Issuu on Google+

Entendiendo el CBC Enid Rivera MD Catedrรกtica Escuela de Medicina, UPR enid.rivera6@upr.edu 787-758-7910 787-777-3535 xt 7013,14,15


Entendiendo el CBC

01/30/13

Enid Rivera MD

2


Complete Blood Count (CBC)

01/30/13

Enid Rivera MD

3


WBC : Leukocytes • With cytoplasmic granules – have a multi-lobed nucleus – Neutrophils (segmented, polys) – eosinophils, and basophils

• Without granules – lymphocytes and monocytes – have non-lobular nuclei

01/30/13

Enid Rivera MD

4


Different WBC

01/30/13

Enid Rivera MD

5


Leukopenia : WBC <5,000 • Infectious related (dengue, others) • Congenital, or hereditary • Collagen-vascular diseases (SLE) • Diseases of the liver or spleen • Presence of cytotoxic substance • Bone marrow failure (malignancy, tumor, fibrosis) • Radiation exposure 01/30/13

Enid Rivera MD

6


Lymphocytes • 25-40% of WBC, lifespan years • immune competence achievement – bone marrow, B cells – thymus, T cells – Both produce lymphokines

• B cells: differentiate into plasma cells & secrete specific antibodies • T cells: recognize cell associated antigens, lyse foreign or virus infected cells, regulate other immune cells 01/30/13

Enid Rivera MD

7


Lymphopenia and neutropenia • Classification

• Lymphopenia – Virus, fungal, intracellular parasites, Tb – Decreased immunoglobulins

– Mild (1500-1000) – Moderate(999-500) – Severe (499-0)

• Neutropenia – Bacterial infections 01/30/13

Enid Rivera MD

8


• A 12 year old white female was taken to the ER because of generalized body aches, and fever since 3 days ago. Any cytopenia?

WBC 3,000 Neu 63%, Lym 20%, Mo 8%

• RBC 4.3 – Hg 15.9, Hct 48.0

• Plt 100,000

01/30/13

Enid Rivera MD

9


• A 2 year old white female was taken to the ER because of pain in her arms and legs and she was complaining of a sore throat. The child was pale and had fever. PE revealed a well nourished but listless child. The child had both lymphadenopathy and hepatosplenomegaly. Has she any cytopenia?

WBC 3,000

RBC 2.3

Segs 3%

Hgb 6.9

Lymphs 2%

Hct 18.0

Blasts 95%

Plt 10,000

01/30/13

Enid Rivera MD

10


Peripheral Smear: Diagnosis?

01/30/13

Enid Rivera MD

11


Leukocytosis: High WBC # • Infection • Inflammation (RA) • Medications: steroids • Malignancy: leukemia • Tissue damage (burns) • Severe stress :↑ cortisol 01/30/13

Enid Rivera MD

12


Neutrophilia: Increased neutrophil count

01/30/13

Enid Rivera MD

13


“patient with acute appendicitis” • WBC 15,000 – 65% mature neutrophils – increase in stabs or band cells to 10%". • typical report of a "shift to the left“ • "shift to the left" " means that bands or stabs have increased, indicating an infection in progress. 01/30/13

Enid Rivera MD

14


Neutropenia: decreased neutrophil count • Viral illness (↑ lymphocytes) • Cyclic (neutrophil drop q 21d) • Chronic benign (asymptomatic, ↑ monocytes) • Familial • Severe & symptomatic • Drug related • Syndrome related 01/30/13

Enid Rivera MD

15


Monocytes • about 4% of circulating leukocytes • Circulate in the peripheral blood prior to emigration into the tissues. • Scavenge debris, present antigen to lymphocytes • Names: liver Kupfer cells, brain microglia, kidney mesangial cells, and bone osteoclasts. • Lifespan: 01/30/13 days in blood, Enidyears Rivera MD in tissues as macrophages

16


Monocytosis • >4% or >600 AMC (all monocyte count) • Viral infection • Monocytosis assoc to neutropenia • Leukemia, very rare 01/30/13

Enid Rivera MD

17


Eosinophils

01/30/13

Enid Rivera MD

18


Eosinophils (1-4%) • Kill large parasites, as helminths • Helminths activate alternative complement pathway and C3b is produced. • Eos attach C3b receptors, and release their granules. • Lifespan: < 1 day in blood, weeks in tissues. • The granule contents damage parasite membrane. – peroxidase, arylsulphatase B, phospholipase D and histaminase

01/30/13

Enid Rivera MD

19


Eosinophilia • • • • • •

>4% or >600 AEC (all eosinophil count) Allergies Sinusitis Asthma Eczema parasites

