1. Getting to know the CBC… It’s about time!
Ma. Ysabel Lesaca-Medina, MD

2. Do you know :
How to evaluate anemia using MCV, MCH, MCHC, RDW and RETIC count
the significance of different RBC shapes reported in the PBS
How to deal with leukocyte abnormalities seen on PBS
The causes of thrombocytosis and thrombocytopenia

3. Evaluating Anemia -role of MCV, MCH, MCHC

4. MCV (mean corpuscular volume)
Formula (2-10 yrs old)
Lower limit: 70 fL + age in years
Upper limit: 84 fL + ( age in yrs x 0.6 ),
until upper limit of 96 is reached
MEMORIZE !!

5. Evaluating Anemia MCH (Mean Corpuscular Hb)
MCHC (Mean Corpuscular Hb conc)
normo/hyper/hypo chromic
Used in
iron deficiency, thalassemia - ↓
Spherocytosis -

6. MCH/MCHC

7. What’s the MCV range? Give LL and UL
7 year old

8. answer
LL: 77 fL
UL: 88.2 fL

9. RETICULOCYTE COUNT Expressed as % of circulating rbc’s
Take up reticulin stain (supravital):
bec of inc RNA
N = 0.5 % to 1.5 %
or = .005 to .015

11. RETICULOCYTE COUNT Provide crucial info on RATE of red cell production
2 broad classes of anemias
2 red cell loss or destruction – inc retic
- e.g. hemolysis, blood loss
Dec red cell production – dec retic
e.g. aplastic, iron deficiency

12. Reticulocyte index 4.5% x .15/.45 = 1.5 % ( N = 0.5-1.5%)
Anemic patient --> increased retic
so have to correct: retic observed x px Hct / 0.45
Example:
Hb 50 Hct 0.15
Retic count=.045= 4.5 %
Corrected retic =
retic x (px Hct / 0.45)
4.5% x .15/.45 = 1.5 % ( N = %)

13. Absolute Retic Count More accurate Compute : RBC (in n x 1012 )
x # retic/1000 rbc
x 1000
Normal
= 40,000 – 100,000/uL

14. Absolute Retic count EXAMPLE Hb 50 Hct 0.15 RBC = 1.6 x 1012
=.045 = 4.5 %
Compute for absolute retic count
Formula:
RBC (in n x 1012 )
x # retic/1000 rbc
x 1000
= 1.6 x 45 x 1000
= 72 ,000
Normal = 40,000 – 100,000/uL

15. Quiz Compute for absolute retic count : Hb 90 RBC 3 x 1012 /L

16. Answer
45,000 retics / uL

17. Anemia based on MCV and retic
Increased MCV
High retic
Low retic
Decreased MCV
Normal MCV

18. Increased MCV Increased Retic Acute blood loss Hemolysis
- cased by inc # retics
 retics have a large cellular volume

21. Anemia based on MCV and retic
Increased MCV
High retic
Low retic
Decreased MCV
Normal MCV

22. Inc MCV, low retic Bone Marrow Failure
Retic count greatly dec for degree of anemia
E.g. Known case of Aplastic anemia
RBC 1.73 Hb 52 Hct Retic = 1 % or 0.010
> Compute for corrected retic count % absolute retic

23. Answer ( 0.5 – 1.5 %) 17,300 /uL (40,000-100,000) You got it!
Corrected retic:
0.33 %
( 0.5 – 1.5 %)
Absolute Retic Count:
17,300 /uL
(40, ,000)

25. Bone Marrow Failure MCV inc bec of production of stress rbc’s
Examples of bone marrow failure
Aplastic Anemia
Fanconi’s Anemia
Diamond-Blackfan anemia
(Congenital hypoplastic anemia)
Transient Erythroblastopenia of Childhood (TEC)

