Hematology

Complete Blood Count and Differential Count

The CBC and Differential Count is the most basic and commonly ordered of lab tests. This is a series of tests
of the peripheral blood that provides a tremendous amount of information regarding the concentration of the
different cellular and non-cellular elements of blood. This applies to the hematologic system and many other organ
systems.

Results include:

 Red blood cell count (RBC)

 White blood cell count (WBC) and differential count
o Neutrophils (Polymorphonuclear Neutrophils – PMN)
o Bands (stab cells)*
o Basophils (mast cells)
o Eosinophils
o Lymphocytes
o Monocytes
 Hemoglobin (Hgb)
 Hematocrit (Hct)
 Red blood cell indices
o Mean corpuscular volume (MCV)
o Mean corpuscular hemoglobin (MCH)
o Mean corpuscular hemoglobin concentration (MCHC)
o Red blood cell distribution width (RDW)
 Platelet count
 Mean platelet volume (MPV)

*To receive a band count, a manual differential must be ordered.

Formed Elements and Indices

 Formed
o RBC
o WBC
o Platelets
 Indices
o Used to describe the characteristics of the RBC’s

Formed elements

WBC (4,500 – 10,500/mm³)

Helpful in the evaluation of the patient with infection, neoplasm, allergy, or immunosuppression. Also known as
leukocytes. Divided into two main groups: granulocytes and agranulocytes. Lifespan is 13 to 20 days. The
Endocrine system is an important regulator of the number of leukocytes in the blood. Critical values are <2.0 and
>30,000/mm3.

Leukocytosis (>11,000):

 Usually caused by only one type of leukocyte

 Leukemoid reaction
o Measles, pertussis, sepsis
 The degree of increase of leukocytes depends on the severity of the infection, patient’s resistance, age and
marrow efficiency.
 Other causes include sunlight, nausea, vomiting, seizures
 Physiologic leukocytosis is from excitement, stress, exercise, fracture, PE, kidney stone, cold/heat, anesthesia

Leukopenia (<4,000)

 Viral infections
 Hypersplenism
 Bone marrow depression caused by radiation or drugs
 Primary bone marrow disorders
 Marrow occupying disease she

Gauging infection from a CBC

 Increase in absolute WBC count

 Increase % of Neutrophils
 “Left shift” - increase number of bands (immature WBC’s)

Differential

Expressed as a percentage of the total number of leukocytes. The distribution and degree of increase or decrease are
diagnostically significant. Always interpret in relation to the WBC count. The percentages indicate the relative
number of each leukocyte in the blood. The absolute number is the relative percentage by the total leukocyte count.

Neutrophils (3,000 – 7,000/mm³)

 Most numerous and important type in reaction to inflammation

 Primary defense against microbial invasion
 Bands
o Immature neutrophils
o “Left shift”
 Degenerative vs regenerative

Neutrophilia (>8,000/mm3)

 Acute bacterial infection (pyogenic) and trauma

 Inflammation
 Tissue necrosis
 Myeloproliferative disease

Neutropenia (<1,800/mm3)
  Decreased or ineffective production
o Acute overwhelming bacterial infection
o Viral infection
o Drugs
 Decreased survival
o Infection in the elderly or infants
o Vascular disease with ANA (antineutrophil antibodies)

Eosinophils (0 – 700/mm³)

 Allergic and parasitic disease

 Contain histamine

Eosinophilia (>500/mm3)

 Addison’s disease
 Chronic skin diseases

Eosinopenia (<50/mm3)

 Caused by increased adrenal steroid production

Basophils (15 – 50/mm³)

 Contain heparin, histamines, and serotonin

 Tissue basophils are called mast cells
 Chronic inflammation

Basophilia (>50/mm3)

 Granulocytic leukemia
 Basophilic leukemia
 Hodgkin’s disease
 Inflammation or allergy

Presence of mast cells

 Rheumatoid arthritis
 Urticaria
 Anaphylactic shock
 Lymphoma

Monocytes (100 – 500/mm³)

 Second line of defense against infection

 Produce the antiviral agent called interferon

Monocytosis (>500/mm3)

 Severe bacterial infection

 o Tuberculosis
o Subacute bacterial endocarditis
o Syphilis

Decreased monocyte count (<100/mm3)

 Overwhelming infection
 Hairy cell leukemia
 Aplastic anemia

Lymphocytes (1,500 – 4,000/mm³)

 Play an important role in immunologic reactions

 Manufactured in the bone marrow
o B mature in the bone marrow
 Control antigen-antibody response
 Have “memory”
o T mature in the thymus gland
 Master immune cells

Lymphocytosis (>4,000/mm3)

 Acute viral infection or chronic bacterial infection

 Acute and chronic lymphoma

How do I work up infection?

