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The Role of Lab Exam Screening Diagnosis : Routine Lab tests Confirmatory Lab tests Prognosis Monitoring Disease activity Therapy responses 2

Laboratory examination for Infection 3

4 Routine examination Blood cell count  complete blood cont (CBC) Hemoglobin concentration (Hb) Hemoglobin concentration (Hb) White Blood Cell Count (WBC) White Blood Cell Count (WBC) Platelet count Platelet count Differential cell count Differential cell count Red blood cell count & Hematocrit Red blood cell count & Hematocrit Erythrocyte Sedimentation Rate (ESR) HEMATOLOGY :

Routine examination - hematology Blood cell count 5  Hemoglobin concentration Normal range : At birth : 15 – 20 g/dl At 2 months : 9 – 14 g/dl 10 years of age : 12 – 15 g/dl Female adult : g/dl Male adult : 13 – 18 g/dl < Normal range : Anemia Anemia occur in several infection diseases as follows: - bacterial infection - virus infection - parasite infection

Anemia in bacterial infection 6 Extracellular microorganism Clostridial SepticemiaBartonellosis Invade to RBCsAdhere to the exterior surface of the RBC Destruction of RBCs Lysis ANEMIA

Hemolytic anemia in parasites infection 7 Infected cell ruptures Immune complexes ANEMIA Lysis

Anemia of Chronic Disease ACD is associated with an underlying disease (usually inflammation, infection, or malignancy), but is without apparent cause (not due to a lack of the nutrients iron, vitamin B 12, or folic acid) Anemia of chronic disease (ACD) is difficult to define as its etiology and pathogenesis is not clear. ACD is the most common anemia in hospitalized patients. 8

Anemia of Chronic Disease Pathophysiology: Erythropoesis suppression Chronic inflammatory process  secretion of TNF & IL-1  Lack of iron for Hb synthesis Lactoferrin release from granules of neutrophils Lactoferrin competes with transferrin for iron Decreased RBC survival 9

Routine examination - hematology LEUKOCYTE COUNT (WBC)  Measure number of total leucocytes  Method: manually & automatically  Principle : dilution of blood with acid solution in order to lyses erythrocytes  Reference range : adult = cells/μL child = cells/μL newborn= cells/μL 10

Kinetics of Leucocyte 11 Input from marrow Circulating pool Marginal pool Output to tissue Storage pool

Pathology Leukocytosis WBC > 11.0 (x 10 9 /L) Leukopenia WBC < 4.0 (x 10 9 /L) 12 Virus infection Typhoid fever Rheumatoid arthritis Cirrhosis of the liver SLE Radiation, drugs Bacterial infection Leukemia Uremia Physiologic: Pregnancy Strenuous exercise Emotional stress, anxiety WBC

Routine examination - hematology White Blood Cell Differential  To determine the relative number of each type of WBC present in the blood.  Blood smear : - relative number - leukocyte immaturity - morphologic abnormality  Abnormality: Quantitative Qualitative 13

Classification of Leucocytes Granulocyte Neutrophil, Eosinofphl, Basophil Polimorfonuclear Neutrophil, Eosinofphl, Basophil Phagocyte Neutrophil Monocyte Non-granulocyte Monocyte Lymphocyte Mononuclear Monocyte Lymphocyte Immunocyte Lymphocyte 14

15 Growth and differentiation factors (cytokines) produced by and present on bone marrow stromal cells determine the type of white blood cell that will emerge, as well as their relative numbers. All white blood cells originate from the bone marrow

16 Blood cells derived from bone marrow cells

17 Blood cells migrate through blood and lymph nodes or home to tissues

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19 Cells in blood circulation Very few in blood

20 Resting lymphocytes are round cells with a large nucleus

Differential cell count Refference range: 21  Polymorphonuclear neutrophils: 50 – 70 %  Bands: 0 – 5 %  Lymphocytes: 18 – 42 %  Monocytes: 1 – 10 %  Eosinophils: 1 – 4 %  Basophils: 0 – 2 % Course of d’s : shift to the left (acute), shift to the right (chronic) Cause : bacterial, viral and parasites infection neutrophilia (bacterial infection), lymphocytosis (viral infection, tuberculosis)

NEUTROPHILIA  3 major cause : infection, inflammation, malignancy  Severity of neutrophilia in infection depend on: - virulency of organism, - age : child > - patient immunity: immunocompromised host 22 Quantitative abnormality

