Interpretaion of hemogram

Interpretation of hemogram made easy.

1. Haemogram : Interpretation Dr Imtiaz Ahmed MD Pathology, AFMC

2. Automated Hematology Analyzers - Haemogram - Backbone of any lab evaluation - As a routine investigation including anaemia, polycythemia, infection, inflammation, allergy, drug toxicity, malignancy, bleeding tendency etc - Aim - to study RBC, WBC series and platelets

3. Sir Wallace H Coulter

4. 3 part analyser 5 p art analyser Advantage: Cost effective Disadvantage: Granulocytes taken together Blasts counted as lymphocytes Cannot distinguish activated lymphocytes and monocytes Platelet count irregularities No scatter plot Advantage: Full differential Platelet count more accurate Flag for blasts, left shift, giant platelets Scatter plot obtained Malaria parasite Disadvantage Blasts still not detected Newer parameters not given Cannot distinguish between activated lymphocytes and monocytes/basophils

5. 3 Part Analyzer Normal Report

6. 5 Part Analyzer

7. 5 Part Analyzer RBC WBC SCATTERGRAM W BC PLT

8. Discrimination Thresholds WBC Discriminator WBC LOWER discriminator-the optimum position in 30 - 60 fL . Upper discriminator : 300 fL. R BC Discriminator RBC LOWER discriminator- optimum position in 25 -75 fL and UPPER discriminator, 200 - 250 fL . RBC is calculated from the particle counts between this LOWER discriminator and UPPER discriminator. PLATELET Discriminator PLT LOWER discriminator, the optimum position in 2 – 6 fL and and UPPER discriminator- 12 - 30 fL,

9. Electrical Impedance Coulter principle Diluent displacement causes potential difference. No . of impulse = No. of cells. Height = vol. of cells . Freq dist curve & size distribution histograms Requisite – High dilution

10. Optical Light Scatter Each cell flows in a single line through a flow cell A laser device focused On striking the cells scattering in different directions Sensor capture Forward angle light scatter (FALS)-Cell Size Side scatter(SS)-Granularity

11. Parameters Measured Directly Measured Derived From Histograms Calculated 1.RBC Count 2.WBC Count 3.Platelet count 4.Hemoglobin 5.Reticulocyte Count 1.MCV 2.RDW 3.DLC 4.PDW 1.Hematorit 2.MCH 3.MCHC

12. INTERPRETATION

13. Red Cell Indices

14. Normal RBC count: Men: 4.5 to 5.5 x 10 6 per cumm Women: 4 to 5 x 10 6 per cumm

15. Hemoglobin: Men: 13 to 16.5 g% Women: 12 to 16 g% Pregnant women: 11 to 16 g%

16. Mean corpuscular volume Normal: 80 to 100 fL Low MCV: Microcytosis High MCV: Macrocytosis Megaloblastic Non-megaloblastic

17. MCH/MCHC MCH: The amount , or the mass, of hemoglobin present in one RBC, picogram 26-32 pg MCHC: The amount of Hb in the hematocrit, percentage 32-37 g/ dL

18. RDW Uniformity in size of RBCs 11.5 - 14.5 % Low value: more uniform (<14) High values: M ixed population of small and large RBCs Anisopoikilocytosis

19. Reticulocyte count

20. Reticulocyte Production Index Correction of reticulocyte count for the - degree of anemia duration of maturation

21. RBC Histogram Gaussian ( Bell Shaped ) curve Peak ideally within 80-100 fl 2 flexible discriminator LD (25-75fl) UD(200-250fl)

22. RU-Flag Normoblasts Cold agglutinins Rouleaux formation ALL- L1 Large platelets Fragmented RBCs Platelet aggregation RL- Flag

23. MP-Flag Blood transfusion Dimorphic anemia Treated IDA

24. White Blood Cells

25. Normal range: 4 – 11 x 10 3 / cumm DLC: Neutrophils : 40 – 70 % (2 - 8/cumm) Lymphocytes : 20 – 40 %. (1 - 3/cumm) Monocytes : 2 – 10 %. (0.2 – 1/cumm) Eosinophils : 1 – 6 %. (0.02 – 0.5/cumm) Basophils : 0 – 2 % (0.02 – 0.1/cumm) Immature cells Blasts Myelocytes Promyelocytes Metamyelocytes Band forms Activated lymphocytes

26. Leukopenia Acute viral infections Chemo/Radiation Aplastic anemia Collagen vascular diseases Bacterial Inf (Typhoid, Tuberculosis..) Parasitic infection (Malaria..) HIV Sepsis Drugs: immunosuppressants Leukocytosis Infection (Bacterial) Inflammation Trauma, burns Leukemias

