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Sysmex SEED 6 2013 Haematology Results Interferences Flagging and Interpretation - Part II en
Sysmex SEED 6 2013 Haematology Results Interferences Flagging and Interpretation - Part II en
Key words:
WBC, histogram, 3 part differential count, interference.
Introduction and background where possible and taken into account when interpreting
Full blood counting is a relatively easy process, usually results in order to ensure that the accuracy of the results is
simply involving the mixing of blood in an EDTA collection acceptable.
tube, mode selection, introduction of sample for sampling
and start of analysis. A full profile of patient results follows
within two minutes offering an invaluable tool for in vitro What is interference?
diagnosis of a myriad of possible pathological conditions. Aberrant, unreliable patient results may occur due to the
This allows for prompt and accurate medical intervention presence of substances other than the parameter of interest
by clinicians that can be lifesaving. Therefore, with today’s interfering with the measurement principle and thus
heavy burden of disease and without the currently highly affecting the accuracy of the final result. This may include
automated and sophisticated blood analysis systems, patient external or non-haematological substances such as lipids
testing would be very difficult to manage. but may also occur as a result of one blood cell type
As pointed out in part 1 of this topic, despite the rapid interfering with the measurement of another cell type. It is
advances made in automated laboratory testing systems, important that the measurement system should at least
challenges in assuring the quality of results still exist. This detect these occurrences and alert the operator so that
includes factors related to sample collection and handling appropriate action can be taken. These occurrences are
prior to analysis, the testing process itself (system related) known as interferences and the accompanying alert
and the so called post-analytical influences. (For the full messages are termed flags. This discussion will concentrate
detail on the pre- and post-analytical influences please on those interferences affecting the white cells and the
see SEED 4 2013). Interferences that take place during related flags.
analysis need to be understood and eliminated or reduced
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SEED Haematology | No 6 | 2013
What type of flagging messages can we anticipate? volume according to their cell type whereby they are
Some messages are common and their sources are readily identified as a separate population in the histogram. After
identifiable while others may have more complicated origins this special lysis treatment, cells will be shown in a
depending on the analytical technology used. histogram according to their size (see figure 1).
The volume of platelets is usually between 8 - 12 fl, n WU - abnormal height at upper discriminator.
therefore the LD of the WBC histogram separates the white n AG - high number of cells to the left of the lower
blood cells from the platelets and thus they do not interfere discriminator.
with the WBC result. However, please note that large PLT n T 1 - no differentiation between lymphocytes and
clumps can be located immediately to the left of the 30 fl mixed cells.
lower WBC discriminator. n T 2 - no differentiation between mixed cells and
neutrophils.
In 3 part diff measurement only volume of cells is used to n F 1 - relative height of T1 or T2 exceeds the limit.
differentiate the white cell subpopulations. As stated above n F 2 - relative height of T1 or T2 exceeds the limit.
the distribution curve must be within the discriminators and n F 3 - relative height of T1 or T2 exceeds the limit.
each curve must start and end at the base.
Possible causes of white cell interferences and flags in 3
Any particles in the measurement distorting this pattern part diff analysers
may result in flagging and possible incorrect results. The various interferences and flags are described and
presented in tables 1 and 2 below. Possible causes and
The following flag messages may appear: solutions are also suggested (see also figures 2 and 3 for
n WL - abnormal height at lower discriminator. illustration of related histograms).
LD T1 T2 UD LD T1 T2 T1 T2
Fig. 2 The WBC histogram showing the a)“WL“ b) “AG“ and c)“WU“ respectively.
It is important to note that in cases where the histogram does not reach the base at the lower or the upper discriminators,
this may result in incorrect results. In such cases the described flags will be displayed besides the numerical results.
a) “WL” - abnormal height at lower n Lyse resistant RBC. n Retesting a diluted sample (with Cellpack
discriminator. n PLT clumps. or 0.9% NaCl) will help to obtain correct
results.
n EDTA-incompatibility.
n Samples showing platelet clumping
n Coagulated sample. should be recollected in trisodium citrate
n Nucleated red blood cells (NRBC) – anticoagulant and retested.
seldom.
n Clotted samples should be recollected and
n RBC cold agglutinins. retested.
n Presence of NRBCs poses a challenge
because after lysing, their nuclei, which
are about the same size as lymphocytes,
remain.
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b) “WU” flag - abnormal height at n Extreme leukocytosis. n In cases of extreme leukocytosis the
upper discriminator. sample should be diluted at a ratio of 1:5
n WBC aggregation. to obtain a reliable count.
c) “AG” Flag - High number of n Platelet aggregation due to n PLT count should be microscopically
cells to the left of the lower checked for platelet aggregation.
discriminator. n EDTA incompatibility
n In case of EDTA incompatibility sample
n Lyse resistant RBC (see WL) should be recollected in citrated tubes
and reanalysed
n NRBC – seldom (see WL)
LD UD LD T1 UD
WBC WBC
Fig. 3 The WBC abnormal histograms showing a) combined “T1” and “T2” interference and b) “T2” interference.
Flags T1 and T2 (Figures 3a and 3b Abnormal white blood cells Check smear for abnormal white blood cells
respectively) - No differentiation e.g. blasts etc.
between lymphocytes and mixed
If only “T1” or “T2” flag appear the total
cells or between mixed cells and
white cell count is not affected.
neutrophils respectively.
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LD T1 T2 UD
WBC
Fig. 4 The “F1”, “F2” and ”F3” flags showing identification of “T1” and “T2” discriminators but no clear separation of cell
populations.
F1, F2, F3 Flags n Abnormal distribution of WBC Check smear. Please note: In the
populations showing morphological absence of “WL” or “WU” flags the
No clear differentiation between
features that do not allow clear total WBC count is not affected.
lymphocytes, mixed cells or
distinction between them.
neutrophils due to presence of
abnormal cells. n Abnormal or immature WBC
Summary Conclusion
The warning messages described above enable Automated full blood count analysers add great
the user to detect abnormal samples and to react value in terms of providing useful information
with follow-up actions based on the warnings. that aids laboratory staff to correctly interpret
Morphological abnormalities – mostly preliminary results and to help pathologists and clinicians
development stages of normal cells or abnormalities reach a correct diagnosis timeously. Efficient or
of the myeloid and lymphatic cell series – require optimal utilization of the analyser capability that
manual differentiation. Pre-differentiation helps in this process requires understanding of
information will reduce the rate of microscopic the basic workings of the analytical systems. The
differentiation by restricting this to clinically numerical results must be reviewed and interpreted
relevant cases only. Manual work can thus be in conjunction with careful inspection of the
minimised without any compromise in quality histograms and any accompanying alert messages
of results. or flags.
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References:
1. Dacie and Lewis Practical Haematology, ninth edition
by SM Lewis, B J Bain, I Bates.
2. Sysmex XP 300 Instructions for Use.
Compiled by
Ndwakhulu Nemuthengame
Sysmex applications specialist
Checked by
Dr Marion Münster