 Subjective history and physical examination

 Vital signs, including temperature (preferably rectal)
 CBC w/Diff
 Blood cultures x2 (infants < 2 y/o with fever >102.5 or fever of unknown origin)
 Chest x-ray (CXR), 2 views
 Urinalysis with culture and sensitivity (UA C&S)
 +/- CSF analysis, wound culture, stool culture, sputum cultures
 Lactate level

Common causes of fever

 Wind – Pneumonia
 Water – UTI
 Wound
 Walking – DVT, thrombophlebitis – check IV sites
 Wonder drugs – Bactrim
 Abdomen – including stool
 Brain – CSF
 RBC

Carry oxygen from the lungs to the body tissues and carbon dioxide from the body tissues to the lungs. Life span is
approximately 120 days. Also known as erythrocytes.

Erythrocytosis

 Primary
o Polycythemia vera
 Secondary
o Renal/Pulmonary/Cardiovascular disease
 Relative
o Dehydration

Decreased RBC values

 Anemia

Hematocrit

Indirectly a measurement of RBC mass. The percentage of the total blood volume that is made up of erythrocytes.

Hemoglobin

The main component of the erythrocytes, serves as the vehicle for the transportation of oxygen and carbon dioxide.

Increased Hgb levels

 PCV
 Congestive heart failure
 COPD

Decreased Hgb levels

 Anemia
 Liver disease
 Hemorrhage
 Leukemia

There is a 1:3 ratio between Hgb and Hct – if Hgb is 12, Hct is 36.

Platelets (140,000 – 440,000/mm³)

Platelets are the smallest of the formed elements. Platelet activity is essential to blood clotting. Thrombocyte
development takes place primarily in the bone marrow, the life span is about 7.5 days. Can be performed by
automated or manual methods. When platelet count is 50,000 – 500,000 the automated method is more accurate.
Values outside this range exceed the accuracy of instrumentation.

 Thrombocytosis >440,000
 Thrombocytopenia <140,000
Thrombocytosis

 Stress
 Infection
 Splenectomy
 Trauma
 Asphyxiation
 Rheumatoid Arthritis
 Iron deficiency anemia
 Post-hemorrhagic anemia
 Cirrhosis
 Chronic pancreatitis
 Tuberculosis

Thrombocytopenia

Rapid destruction

 Thrombotic thrombocytopenic purpura (TTP)

 Idiopathic thrombocytopenic purpura (ITP)
 Disseminated intravascular coagulation (DIC)
 Hemolytic uremic syndrome (HUS)

Decreased production

 Aplastic anemia
 Leukemia
 Metastatic carcinoma

Medications and therapies

 Heparin – occurs in up to 30% of people who receive the drug

 Antineoplastic agents
 Radiation therapy

Spontaneous bleeding risk when platelet counts fall below 20,000.

Prolonged bleeding may occur from trauma of surgery with platelet counts below 40,000.

Mean platelet volume (MPV)

 Indicates uniformity and size of the platelet population

o Increased
 ITP
 Thrombocytopenia caused by sepsis
 Prosthetic heart valve
 Massive hemorrhage
  Myeloproliferative disorders
 AML/CML

RBC Indices

MCV

The MCV is a measure of the average volume, or size, of a single RBC. Abnormally large cells have an increased
MCV and are called macrocytic. Abnormally small cells have a decreased MCV and are called microcytic.

MCH

The MCH is a measure of the average amount, or weight, of hemoglobin within an RBC.

MCHC

The MCHC is a measure of the average concentration or percentage of hemoglobin within a single RBC. When the
MCHC is decreased the cell has a deficiency of hemoglobin and is called hypochromic, and is seen in iron-deficiency
anemia and thalassemia. When the MCHC is normal, the anemia is said to be normochromic, and is seen in
hemolytic anemia. When the MCHC is increased it is due to an alteration of the RBC shape from spherocytosis or
acute transfusion reaction.

RDW

The RDW is an indication of the variation in RBC size. As this value increases, so does the variability in the size of
the RBC’s. This is the percent difference between the largest and the smallest RBC’s. Normal range is 11 – 15%. An
RDW of 20% would indicate an increase in smaller cells being produced, which may be due to early bleeding or early
iron-deficiency anemia. The RDW will increase before the MCV changes.