27. Neutrophils Absolute neutrophil count: Neutrophils x WBC / 100 Normal : 2000 to 8000 / cumm Neutropenia: ANC < 1500/cumm

28. Neutropenia Neutrophilia Decreased production Aplastic anemia B12, folate def Severe sepsis Leukemia Increased destruction Autoimmune Marginalization and sequestration Chemotherapy Viral infections Acute infections Steroids Post splenectomy Leukemoid reactions Myeloproliferative disorders

29. Lymphocytopenia Lymphocytosis Infections Typhoid HIV Viral hepatitis Autoimmune disorders SLE RA Steroids Aplastic anemia Acute viral infections CMV EBV Chronic inflammatory diseases Tuberculosis Stress Leukemia/ lymphoma

30. Monocytopenia Monocytosis Bone marrow failure Hairy cell leukemia Chronic infections Malaria Bacteria endocarditis Collagen vascular diseases Recovery from leukemia CMML M4/M5

31. Eosinophilia Asthma Other allergies Parasitic infections Inflammatory disorders (Coeliac disease, IBD) Hypereosinophilic syndrome Leukemias

32. Basophilia Allergic reactions (Hay fever) Inflammation (IBD, RA) Tuberculosis Diabetes Mellitus Down’s syndrome Neoplastic conditions CML PMF ET MDS

33. WBC HISTOGRAM * Different in the three part analyser of our lab

34. WL-Flag Platelet aggregation Lyse resistant RBCs Cold agglutinin disease nRBCs . Giant platelets WU- Flag Curve does not end at baseline Immature WBCs Hyperleucocytosis

35. Peak Between T1- T2: Acute Leukemia Peak Between LD- T1: CLL Peak Between T2- UD : Neutrophilia

36. Platelet Normal range: 150 – 400 x 10 3 / cumm Thrombocytopenia Thrombocytosis ITP Splenomegaly HUS, TTP HELLP syndrome Dengue Drug induced Transfusion associated Aplastic anemia Leukemia/Lymphoma Reactive: Chronic infection Acute inflammation Iron def Post splenectomy Myeloproliferative disorders Malignancies of lung, GIT

37. Platelet Histograms Between 2 discriminators Touch baseline LD ( 2-6fl) UD ( 12-30fl)

38. PL-Flag Cell Fragments Contamination-Bacteria Platelet aggregation PU-Flag Clotted Blood Fragmented RBCs Microerythrocytosis Large platelets Platelet clumps

39. MP-Flag Platelet Anisocytosis Aggregation Recovery after chemo

40. Hemogram Hb 9.5 g/ dL TLC 4900/cumm TRBC 3.2 x 10 6 DLC WNL MCV 87 fL Platelet: 196,000/cumm MCH 29 pg MPV 8.4 fL MCHC 34 g/ dL RDW 17 % Normocytic Normochromic Anemia

41. Microcytic hypochromic Anemia Hemogram Hb 8.4 g/ dL TLC 4900/cumm TRBC 2.8 x 10 6 DLC WNL MCV 71 fL Platelet: 450,000/cumm MCH 23 pg MPV 10 fL MCHC 29 g/ dL RDW 21 %

42. Megaloblastic Anemia

43. Macrocytic Anemia Hemogram Hb 8.9 g/ dL TLC 4100/cumm TRBC 2.9 x 10 6 DLC WNL MCV 107 fL Platelet: 154,000/cumm MCH 29 pg MPV 10 fL MCHC 35 g/ dL RDW 21 %

44. Hemogram Hb 7.1 g/ dL TLC 2100/cumm TRBC 2.5 x 10 6 DLC N 65 L 28 M 05 E 02 MCV 118 fL Platelet: 72,000/cumm MCH 31pg MPV 10 fL MCHC 37g/ dL RDW 22.4 % Aplastic Anemia/ Megaloblastic Anemia/ MDS

45. Marked macrocytosis with markedly increased MCH , MCHC COLD AGGLUTININ DISEASE Hemogram Hb 5.6 g/ dL TLC 17600/cumm TRBC 1.96 x 10 6 DLC N 89 L 9 M 1 E 1 MCV 138 fL Platelet: 23,000/cumm MCH 53 pg MPV 9.7 fL MCHC 59 g/ dL RDW 26 %

46. Microcytic hypochromic blood picture Hemoglobinopathies – (Beta – Thal trait, HbE heterozygous) Mentzer Index: MCV/RBC count, <13> Mentzer Index: 9.6 Hemogram Hb 12 g/ dL TLC 7600/cumm TRBC 5.8 x 10 6 DLC WNL MCV 56 fL Platelet: 168,000/cumm MCH 23 pg MPV 9.6 fL MCHC 26 g/ dL RDW 21.8 %