26. TEC vs DBA Transient erythroblastopenia of childhood Acquired
90% cases in > 1 y.o.
Recovery within 2 mos
In recovery phase, inc MCV bec inc retics
ADA normal
Diamond Blackfan Anemia
- Congenital
90% cases < 6 mos
Some recover by 7 years old
- ADA increased

27. Inc MCV, Dec Retic 2. Megaloblastic disorders
Folate and Vit B 12 deficiency
Other things seen :
Hypersegmentation of PMN’s
Giant segmenters, stabs
Macroovalocytosis
Megaloblastic changes in BM

28. hypersegmentation

29. Inc MCV, Dec Retic 3. Alcohol direct toxic effect on BM
Induces folate deficiency

30. Inc MCV, dec retic Anti-metabolites Hypothyroidism
Methotrexate (folic acid anti-metabolite)
Co-trimoxazole
Hypothyroidism
a. Causes red cell hypoplasia
Usually normocytic/normochromic
Macrocytosis may develop

31. Next …DECREASED MCV

32. Decreased MCV Caused by insufficient Hb synthesis Mostly caused by:
Iron deficiency
Inability to use iron
Chronic disease
Thalassemia
Lead poisoning
Sideroblastic anemia

33. Decreased MCV Increased retic Thalassemia major
Normal /decreased retic

34. Thalassemia major Presents : 6 to 24 months old Symptoms
Profound anemia
Hepatosplenomegaly
Jaundice
Growth retardation

35. Decreased MCV Increased retic Normal /decreased retic Iron deficiency
Thalassemia major
Normal /decreased retic
Iron deficiency
Thalassemia Trait
Anemia of chronic disease
Lead poisoning
Sideroblastic anemia
hardest differentials !

36. 1. Iron deficiency ↑RDW  Remember! First manifestation : RDW
Common cause in 1-3 years of age
As iron stores become depleted:
↑RDW 
↓serum Fe 
↓ MCV  ↓ Hb
Remember!
First manifestation : RDW

37. 1. Iron deficiency Reasonable approach: Oral iron replacement
(+) response:
Hb by in 1 month
PRESUMPTIVE DX MADE !

38. 2. Thalassemia trait Microcytosis +/- mild anemia
1 of 2 B-globin genes are intact
or 2 of 4 alpha-globin genes are intact
Often confused with iron deficiency

39. Thal trait vs Iron deficiency
Mentzer index
(MCV/RBC count)
< 12
Smaller cells,
More rbc number
>13
Bigger cells, less rbc number
Poikilocytosis;
Basophilic stippling
More
RDW
Normal
increased

40. RED CELL DISTRIBUTION WIDTH
Quantitative measure of anisocytosis
The greater the # of sizes of rbc’s, the higher the RDW
Normal =
No subnormal values have been reported

41. RDW HIGH ( HIGH-F ) Iron deficiency Hb H disease Fragmentation G-6PD
Chronic disease

42. 3. Anemia of Chronic Disease
Mild to moderate anemia (Hb 100 – 110)
Slight inc RDW; dec Fe, inc Ferritin
Px has chronic INFLAMMATION
Disturbs iron recycling  iron left trapped in RES
Cytokines IL-1, IL-6  inc ferritin syn  empty ferritin shells provide excess iron storage capacity  iron sequestered in RES

43. Decreased MCV 4. Lead poisoning
Inhibits enzymes involved in heme synthesis
Reduction of intracellular iron
5. Sideroblastic Anemia
Rare in childhood
Failure to incorporate iron into heme
Causes:
Inherited (XL)
MDS
Drugs ( INH, ethanol)

44. NEXT. ..
NORMAL MCV

45. MCV NORMAL

46. MCV NORMAL

47. MCV NORMAL

48. Renal Disease Cause: erythropoeitin insufficiency
Serum inhibitors of erythropoeisis accumulate in uremic patients  shortened rbc lifespan
Acanthocytosis
When BUN > 150 mg/dL