01/30/13

Enid Rivera MD

20


Red blood cells, or erythrocytes

01/30/13

Enid Rivera MD

21


Hemoglobin: critical low and high values â&#x20AC;˘ A hemoglobin value < 5 gm may cause heart failure â&#x20AC;˘ A hemoglobin value > 20 gm may cause clogging of capillaries due to hemoconcentration. 01/30/13

Enid Rivera MD

22


RBC count • # RBC per cubic millimeter of blood • Adults:

males: 4.6 - 5.9 million females: 4.2 - 5.4 million

• Pregnancy: slightly lower than normal adult • Newborn: 5.5 - 6 million • Children: 4.6 - 4.8 million 01/30/13

Enid Rivera MD

23


Normal hemoglobin values

• • • • •

Adult males: 14 - 18 gm Adult females:12 - 16 gm Pregnancy: 11 - 12 gm Children: 11 - 16 gm Newborn: 17 - 19 gm

01/30/13

Enid Rivera MD

24


Increase in red blood cells # : polycythemia

Cyanotic heart disease

01/30/13

Enid Rivera MD

25


Polycythemia: Increase in RBC# ∀ ↑hgb and ↑ hct • Physiological polycythemia – neonatal period – at high altitudes – after strenuous physical training

01/30/13

Enid Rivera MD

26


Pathological polycythemia • Primary: HIF mutation, RBC overproduction does not result from hypoxia

• Secondary : occurs in response to hypoxia – cyanotic heart disease – high oxygen binding hemoglobins – chronic lung disease – smokers 01/30/13

Enid Rivera MD

27


Factitious polycythemia • • • • •

Dehydration Diarrhea Severe Burns Hypovolemic shock Eclampsia

01/30/13

Enid Rivera MD

28


Anemia

01/30/13

Enid Rivera MD

29


Anemia anisocytosis: normal appearance, different sizes poikilocytosis: abnormal appearance

01/30/13

Enid Rivera MD

30


A 3 year old black female was admitted to the emergency room complaining of joint pain. The child had a right knee that was swollen and painful to the touch. The following laboratory data was observed. WBC 10.5 Segs 24, Lymphs 62, Monos 10, Eosins 4 RBC 2.22 Hgb 7.0 Hct 21.5 MCV 90 Plt. 340,000 15 NRBCâ&#x20AC;&#x2122;s /100 WBC

01/30/13

marked poikilocytosis - moderate anisocytosis

Enid Rivera MD

31


normocytic anemia

01/30/13

Enid Rivera MD

32


Normocytic anemia Hemolysis (SS, Sphero, G6PD) Autoimmune disorders ( SLE, RA, thyroid ) Anemia of chronic disease / inflammation Acute blood loss Erythropoietin deficiency Bone marrow failure (malignancy radiation, toxin) 01/30/13

Enid Rivera MD

33


On a routine health supervision visit, a 1y/o boy has this CBC

01/30/13

Enid Rivera MD

34


Microcytic anemia

• Iron deficiency • thalassemia • lead intoxication • sideroblastic anemia • Anemia of chronic disease / inflamation

01/30/13

Enid Rivera MD

35


01/30/13

Enid Rivera MD

36


Normocytic anemia • • • • • •

Hemolysis Chronic disease/inflamation Hormone deficiency (thyroid, adrenal) Marrow failure Malignancies Renal failure

01/30/13

Enid Rivera MD

37


Normocytic anemia evaluation

01/30/13

Enid Rivera MD

38


Macrocytic anemia • B12 deficiency (pernicious anemia) • folic acid deficiency • Syndromes (Fanconi)

01/30/13

Enid Rivera MD

39


Platelets • normal range 150,000 - 450,000 • Thrombocytopenia < 150,000. • < 20,000 may have spontaneous bleeding • Should be reported in # & MPV • A report of "adequate platelets" is not adequate • implies there is at least one platelet for 20 RBC

01/30/13

Enid Rivera MD

40


Critical low value for platelets • fewer than 50,000 platelets – risk for bleeding with even trauma

• under 20,000 – may cause spontaneous bleeding 01/30/13

Enid Rivera MD

41


Thrombocytopenia • Infection • Autoimmune • Factitious • Sequestration • Marrow problem • Syndrome related 01/30/13

Enid Rivera MD

42


Pseudo thrombocytopenia Platelet clumping • Frequent collection problem • Minimized by draw from large peripheral vein • Mix blood with the anticoagulant ASAP after collection, by gentle rotation or inversion. • Platelet clumping increases with time, so analyze CBC soon. 01/30/13

Enid Rivera MD

43


â&#x20AC;˘ A 13 y/o girl was admitted through the emergency room with a fever and was disoriented. She had been suffering from a viral infection during the previous week. There was bruising on the arms and legs. WBC 5,000

RBC 2.80

Segs 85

Hgb 10.5

Lymphs 8

Hct 30.0

Monocyte 2

MCV 82

Eos 5

Plt 10,000

Poikilocyte - moderate Helmet cells, burr cells, spherocytes, microcytes 01/30/13Polychromasia - moderate Enid Rivera MD

44


In TTP and DIC, platelets are used up rapidly, and the platelet count falls significantly.