47. Microcytic hypochromic blood picture Hemoglobinopathies ( Beta thal major, HbE heterozygous, HbE homozygous) Mentzer Index: MCV/RBC count, <13> Mentzer Index: >13 Hemogram Hb 7.9 g/ dL TLC 7600/cumm TRBC 2.4 x 10 6 DLC WNL MCV 56 fL Platelet: 168,000/cumm MCH 23 pg MPV 9.6 fL MCHC 26 g/ dL RDW 21.8 %

48. Hereditary Spherocytosis

49. Hemogram Hb 13.2 g/ dL TLC 7600/cumm TRBC 4.31 x 10 6 DLC WNL MCV 88 fL Platelet: 42,000/cumm MCH 28 pg MPV 11.7 fL MCHC 33 g/ dL RDW 13.2 % Immune Thrombocytopenia Bone marrow – Adequate megakaryocytes

50. Dengue Fever Monocytosis/ Basophilia Activated lymphocytes

51. Hemogram Hb 8.9 g/ dL TLC 17600/cumm TRBC 2.8 x 10 6 DLC N 89 L 9 M 1 E 1 MCV 77 fL Platelet: 23,000/cumm MCH 22 pg MPV 9.7 fL MCHC 24 g/ dL RDW 23.1 % 3 rd trimester pregnancy HELLP syndrome

52. Hemogram Hb 15 g/ dL TLC 47600/cumm TRBC 5.1 x 10 6 DLC N 45 L 50 M 2 E 3 MCV 109 fL nRBC 200/100 WBC MCH 31.5 pg Corrected TLC 15,600/cumm MCHC 36.3 g/ dL Platelet: 293,000/cumm RDW 14.9 % MPV 9.7 fL 5 day child, Rh negative mother Erythroblastosis foetalis

53. Hemogram Hb 21 g/ dL TLC 18600/cumm TRBC 6.5 x 10 6 DLC N 45 L 50 M 2 E 3 MCV 91 fL Platelet: 593,000/cumm MCH 31.5 pg MPV 9.7 fL MCHC 36.3 g/ dL RDW 14.9 % Panmyelosis Polycythemia 70/M

54. Hemogram Hb 9.1 g/ dL TLC 108600/cumm TRBC 2.9 x 10 6 DLC N 75 L 7 M 2 B 16 MCV 91 fL Left Shift Marked MCH 31.5 pg Platelet: 60,000/cumm MCHC 36.3 g/ dL MPV 9.7 fL RDW 14.9 % Chronic Myeloid Leukemia 35/M

55. Hemogram Hb 9.9 g/ dL TLC 50600/cumm TRBC 3.1 x 10 6 DLC N 75 L 7 M 2 B 16 MCV 81 fL Left Shift Marked MCH 31.5 pg Platelet: 190,000/cumm MCHC 36.3 g/ dL MPV 9.7 fL RDW 14.9 % Leukamoid reaction 6 5/M, Uncontrolled DM, Fever, Cellulitis

56. Hemogram Hb 10.1 g/ dL TLC 108600/cumm TRBC 2.9 x 10 6 DLC N 5 L 92 M 2 E 1 MCV 91 fL Platelet: 60,000/cumm MCH 31.5 pg MPV 9.7 fL MCHC 36.3 g/ dL RDW 14.9 % Chronic Lymphocytic Leukemia 65/M

57. Hemogram Hb 10.1 g/ dL TLC 108600/cumm TRBC 2.9 x 10 6 DLC N 5 L 92 M 2 E 1 MCV 91 fL Platelet: 40,000/cumm MCH 31.5 pg MPV 9.7 fL MCHC 36.3 g/ dL RDW 14.9 % Acute Lymphoblastic Leukemia 4 yr / M

58. WBC Research Population Data Case Study – Malaria Parasites( Normal plot and Research Population Data compared to a patient infected with malaria type Plasmodium falciparum. Note the increased size and variation of the lymph's and Monocyte's.) NORMAL Normal Normal MO Normal LY Macrophage Parasitized RBC MALARIA MP Positive Reactive LY

59. INTERFERENCE Hemoglobin Clotted specimen (micro- clots). Cryoglobulin , Haemolysis , Severe lipemia , Hyperbilirubinemia . RBC count Clotting, Cold agglutinins, Microcytic RBCs Cryoglobulin , Giant platelets, Raised WBC count . WBC count Clotting , Cryoglobulin , Heparin , Monoclonal proteins. Platelets Clotting, Giant plt , Plt clumps Cryoglobulin , Haemolysis , Microcytic RBCs. Parameter Spurious Decrease Spurious Increase

60. Its all about interpretation!!!