Evaluation of Peripheral blood Huang Jinwen Sir Run Run Shaw Hospital

Automated hematology instrumentation

WBC differential Advia 2120 Monocytes Neutrophils 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). cell size Lymphocytes eosinophils peroxidase

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

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 Rouleaux in myeloma Normal peripheral blood smear

Definition and mechanisms of leukocytosis and neutrophilia

WBC Count The normal limit in adults: 4.400 to 11.0. (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 cytoplasmic vacuoles left-shift 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 0.500 ~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 minimal or absent even in patients with pneumonia. ■ 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.

Empiric antimicrobials None clearly superior antibiotics. Coverage targeted at Gram negative bacilli, especially P. aeruginosa. Aminoglycosides and fluoroquinolones exhibit concentration-dependent killing Beta-lactams exhibit time-dependent killing

Addition of vancomycin Hypotension, mucositis, skin or catheter site infection, history of MRSA colonization, or recent quinolone prophylaxis. Clinical deterioration or persistent fever despite empiric antibiotics. Withdrawal of empiric vancomycin after 72 hours without improvement of events or culture negative.

Addition of antifungal drugs ■ Antifungal therapy is routinely added at 5 to 7 days ■ Undiagnosed fungal infection is present in many patients.

Documented antimicrobial Optimal coverage for this organism and should ideally be bactericidal. Broad empiric coverage for the possibility of other pathogens.

" Stepdown" ■ Initially with parenteral therapy, then switched to an oral regimen. ■ “Stepdown” used successfully by experienced centers even in patients at increased risk.

Scoring index for identification of low-risk febrile neutropenic patients at time of presentation with fever Characteristic score *Extent of illness No symptoms 5 Mild symptoms 5 Moderate symptoms 3 *No hypotension 5 *No chronic obstructive pulmonary disease 4 *Solid tumor or no fungal infection 4 *No dehydration 3 *Outpatient at onset of fever 3 Age < 60 year 2 Highest theorhetical score is 26. A risk index score of ≥21 indicates that the patient is likely to be at low risk for complications and morbidity.

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.

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