01/30/13

Enid Rivera MD

45


Thrombocytosis • • • • • •

Reactive, Reactive, Reactive Anemia Infections Surgery Burns others

01/30/13

Enid Rivera MD

46


Entendieron el CBC? Muchas gracias, Enid Rivera

01/30/13

Enid Rivera MD

47


WBC interaction

01/30/13

Enid Rivera MD

48


reticulocyte count • immature forms of erythrocytes, circulating in the bloodstream • 0.5% to 1.5% of the total RBC in men • 0.5% to 2.5% in women

01/30/13

Enid Rivera MD

49


reticulocyte count • low reticulocyte count – bone marrow failure/dysfunction – folic acid deficiency – cirrhosis

• high reticulocyte count – bone marrow responding to the need for increased rbc cell production – responding to treatment for anemia – hemolytic anemia – recent donation of whole blood 01/30/13

Enid Rivera MD

50


MCV/MCH

01/30/13

Enid Rivera MD

51


MCV/MCH • MCV= RBC size • MCH= hg concentration in RBC • If low hemoglobin, you need to know if RBC are of normal size and if they have a normal concentration of hemoglobin. • These measurements, provide important information about various types of anemias. 01/30/13

Enid Rivera MD

52


Mean corpuscular volume (MCV) • MCV: hematocrit is divided by the total RBC count • low MCV: cells are smaller than normal – iron deficiency anemia, lead poisoning – thalassemia major and thalassemia minor

• high MCV cells are macrocytic, or larger than normal – pernicious anemia and folic acid deficiencies

• normal MCV cells are referred to as normocytic – renal failure, endocrine disorders, acute hemorrhage 01/30/13

Enid Rivera MD

53


MCV: Mean cell volume Normal values for erythrocyte indices Neonate 100-120 fl

Children 1-10y/o 70 + age in years to 90fl (3rd percentile)

Adolescents 11-17 y/o Adults >18y/o 01/30/13

78-95 fl 78- 98 fl Enid Rivera MD

54


Mean corpuscular hemoglobin (MCH) • Measures the amount of hemoglobin present in one RBC. • divides the hemoglobin by the total RBC count. • The result is reported by a very small weight called a picogram (pg).

01/30/13

Enid Rivera MD

55


Mean corpuscular hemoglobin concentration (MCHC)

• Proportion of hemoglobin in the RBC. • The hemoglobin is divided by the hematocrit and multiplied by 100 to obtain the MCHC. • MCHC - 32-36% MCH- 27-31 picomoles 01/30/13

Enid Rivera MD

56


MCH and the MCHC • Used to assess whether RBC are normochromic, hypochromic, or hyperchromic. • An MCHC of less than 32% or an MCH under 17 pg. indicates that are RBC deficient in hemoglobin concentration. • This situation is most often seen with iron deficiency anemia. 01/30/13

Enid Rivera MD

57


Platelets • major coagulation role • adhere to underlying tissue exposed by any gaps in the endothelial lining of injured vessels • form plugs that prevent further blood loss while healing takes place Enid Rivera MD • lifespan 9 to 12 days

01/30/13

58


platelets granule contents â&#x20AC;˘ adhesive glycoproteins (fibrinogen, von Willebrand factor, thrombospondin, and fibronectin) â&#x20AC;˘ growth stimulators (as platelet derived growth factor = Thrombocytopenia PDGF) â&#x20AC;˘ vasoactive substances (such as serotonin, a potent vasoconstrictor), and adenine nucleotides, which stimulate platelet aggregation. 01/30/13

Enid Rivera MD

59


Thrombocytopenia • platelet destruction • impaired platelet production • ITP • HIV • radiation • chemotherapy • drugs that damage the bone marrow • Malignancies of the bone marrow, such as leukemia 01/30/13

Enid Rivera MD

60


bleeding due to a low plt count (<20k)

• Easy bruising • Unusual or heavy nosebleeds • Hematuria • Black, tar-like stools or frank bleeding with BM • Hematemesis Syncope or visual disturbances due to intracranial bleeding • Gingival bleeding • Heavy vaginal bleeding 01/30/13

Enid Rivera MD

61


Entendiendo el CBC