Hematology Cell Counters

FLAGS AND TROUBLESHOOTS

– 3 PART DIFFERENTIAL CELL COUNTERS

DR. PRASAD P. SHENOYCENTRAL CLINICAL LABORATORY

PANAJI – GOA

[email protected]

3 PART DIFFERENTIAL CELL COUNTER

COMMON INSTRUMENT IN A HEMATOLOGY LABORATORY

CBC – ‘BREAD AND BUTTER’ OF HEMATOLOGY LAB

RAPID, ACCURATE AND PRECISE BLOOD COUNTS (CONSISTENT)


• HYDRODYNAMIC FOCUSSING

• ELECTRICAL IMPEDENCE

• VOLUMETRIC METERING

• COLORIMETRY (Hb)


PARTICLE > 35 fl: RBC

PARTICLE 2 – 20 fl: PLATELET

HEMOGLOBIN AND WBC COUNT IN SECOND CHAMBER

RBC AND PLATELET COUNTED IN ONE CHAMBER


DIRECTLY MEASURED PARAMETERS AND HISTOGRAMS

HEMOGLOBIN CONCENTRATION

WBC COUNT

RBC COUNT

PLATELET COUNT

WBC HISTOGRAM

RBC HISTOGRAM

PLATELET HISTOGRAM


PARAMETERS DERIVED FROM HISTOGRAMS

LYMPHOCYTE PERCENTAGE

MID-SIZE CELL PERCENTAGE

GRANULOCYTE PERCENTAGE

MCV

RDW

MPV

PDW


CALCULATED PARAMETERS

LYMPHOCYTE #

MID-SIZED CELL #

GRANULOCYTE #

HEMATOCRIT

MCH

MCHC

PCT


• MANUAL DIFFERENTIAL COUNT REMAINS A DEFINITIVE TOOL FOR COMPLETE HEMATOLOGIC ANALYSIS

• PERIPHERAL BLOOD SMEAR REVIEW IS

MANDATORY

FLAG

• SIGNAL TO THE OPERATOR

• INDICATES A SIGNIFICANT ABNORMALITY IN THE ANALYSED SAMPLE / ANALYSER ITSELF

QUESTIONABLE RESULT

ANALYSER RELATED

SAMPLE RELATED

TROUBLESHOOTING

?

TROUBLESHOOTING

• SYSTEMATIC APPROACH

• ISOLATE A SOURCE OF A PROBLEM AND FIX IT

• THROUGH A PROCESS OF ELIMINATION

• FIX THE MOST OBVIOUS / EASIEST PROBLEM FIRST

QUESTIONABLE RESULT

ANALYSER RELATED

SAMPLE RELATED

QC ACCEPTABLE

SAMPLE RELATED

QC IS OUT OF RANGE

ANALYSER RELATED

QC

ANALYSER RELATED ERRORS

• ELECTRONIC (HARDWARE / SOFTWARE)

• PRESSURE / HYDRAULIC

• REAGENT


FLAGS ARE FEW

OPERATOR MUST BE ALERT

Hb: 15.6 g/dL

RBC: 5.19 x 106 / uL

HCT: 45.9 %

MCV: 88.6 fl

MCH: 30.1 pg

MCHC: 33.3 g/dL

RDW: 12.9 %

RULE OF 3

NORMOCYTIC NORMOCHROMIC

WBC : 7.0 x 103 / uL

Lymph#: 1.8 x 103/uL

Mid# : 0.3 x 103/uL

Gran# : 4.9 x 103/uL

Lymph%: 25.9 %

Mid% : 4.3 %

Gran%: 69.8 %

PLT : 267 x 103 / uL

MPV : 9.5 fL

PDW : 14.2

PCT : 0.183 %

INTERFERENCES

• RBC FRAGMENTS, VERY SMALL RBC’s

• NUCLEATED RBC’s, LYSE RESISTANT RBC’s

• COLD AGGLUTININS

• HIGH LEUKOCYTE COUNTS (>50 x 103/uL)

• GIANT PLATELETS, PLATELETS CLUMPS

• LIPEMIC SAMPLE

• CRYOGLOBULINS

• CLOTTED SAMPLE

• AIR BUBBLES

CASE: 1

20 years / FemaleBreathlessness, easy fatiguability

Lack of concentration, giddiness

Hb: L 4.2 g/dL

RBC: L 3.09 x 106 / uL

HCT: L 15.3 %

MCV: L 55.0 fl

MCH: L 13.5 pg

MCHC: L 24.8 g/dL

RDW: H 24.5 %

WBC: 5.5 x 103 / uL

PLT: H 561 x 103 /ul

MICROCYTIC HYPOCHROMIC ANEMIA

• IDA• THALASSEMIA• ANEMIA OF CHRONIC

DISORDERS

MENTZER’S INDEX (M. I.)