Anemia

Anemia is not a disease but is a symptom of a disease. Symptoms of anemia are based on onset and severity.

Iron

 Necessary for the production of hemoglobin

Transferrin

 Also called siderophilin

 Transport protein largely synthesized by the liver
 Regulates iron absorption
Total iron-binding capacity

 Correlates with serum transferrin

Ferritin

 Reflects the body iron stores

 Most reliable indicator of total body iron status

Microcytic Anemia

Iron-deficiency anemia

 Blood loss
 Decreased iron absorption
 Gastric bypass
o Serum ferritin – low
o Serum iron – low
o Total iron binding capacity (TIBC) – high

Sideroblastic

 Caused by heavy metal ingestion (lead)

 Basophilic stippling
o Serum ferritin – high
o Serum iron – high
o TIBC – low/normal/high

Thalassemia

 Seen in people of Mediterranean, Middle Eastern, Asian, and African descent

o Serum ferritin – high
o Serum iron – high
o TIBC – low/normal/high
 Teardrop red cells or Target cells
 Minor
o If you receive the gene from only one parent
o Carrier, rarely symptomatic
 Major
o Also known as Cooley’s anemia
o Stillborn
o Severe anemia during first year of lie
o Bone deformities
o Growth failure

Anemia of chronic disease

 Diagnosis of exclusion
 o Serum ferritin – normal/high
o Serum iron – low
o TIBC – normal/low

Normocytic Anemia

Hemolytic anemia

 Increased LDH, increased indirect bilirubin, decreased haptoglobin

Acute blood loss

Bone marrow suppression

 Low reticulocyte count

Renal Disease

 Healthy kidneys secrete erythropoietin, the hormone that stimulates production of RBC’s
 Renal failure patients will have low erythropoietin levels, low RBC production, and therefore anemia
 Treatment is erythropoietin injections

Macrocytic Anemia

B₁₂ deficiency

 Necessary for the production of RBCs

 Obtained from ingestion of animal protein
 B₁₂ is stored in the liver, to be absorbed from the GI tract vitamin B₁₂ must be bound to intrinsic factor
(produced by parietal cells of the stomach)
 The liver can store several years worth of B ₁₂
 If B₁₂ absorption suddenly ceased in a patient with normal liver stores, several years would pass before any
abnormalities occurred due to vitamin deficiency
 Causes
o Inadequate dietary intake
o Defective production of intrinsic factor
o Defective or deficient absorption of B₁₂-intrinsic factor complex
o Gastrectomy
 Pernicious Anemia
o A disease characterized by atrophic gastritis in which antibodies against intrinsic factor and gastric
parietal cells exist
o Diagnosed by Schilling test
 o Treatment is IM B₁₂ injections
 Methylmalonic acid
o May be used to diagnose early or mild vitamin B 12 deficiency
o Necessary for metabolism and energy production
o Vitamin B12 promotes conversion of methylmalonic CoA to succinyl Coenzyme A
o Confirmatory test of choice

Folic acid deficiency

 Necessary for normal RBC and WBC function and the production of cellular genes
 Depends on normal functioning of intestinal mucosa for absorption
 Formed by bacteria in intestines and stored in the liver
 Causes
o Inadequate dietary intake
o Defective absorption
o Defective conversion to the active form
 Inadequate dietary intake is the major cause. Folates are found in green, leafy vegetables. Development of a
deficiency takes 3 – 6 months once folic acid ceases.
 Alcoholics classically have poor nutritional intake of folic acid.
 Physiologic states, such as pregnancy, require an increase in folic acid.
 Certain medications can act as antagonists by interfering with the conversion of folic acid into its
metabolically active form.
o Methotrexate
o Trimethoprim-sulfamethoxazole
o Anticonvulsants
o OCP

Patients who are chronic alcohol drinkers will have a macrocytosis +/- a significant anemia.

Other causes

 Liver disease
 Hypothyroidism
 Drugs

Reticulocyte Count

The reticulocyte count is a test for determining bone marrow function. A reticulocyte is an immature RBC. Normally
1% of the bodies RBC’s are replaced daily, this results in a retic count of 1%.

Increased reticulocyte count – increased RBC production compensating for ongoing loss

 Hemolytic anemia
 Acute blood loss
 After treatment for anemia
Decreased reticulocyte count – bone marrow is not producing enough erythrocytes

 Iron deficiency anemia

 Aplastic anemia
 Pernicious anemia
 Bone marrow failure
 Alcoholism