INTERPRETATION

OF CBC

DR. N. BAJAJ
 TERMS
 Anisopokilocytosis: variation in size and shape
 Cytometry: measurment of the cell either visual or automated
 Cluster analysis: analysis that is based upon the instrument’s ability to cluster
different populations, together based upon size, staining, absorption or other
parameter
 Contour grating: analysis where information is plotted three dimentionally, that can
be separate subpopulation of cells
 Coulter principle (electrical impedence): sizing and counting cells by detecting and
measuring changes in electrical resistance when cell passes through small aperture.
 Dimorphic : two population of cells in single blood sample
 Forward angle light scatter: light from laser source is scatter in forward direction (0
degree) when it strike a cell or particle, larger object more forward light scatter
 Forward high angle light scatter: similar to forward angle light scatter, but angle is 5
to 15 degree variation
 Forward low angle light scatter: similar to forward angle light scatter, but angle is 2
to 3 degree variation
Introduction

 Haematology comprise of
 ‘Haima’ = blood in Greek
 ‘Logos’ = study
 Haematology is a unique super speciality in medicine
which encompasses the fields of pathology, physiology,
biochemistry, molecular biology, obstetrics and
gynecology, medicine and paediatrics
CBC

 A complete blood count is a series of tests used to

evaluate the composition and concentration of the
various cellular component of the blood.
 Is a basic test
 Most informative single investigation
 Tests consists of
1. Counts of RBC, WBC, Platelets
2. Haemoglobin, haematocrit, and red cell indices
3. TLC, DLC
4. Platelet count, mean platelet volume, plateletcrit,
PDW
5. Histogram of RBC, WBC, Platelets
How important is CBC ?

 To know the importance of CBC we need to know…..

 What is CBC?
 Why CBC?
 What are various parameter of CBC?
 What are variation in parameter of CBC?
 What these variation can tell us?
 How these variations affect the assessesment and care of
patients?
Why CBC?

 CBC is an inexpensive tool and powerful

tool which provide information about

 Blood, also about

 Marrow,

 Health or disease state of other organ

of body
CBC USES

To diagnose
1. Anemia
2. Haemoglobinopathies
3. Bone marrow aplasia
4. Nutritional deficiencies
5. Thrombocytopenia
6. Autoimmune conditions
7. Infections and Parasitemia
8. Malignancies, response to drug, chemotherapy etc.
Red blood cells
 RBC produced in marrow and requires
 Iron, copper, magnease, cobalt
 Vitamins; especially B12, folic acid
 Regulated by erythropoietin, thyroid
hormone, androgens
 Counts depend upon age, sex, altitude,
exercise, drug, tobacco use etc.
 Life span - 120 days
 Clinical importance of assessment of RBC is to: measures oxygen
carrying capacity of blood

Normal values
 Newborn 4.1-6.1 million/mm3
 Children 3.6-5.5 million/mm3
 Adult (M) 4.6-6.0 million/mm3
 Adult (F) 4.2-5.0 million/mm3
 Decreased RBCs
Blood loss Impaired production Increased destruction
• Trauma • Pure red cell aplasia Intra-corpuscular
• Surgery • Pernicious anemia • Hereditary spherocytosis
• GI bleed • Megaloblastic anemia • Sickle cell anemia
• Gynecological • Iron deficiency anemia • Abetalipoprotienimia
disturbance • Thalassemia • G6PD
• Anemia of prematurity • Pyruvate kinase deficiency
• Anemia of chronic • PNH
disorder Extra-corpuscular
• Autoimmune
• Haemolytic disease of newborn
• Mismatch transfusion
• Microangiopathic haemolytic
anemia TTP, HUS
• DIC
• infections
 • Increased RBCs

• Polycethemia vera
• High altitude
• chronic obstructive pulmonary disease(COPD,
emphysema, chronic bronchitis),
• pulmonary hypertension,
• Hypoventilation syndrome,
• congestive heart failure
• obstructive sleep apnea,
• poor blood flow to the kidneys, and
Haemoglobin

 Oxygen carrying component of blood

 Synthesize in polychromatic normoblast stage of red cell development
 Values
 Newborn 15.5-24.5 g/L
 Adult male 13.5-16.5 g/L
 Adult female 12.0-15.5 g/L
Hb estimation
Cynemethamoglobin Method: Recommended
 20 microL blood + diluent (potassium cynide
and potassium fericynide)
 Mixed and read in photo colorimeter
 Photo colorimeter is used to determine the
concentration
 Hb% =(test sample absorbance/ standard sample
absorbance)x concentration of standard x dilution
factor
 Advantage – haemoglobin, methamoglobin and
carboxyhaemoglobin are used in measurment.
 Disadvantage – sulphamethamoglobin cannot be
included in measurment, takes more time for
estimation
Hb estimation: other method

 Sahli acid haematin

 Alkaline haematin method
 Sulphahaemoglobin method
 Oxyhaemoglobin method
Reticulocyte

 Normal value 0.5% - 1.5%.