Causes of neutrophilia 1. Bacterial Infection 2. Toxic agent 3. Metabolic: uremia, eclampsy, metabolic acidosis 4. Drugs & chemicals: mercury, digitalis, steroid 5. Physic & emotional stimuli 6. Tissue damage & necrosis: myocardial infarct, wound, neoplastic diseases 7. Hemorrhage: especially intra serous cavity (peritoneal, pleural, joint space, subdural) 8. Hematological diseases: leukemia. 23 Quantitative abnormality

Qualitative Abnormality Shift to the left or right: 24 Shift to the left : increase immatur cells most frequent: stab, metamielosit, mielosit, promielosit acute infection (bacterial) Shift to the right: increase of segment hypersegmentation chronic infection batangsegmen metamielosit mielosit promielosit mieloblas

Leukemoid reaction mielocytic/netrophyilic 25 Bain, Blood Cells, A Practical Guide,3 rd ed, Blackwell Publ, UK Quanti+Qualitative abnormality

White blood cell (blood smear) 26 Leucocytosis : netrophilia absolute with toxic granulation & vacuolisation Toxic granulation vacuolisation Qualitative abnormality vacuolisation Bacterial infection

27 vakuolisation Toxic Granulation Vacuolisation & toxic granulation Bacterial infection

Toxic Granulation Stimulated by organism or antigen Color of granule: dark blue-blackish Profound toxic granulation  worse prognosis Vacuolisation of cytoplasm  phagocytosis process 28 Qualitative abnormality

Neutropenia Netropenia lekopenia Agranulositosis: severe netropenia Causes of netropenia: Viral infection Certain Bacteria: Tifoid/ paratifoid Severe infection Immune reaction: autoimmune/ drug induced 29

EOSINOPHILIA : 1. Parasite investation - correlate with killed parasites - eosinophyl attracted to parasite will be killed by degranulation process 2. Allergy/ hypersensitivity 30

31 EOSINOPHILIA :

Lymphocytosis 32 Absolute lymphocytosisViral infection

33 Variant / atypical/ virocyte/ reactive lymphocyte  response to infection Qualitative abnormality

 Lymphocytosis with variant lymph: - Mononukleosis infecsiosa (var lymph  40%), acute hepatitis, citomegalovirus (CMV) - measles, pneumonia viral, rubela  relatif - Non viral : Tuberculosis, syphilis, malaria, typhus, diphteria, toxoplasmosis  Lymphocytosis without var lymph: asimptomatic viral inf., diarrhea, resp. inf  Lymphopenia; HIV, SLE, intensive chemotherapy 34

Virus Infection MONONUKLEOSIS INFEKSIOSA (MI) cause: virus Epstein- Barr (EBV) Lekositosis with limphocytosis, dan atypical lymphocyte “Kissing-cell” 35

36 Dengue virus infection Reactive Lymphocyte Blue cytoplasm- Lymphocyte

37 Monocyte

MONOCYTOSIS  Some bacterial inf.,: - Active Tuberculosis : - Sub acute bacterial endocarditis - Syphilis  Myeloproliferatif  Recovery 38

Erythrocyte Sedimentation rate (ESR) ESR is the rate in millimeters at which the RBCs fall in 1 hour Monitoring the course of an existing inflammatory disease Normal range: 0-20 mm/hrs F 0-15 mm/hrs M Elevated : bacterial infection 39 Routine examination - hematology

Normal sedimentation  Polisitemia : AE   Dekompensasi jantung  Sickle sel anemia, sferositosis  Neonatus Increase Sedimentation  infection  myocardial infarct  Rheumatic fever  Malignancy with necrosis  Active tuberculosis, tissue destruction  Surgery Trauma, shock  Hiperglobulinemia  Pregnancy 40

C-REACTIVE PROTEIN (CRP) an acute phase reactant In general parallel ESR but not influenced by erythrocyte More sensitive than ESR Increase & decrease faster : - early indicator of acute infection - monitor course of disease 41

CRP increase in : Infection: Lower in viral compared to bacterial infection Useful to monitor disease activity Inflammatory disorders: Earlier,more intense increase than ESR Dissaperance of CRP precedes the return to normal of ESR Tissue injury or necrosis AMI : appears within hrs Malignant disease, Following surgery, burns 42