Evaluation of Peripheral blood Huang Jinwen Sir Run Run Shaw Hospital

Automated hematology instrumentation

WBC differential Advia 2120 peroxidase cell size Neutrophils (pink) and eosinophils (yellow) containing the most perox activity are found to the right. Cells with little or no perox cluster to the left, such as lymphocytes/basophils (blue) and large unstained cells (blasts, variant and atypical lymphocytes, light blue). Monocytes (green) contain a small amount of perox and are located between the neutrophils and large unstained cells. Noise is indicated in the lower left hand corner (white). Neutrophils eosinophils Monocytes Lymphocytes blasts

Red cell size distribution curves in hereditary sideroblastic anemia Presence of two populations of red cells A broad population of red cells, varying markedly in size, with the majority of the cells being microcytic.

Comparison between automated optical and immunologic platelet counts The majority of the data points well outside of the 95 percent confidence limits are above the best- fit line, suggesting that the optical method is more prone to overestimate platelet counts than the immunologic method in this range.

Optimal area for review Suboptimal blood smear Normal peripheral blood smearRouleaux in myeloma

Definition and mechanisms of leukocytosis and neutrophilia

WBC Count The normal limit in adults: to (4.0 to 10.0) x109/L Leukocytosis: NL + 2SD, or> 11.0 x109/L Hyperleukocytosis or leukemoid reaction: > 50.0 x109/L Neutrophilic leukocytosis: >11.0 x109/L, + ANC>7,700 x109/L ANC = WBC x percent (PMNs + bands) ÷ 100

Neutrophilic leukocytosis It commonly seen in It can also occur in Neutrophilia Infection, Stress, Smoking, Pregnancy, Following exercise. Chronic myeloproliferative disorders, Chronic myeloid leukemia

Lymphocytic leukocytosis WBC 11.0 X109/L, an absolute lymphocyte count > 4.8 X109/L. Infectious mononucleosis and pertussis Lymphoproliferative disorders, such as the acute and chronic lymphocytic leukemias

Monocytic leukocytosis WBC> 11.0 x109/L, an absolute monocyte > 0.8 x109/L. Acute and chronic monocytic variants of leukemia Acute bacterial infection or tuberculosis Monophilia.

Eosinophilic and basophilic leukocytosis WBC>11.0 x109/L, an absolute eosinophil > 0.45 x109/L or basophil >0.2 x109/L Eosinophilic leukocytosis can be seen in Basophilic leukocytosis is a distinctly unusual condition, Chronic leukemia, Solid tumors, Infection with parasites, Allergic reactions, Following treatment with IL-2 Basophilic or Mast cell variants of acute or chronic leukemia

Regulation of neutrophil counts PMN development

Detection of infection or inflammation band count ≥20 left-shift cytoplasmic vacuoles Dohle bodies, Toxic granulation

The leukocyte alkaline phosphatase score LAP is high in LAP is low in Infection Inflammation Polycythemia vera Chronic myeloid leukemia Paroxysmal nocturnal hemoglobinuria

Definitions of neutropenia Mild neutropenia: ANC 1.0 ~1.5 X109/L Moderate neutropenia: ANC ~1.0 X109/L Severe neutropenia: ANC < 0.5 X109/L

Neutropenia and hospitalization for infection

Etiology of isolated neutropenia Acquired neutropenias Postinfectious neutropenia Drug-induced neutropenia and agranulocytosis Primary immune disorders Hypersplenism Bone marrow disorders Congenital neutropenias Myeloperoxidase deficiency

NIH grading of hematologic toxicity of chemotherapy

Fever in the neutropenic adult patient with cancer

Risk Factors of Fever ■ A rapid decline in ANC or ANC <0.1 X109/L ■ Prolonged duration of neutropenia (>7 to 10 days) ■ Leukemic induction ■ Cancer not under control ■ Comorbid illnesses requiring hospitalization ■ Use of central venous catheters ■ Disruption of mucosal barriers ■ Use of monoclonal antibodies

INFECTIONS IN FEBRILE NEUTROPENIA ■ A majority of patients had occult bacterial infections ■ An infectious source identified in ~ 30 % ■ Bacteremia documented ~25% ■ ~80% of identified infections arised from patients‘ own endogenous flora.

Symptoms and a physical examination daily

Laboratory studies CBC with differential, transaminases, bilirubin, amylase and electrolytes, a chest radiograph, and cultures. Two or more blood cultures, sputum Gram stain and culture, and urine Gram stain and culture. Pulmonary infiltrates frequently can not produce sputum; a more invasive approach including bronchoscopy or open lung biopsy. Lumbar puncture is not usually recommended.

Blood cultures One set /day for a stable fever pattern. Two or three sets initially and to wait 48 to 72 hours to repeat blood cultures.

Chest radiographs ■ Findings are often minimal or absent even in patients with pneumonia. ■ Findings may develop along with an increase in symptoms as the neutropenia begins to resolve.

Chest CT scanning CT should be ordered for the patients with pulmonary symptoms.

Colony stimulating factors ■ CSF reported to decrease the duration of neutropenia, fever, and hospitalization. ■ CSF have not been shown to decrease mortality. ■ These agents should not be used routinely for patients with fever and neutropenia. ■ It may be appropriate to consider their use in critically ill patients.

THANKS