Hence 0.5% - 1.5% RBCs are replaced per day
 Uses
 To evaluate anemia
 Response to treatment of anemia
 Note
 If the disease causing the anemia is inside the marrow,
the reticulocyte count is decreased
 If the disease causing the anemia is outside the
marrow, the reticulocyte count is increased
Methods

 Manual reticulocyte count using supravital stain

 Automated reticulocyte count by flouroscent
method - gives immature reticulocyte fraction
(IRF) and removes errors like Howell-Jolly bodies,
pappenheimer bodies

 Reticulocyte production index or corrected

reticulocyte count: an index corrected according
to level of anemia
 Reticulocyte index = reticulocyte count x
patient’s haematocrit/ normal
haematocrit
 Reticulocyte proliferation index: Index is used to
determine if a person's bone marrow is properly
responding to the body's need for red blood cells
 Shift correction factor: normal reticulocyte count
survive 3.5 days in marrow and 1 day in peripheral
circulation at normal PCV. In case of variation in PCV
the survival time is increased which is termed as shift
correction factor
 Reticulocyte proliferation index = reticulocyte
index/ shift correction
Shift correlation factor factor
PCV% Maturation days = shift correction factor
45 1
35 1.5
25 2
15 2.5
Increased reticulocyte count
 Haemolytic anemia
 Recent haemorrhage
 Thalassemia
 Pregnancy
 Response to treatment
 Hypoxia
 Leukamia
Decrease reticulocyte count
 Aplastic anemia
 Megaloblastic anemia
 Anemia of chronic disease
 Cirrhosis
 Radiation
 Decrease ACTH and pitutary
hormones
 Reticulocyte haemoglobin
measurement (RET-He)
 Reticulocyte Hemoglobin (Ret-He) is a direct assessment of the incorporation
of iron into erythrocyte hemoglobin.

 It is a direct estimate of the recent functional availability of iron (2–3 days).

 Traditional chemistry tests used for iron assessment (serum iron, Tsat,
ferritin) are indirect measurements.

 As a direct measurement, Ret-He may identify iron deficiency earlier than

traditional parameters.

 It is an established parameter used in KDOQI (Kidney Disease Outcome

Quality Initiative) guidelines for assessing iron status
Haematocrit

 Ratio of the volume of erythrocytes to that of the whole blood in percentage

 Most precise method for determining the degree of anemia or

polycythemia i.e. increase or decrease RBC concentration

Normal values
 Newborn 42-68%
 Upto 1 year age 29-41%
 Adult Male 39-47%
 Adult female 36-44%

 Rule of 3:– RBC x 3 = Hb and Hb x 3 = Hct

 High Low
 Polycythemia vera  Anemia
 Dehydration  Blood loss
 Low oxygen in blood  Haemolysis
 Congenital heart disease  Bone marrow aplasia
 Cor pulmonale  Leukamia
 Smoking  Malnutrition
 Haemoconcentration (Dengue)

An elevated haematocrit may be due to spleen hyper

function, and reduced haematocrit may indicate low thymus
function
Mean corpuscular volume
 Measures average volume of RBC
 MCV = haematocrit/ red cell count x100

 Normal values
 Newborn 103-106fL
 Child upto 1 year 78 fL
 Adult 79-98fL
 Classified accordingly as
 Microcyte – MCV <79
 Macrocytic – MCV >98
 Presence of microcytic and macrocytic cells in same sample may result
in normal MCV
 MCV <72 without heterogeneity, is a sensitive and specific predictor
of thalassemia trait
Microcytic MCV • Normocytic MCV  Macrocytic MCV
 Hypochromic • Acute haemorrhage  Megaloblastic
• Diamorphic anemia anemia
 Iron deficiency
• Haemoglobinopathi  Pernicious anemia
 Thalessemia es
 Sprue
 Lead poisoning • Endocrinopathies
 Di Gulielmo disease
 Porphyria
 MDS
 Normochromic
 Post spleenectomy
 Anemia of chronic
disease  Alcoholism

 haemoglobinopath  Liver disease

ies  Drugs
(anticonvulscents,
anticancer etc)
Interference in MCV

 Cold and warm antibodies

 Marked hyperglycemia
 Marked leukocytosis
 Marked reticulocytosis
 Methanol poisoning
Mean corpuscular
haemoglobin
MCH = haemoglobin/ red cell count x 100