M. I . = MCV / RBC

If M. I. > 13: IDA

If M. I. < 13: Thalassemia

Suggestive of Iron deficiency AnemiaAdv: Sr. Iron, TIBC, Ferritin

Iron: 12.30 37 - 145 ug/dL

TIBC: 563 215 - 535 ug/dL

% Transferrin: 3.23 13 - 45 %

Ferritin : 1.80 13 - 150 ng/mL

M. I. = 55/3.09 = 17.8

CASE: 2

23 years / Female

Pregnant, 12 weeks

Total Bil : 1.1 mg/dL

Conjugated Bil: 0.3 mg/dL

Transaminases: Normal

Hb: L 10.1 g/dL

RBC: 4.89 x 106 / uL

HCT: L 31.9 %

MCV: L 65.0 fl

MCH: L 22.8 pg

MCHC: L 30.5 g/dL

RDW: H 17.2 %

WBC: 7.5 x 103 / uL

PLT: 418 x 103 /ul

M. I. = 65/4.89 = 13.29

MICROCYTIC HYPOCHROMIC ANEMIAAdv: Sr. Iron, TIBC, Ferritin

Hemoglobin electrophoresis

Hemoglobin Electrophoresis

HbA = 93.7 94.3 – 98.5HbF = 0.9 0.2 – 2.0HbA2 = 4.8 1.5 – 3.5

Iron: 21.40 37 - 145 ug/dL

TIBC: 405.10 215 - 535 ug/dL

% Transferrin: 5.28 13 - 45 %

Ferritin : 8.19 13 - 150 ng/ml

β Thalassemia trait with Iron deficiency

CASE: 346 years / Female

Weakness, Paresthesia

No organomegaly

Hb: L 7.1 g/dL

RBC: L 1.80 x 106 / uL

HCT: L 21.5 %

MCV: H 119.9 fl

MCH: H 39.4 pg

MCHC: 34.0 g/dL

RDW: H 20.6 %

WBC: 3.8 x 103 / uL

PLT: 127 x 103 /ul MACROCYTIC ANEMIA

MACROCYTIC ANEMIA, FAVOUR MEGALOBLASTIC

Adv: Sr. Vitamin B-12 and Folic acid

Vitamin B-12 113.23 211 – 946 pg/ml

FOLIC ACID 1.12 >5.38 ng/ml

MEGALOBLASTIC ANEMIA

THERAPEUTIC TRIAL

RETICULOCYTE RESPONSE

• Vitamin B 12 & Folic acid deficiency• Myelodysplastic syndromes• Hemolytic anemias• Myelophthisic anemias• Aplastic anemia• Chronic Liver diseases

MACROCYTIC ANEMIA

MACROCYTIC ANEMIA

Adv: Sr. Vitamin B-12 and Folic acid

Vitamin B-12 874.89 211 – 946 pg/ml

FOLIC ACID 27.46 >5.38 ng/ml

?

MACROCYTIC ANEMIA WITH FEATURES OF

DYSPLASTIC HEMATOPOIESIS

BONE MARROW &

CYTOGENETIC STUDIES

CASE: 4

63 years / Male

Hb: L 9.0 g/dL

RBC: L 3.86 x 106 / uL

HCT: L 27.9 %

MCV: L 72.3 fl

MCH: L 23.3 pg

MCHC: 32.2 g/dL

RDW: H 29.2 %

WBC: 8.3 x 103 / uL

PLT: 258 x 103 /ul

DUAL PEAK

M. I. = 72.3 / 3.86= 18.73

POST BLOOD TRANSFUSION

CASE: 5

53 years / Female

? FEVER

WBC: H 310.6 x 103 / uL

Lymph#: H 31.4 x 103/uL

Mid# : H 43.8 x 103/uL

Gran# : H 235.6 x 103/uL

Lymph%: L 10.1 %

Mid% : 14.1 %

Gran%: H 75.8 %

Hb: L 9.4 g/dL

PLT: H 689 x 103/uL

Features compatible with a Myeloproliferative neoplasm:

CHRONIC MYELOID LEUKEMIA IN CHRONIC PHASE

Adv: Molecular / Cytogenetic studies for Philadelphia chromosome

Hb: L 9.4 g/dL

RBC: L 1.77 x 106 / uL

HCT: L 16.6 %

MCV: 94.1 fl

MCH: H 53.1 pg

MCHC:H 56.6 g/dL

RDW: H 22.3 %

PLT: H 689 x 103/uL

HEMOGLOBIN PERFORMED BY MANUAL (CYANMETH) METHOD

8.3 g/dL

7.1 g/dL (after centrifugation)

CASE: 6

63 years / Female

Operated case of Ca-Ovary, on Chemotherapy, for

follow up

Hb: 12.4 g/dL

RBC: 4.57 x 106 / uL

HCT: 35.9 %

WBC : 6.7 x 103 / uL

PLT : L 56 x 103 / uL

MPV : H 14.5 fL

PDW : H 19

Giant Platelets

Platelet clumps

EDTA induced platelet clumping

SPURIOUS THROMBOCYTOPENIA

Acknowledgement

Dr. P. R. Malur, Dr. Anita Borges

Dr. C. N. Nair, Dr. Sumeet Gujral

Dr. Mona Anand, Dr. Mani

Drs: Archana, Anshuman, Aditi, Sunita, Kiran, Kanchan, Manu, Sanica.

Entire Staff of Hematopathology Laboratory, TMH, Mumbai

Ms. Salini Gopinathan

Dr. Prasad P. ShenoyCentral Clinical Laboratory

Panjim – Goa

Hematology Cell Counters

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