000/ cmm 5-Give one unit of platelets for 6units of packed RBCs 6-Every one unit of platelets increases count by 10.000/ cmm

75. How to investigate platelets 1-Blood film 2-Bone marrow biopsy 3-Infection screen (HIV,HCV) 4-Liver function tests 5-LDH 6-Serum B12,folate 7-Coagulation profile 8-CRP

76. Conditions that may enhance platelet function 1-Atherosclerosis 2-Diabetes 3-Smoking and 4-Hypercholesterolaemia

77. 1-Haematinics Folic acid , B12 , S. ferritin 2-Thyroid function tests 3-Blood film , bone marrow biopsy ( haemolytic , sideroplastic ) Investigations of a case of anaemia

78. 4-Hb electrophoresis ( Thalassaemia , Sickle cell) 5-Bilirobin : ( haemolysis ) 6-Iron studies Serum Fe , transferrin , TIBC, ferritin , transferrin saturation, soluble transferrin receptor Investigations of a case of anaemia

79. 1-Increased un-conjugated bilirubin 2-Increased LDH 3-Increased urinary urobilinogen 4- Reticulocytosi s Investigations to confirm haemolysis

80. 5-Increased urinary haemosiderine 6-Decreased hepatoglobulin 7-Haemoglobinuria Investigations to confirm haemolysis

81. 1. Which blood cells and blood elements are included in a CBC test? Red blood cells (also called erythrocytes) White blood cells Platelets All of the above

82. 2. What do white blood cells do? Carry oxygen from the lungs Carry waste products from the cells Fight infection Help stop bleeding by forming clots All of the above

83. 3. What do red blood cells do? Carry oxygen from the lungs Carry carbon dioxide, a waste product, from the cells Fight infection Help stop bleeding by forming clots All of the above A and B

84. 4. What do platelets do? Carry oxygen from the lungs Carry waste products from the cells Fight infection Help stop bleeding by initiating clots E. All of the above

85. 5. What is haematocrit ? sometimes fatal blood disease The portion of red blood cells compared with total blood volume A blood pressure measuring device A medicine that helps stop bleeding

86. 6. What are neutrophils ? Immature red blood cells A type of white blood cell A type of platelet A type of bacteria

87. 7. What is severe neutropenia ? An absolute neutrophil count of less than 500 An ANC of less than 1.000 An ANC of less than 50 An ANC of less than 25

88. 8. Which is a symptom of anaemia ? Itching Nausea Fever Fatigue

89. 9. What is the name of the decreased platelets? Thrombocytopenia Thromboangiitis Thrombocythemia

90. 10-Which of the following conditions can be ruled out by normal CBC 1-*B12 deficiency 2-* Folate deficiency 3-*Bacterial infection 4-*Viral infection 5-*Iron infection

91. 11- What statements are true about WBC 1-It is more useful than absolute count of each cell type 2-*It may be normal in neutropenia 3-*It may be normal in lymphcytosis 4-It will be elevated in all infections

92. 12- What would be appropriate action in neutrophil count<1.0x1000.000/ml 1-Repeat neutrophil count after 4-8wks 2-*Consider medicatin effect 3-*Look for other blood abnormalities 4-Urgent referal to all patients 5-*Urgent referal if the patient is feverish or unwell

93. 13- What of the statements about neutrophil shift to left are true 1-*The cells are less mature 2-*Can be produced to infection 3-?Does not occur with inflammation 4-*The cells can show toxic granulation

94. 14- What of the following statements is true about thalassaemia 1-*Often presents with microcytisis 2-Frritin level is usually low 3-CRP is usually raised

95. 15- A reticulocytosis is usually present in which conditions 1-*Blood loss 2-* Haemolysis 3-Thalassaemia 4-Pregnancy

96. 16-Which of the following factors may contribute to thrombocytopenia 1-*Autoimmune disease 2-*Viral infection 3- *Pregnancy 4-Smoking

97. 17- A neutriphilia an occur in which conditions 1-*Heavy exercise or stress 2-*Pregnancy 3-*MI 4-?Viral infection

98. 18 - What is true about lymphocytopenia 1-It usually due to acute infections as EBV 2- May be due to smoking 3-*Can be seen late in HIV infection 4- *Can be related to radiation

99. THANK YOU Prepared by Hesham Abd Elaziz Elmahalla gen. hosp. [phone]