Normal range
 Newborn 36-38%
 Upto 1 year age 23-27%
 Adult 26.7-31.9%
 MCH decreased in
 Microcytic and normocytic anemias

 MCH increased in
 Macrocytic anemias
 Infants and newborns

 Interference in MCH
 Lipemia
 Marked leukocytosis
 Cold agglutinin
 Monoclonal protein in blood
Mean corpuscular
haemoglobin concentration
MCHC = haemoglobin/ haematocrit x 10

Normal range
 Newborn 34-36%
 Upto 1 year age 31-33%
 Adult 32-36%
 MCHC decreased in
 Hypocromic microcytic anemia

 MCHC increased in
 Heridietery spherocytosis
 Infant and newborns
 Autoagglutinations

 Interference in MCHC
 Marked leukocytosis
 Haemolysis
 Cold aggutinins
 Rouleaux
Red cell distribution width
(RDW)
 Red cell distribution is a quantative measure or numerical
expression of anisocytosis. It is a coefficient of variation of the
distribution of individual RBC volume
 In microcytes, RDW increased in iron deficiency anemia but in
thalessemia it is not raised
 RDW-CV:It is the ratio of standard deviation to the
mean corpuscular volume
RDW-CV = standard deviatiom of RBC volume/ mean MCV x
100
value 11.5%-14.5%

 RDW-SD: It is the actual measurnment of the width of

the RBCdistribution curve
 Values 35-45 fL
RBCs on peripheral smear
Preparation

 The wedge slide (push slide) technique was developed

by Maxwell Wintrobe as is a standard method
 The “zone of morphology” (area of optimal thickness for
light microscopy examination) should be at least 2cm in
length. The smear should occupy the central area of the
slide and be margin free at the edges.
RBCs in peripheral smear
 Microcytic hypochromic
 Size smaller than the nucleus of small
lymphocyte
 < 7 micron
 Markedly increase central pallor >1/3
of the diameter of RBC
 Causes
 Iron deficiency anemia
 Thalassemia
 Sideroblastic anemia
 Anemia of chronic disease
 Haemoglobinopathies
Macrocytic cells
 Size > 8.3 micron kin diameter

 Causes
 Vitamin B 12 and folic acid deficiency
 Alcoholism
 Liver disease
 Myleodysplastic syndrome
 Hypothyroidism
 Drug that impair DNA synthesis
 Oval macrocytes
 Vitamin B 12 and folic acid deficiency
 Pernicious anemia
 Myleodysplastic syndrome
 Hypothyroidism
 Drug that impair DNA synthesis
 Round hypochromic macrocytes
 Alcoholism
 Hypothyroidism
 Liver disease
 Post splenectomy
 Blue tinged macrocytes
 Neonate
 Response to anemic stress
Target or bell cell
 They have a characteristic ringed
appearance. This is because of the
“increase surface area to volume ratio”
i.e. increase in red cell membrane which
get pooled at the centre of cells

 Causes
 Thalessemia
 Haemoglobinopathies Hb AC or CC,
HbSS,SC
 Liver disease
 Post spleenectomy
 Severe iron deficiency anemia
 abetalipoprotenimia
Schistocytes
 ‘Schisto’ = split or cleft
 Physical assault to erythrocytes with in the
blood stream creates these cells
 which include
 Helmet cells
 Triangles
 Crescents
 Microspherocytes
 Horns
 Purse
Causes
 DIC
 Severe haemolytic anemia
 Microangiopathic haemolytic anemia
 HUS &TTP
 Prosthetic cardiac valves
 Connective tissue disorders
 Burns
 Acute tubular necrosis, glomerulonephritis
 Malignant hypertension
Tear drop cells(Dacrocytes)

 Pear shape cells, usually microcytic and hypochromic

 Seen in
 Newborn
 Thalassemia major
 Myleoproliferative disorder
 Leukoerythroblastic reaction
Spherocytes
 Ball shaped red cells, decreased surface: volume ratio,
hyperdense (> MCHC)
 Seen in
 Hereditary spherocytes
 ABO incompatibility
 Autoimmune haemolytic anemia
 Microangiopathic haemolytic anemia
 SS disease
 Hyperspleenism
 Burns
 Posttransfusion
Elliptocytes
 Elliptical and normochromic cells, seen normally in
less than 1% of RBCs
 Causes
 Hereditary elliptocytosis
 Iron deficiency anemia (increased with severity)
 SS disease and SA trait
 Thalassemia Major
 Leukoerythroblastic reaction
 Malaria
 Megaloblastic anemia
Burr cells (Echinocytes)

 10-30 spicules equal in size and evenly distributed over

RBC surface; caused by alteration in extracellular
environment
 Seen in
 Liver disease
 Renal failure
 Dehydration
 Pyruvate kinase deficiency
 Storage artefacts
Spur cell - Acanthocyte

 Acantho = thorn
 Cells with 5-10 specules of varying length, irregular in shape,
thickness, with wide bases and appear smaller than normal cell
because they assume spheroid shape
 Result from changes in membrane lipid content
 Seen in
 Spur cell anemia
 Alcoholism
 Hypothyroidism
 Abetalipoprotinemia
 Vitamin E deficiency
 Malsbsorption
 Postsplenectomy
Bite cell (Degmacyte)
 Appear as a cookie with a bite taken
out
 Seen in G6PD
 When spleen removes the Heinz bodies
from RBCs
Stomatocyte
 When examined on dry smear, it has a central slit or stoma
 Seen in
 Few may be seen normally
 Various cardiovascular
and pulmonary disorders
 Hereditary
 Alcoholism
 Liver disease
 Malignancies
Howell – Jolly bodies

 Small well defined, rounded, densely stained inclusions,

1 micron in diameter, ecentric, that represent DNA
fragments
 Associated with rapid or abnormal RBC formation
 Seen in
 Post spleenectomy
 Newborns
 Megaloblastic anemia
 Dyserythopoietic anemias
 Hereditary spherocyosis
Heinz Bodies

 Inclusion of denatured haemoglobin caused by oxidation

of globin portion of haemoglobin
 Removal of Heinz body leads to formation of ‘bite cells’
 Causes
 Drugs
 Certain foods like fava beans
and onion
Sideroblastic granules/
pappenheimer bodies
 Irregular dark blue iron containing granules occuring in
small clusters, predominantly in periphery
 Seen in
 Sideroblastic anemia
 Spleenectomy
 Haemolytic anemia
 Myelodysplastic syndromes
 Lead poisoining
 Its presence can rule out iron deficiency anemia
Sickle cell
 Crescent shape cells develop in
 people homozygous for haemoglobin S
 Heterozygous HbS and either
thallasemia or another Hb like Hb C
Nucleated red cells
 Cells have dense dark nucleus in the center
of the cell
 Results from marked stimulation of the
bone marrow
 Seen in
 New born (first 3-4 days)
 Acute bleeding severe haemolytic anemia
 Megaloblastic anemia
 Congenital infections (syphilis, CMV, rubella)
 Postspleenectomy
 Leukoerythroblastic reaction
 Fungal and mycobacterial infections
 Dyselectropoeitic anemia
Basophilic stippling

 Numerous small, purplish inclusions, which results from

RNA and mitochrondrial remenants
 Seen in
 Lead toxicity
 Thalessemia
 Haemoglobinopathies
 Macrocytic anemia
Cabot ring

 These are delicate thread like inclusions, remenants of

the nuclear membranes, in the RBC
 They can take any shape like purplish ring, figure of
eight, incomplete ring
 Seen in
 Pernicious anemia
 Lead poisoning
 Alcoholic jaundice
 Severe anemia
 Leukamia
Roulex formation

 A stack like arrengment of red blood cells where the

biconcave surdface of RBCs are next to each other.
 Seen in
 Increase in cathodal protien,
such as immunoglobins
and fibronegen
 Multiple myleoma
 Macroglobulimias
 Acute and cronic infections
 Connective tissue disease
 Diabetes mellitus
 Malignancies
 Grading of inclusions
 Rare 0-1/hpf
 Few 1-2/hpf
 Mod 2-4/hpf
 Many >5/hpf
 Qualitative grading of abnormal RBC morphology
Grade degree of abnormalities
1-5 cells /10fields slight
6-15cells /10fields moderate
>15cells /10fields marked