49. Hyperparathyroidism
Fibrosis in marrow cavity
Decreased erythropoeisis

50. Liver disease Anemia is due to Hypersplenism
Vitamin-nutritional deficiencies (lipid soluble)
Blood loss

53. PLATELETS Cytoplasmic fragments ; no nucleus Life span = 7-10 days
1/3 in spleen, 2/3 in circulation
Size= 1 – 4 um
Large
Young
2 peripheral destruction
Small or normal
Production defect

55. THROMBOCYTOSIS Platelet count > 600,000
Rarely causes complications !
Therefore, antiplatelet tx is rarely indicated
Kawasaki is an exception

56. THROMBOCYTOSIS Hemolytic anemia Hemorrhage Infection Iron def anemia
Vit E deficiency
Vascular Collagen disorders
Post-splenectomy
Post-op
Inflammatory Bowel Dis
Trauma
Tumors
Syndrome, kawasaki
Syndrome, nephrotic
Syndrome, myeloprolif
HIV is the PITS !

57. THROMBOCYTOPENIA Immune Platelet Destruction Infections
Platelet clumping
- falsely low
- 2 inadequate coagulation

59. RBC abnormalities Anisocytosis Poikilocytosis Microcytes Macrocytes
Normocytes
Poikilocytosis
Different shapes

60. Spherocytes Hereditary spherocytosis ABO incompatibility
Hemolytic anemia
Hypersplenism
Malaria
Hemoglobinopathies
Post-transfusion !
Liver disease

61. Acanthocytes Abetalipoproteinemia Hemolytic anemias Thalassemia
Liver disease
Severe burns
Post splenectomy
Renal disease
Enzyme deficiencies

62. Schistocytes Hypersplenism Megaloblastic anemia Thalassemia
- Hemolytic anemia
Hypersplenism
Megaloblastic anemia
Thalassemia
Acute Leukemia
Post severe burns

63. Ovalocyte Hypochrom ovalocyte Macrocytic ovalocyte
Normochrom ovalocyte
Ovalocytosis
Thalassemia
Hypochrom ovalocyte
Iron deficiency
Macrocytic ovalocyte
Megaloblastic anemia

64. Elliptocytes Elliptocytosis Megaloblastic anemia Myelofibrosis
Thalassemia

65. TARGET CELLS Liver disease Thalassemia Iron deficiency
Post-splenectomy

66. Abn RBC shapes Blister cell Tailed RBC Tear drop
Microangiopathic hemolytic anemia
Tailed RBC
Megaloblastic anemias
Iron deficiency
Tear drop
Hypersplenism
Thalassemia
Hemolytic Anemia

67. BURR CELLS Hemolytic anemias Iron deficiency Megaloblastic anemia
Thalassemia
Hypersplenism

68. STOMATOCYTES Hereditary stomatocytosis Artefact
Acute leukemia, treated
Alcoholics with liver disease

69. The following scale is used by many laboratories in the delta region of the U. S. morphology                        normal       1+             2+           3+           4+ characteristics                     limits Macrocytes (>9 μ dia.)            0 - 5                        >50 Microcytes (<6 μ dia.)             0 - 5                         >50 Hypochromia                         0 - 2                        >75 Poikilocytosis                        0  - 2                        >50 Anisocytosis                           0 - 2                         >50 Acanthocyte                          none       1 - 5                      >20 Burr Cell                                0 - 2                         >50 Target cell (codocyte)            0 - 2                         >50 Tear drop cell (dacryocyte)     0 - 2        2 - 5                    >50 Sickle Cell (depranocyte)        none   (If present in any number, report as positive.) Elliptocyte/Ovalocyte             0 - 2                         >50 Helmet cell / Bite cell             none        1 - 5                    >20 Schistocytes                           none        1 - 5                    >20 Spherocytes                            0 - 2                         >50 Stomatocytes                          0 - 2                         >50 Basophilic stippling                  0 - 1        1 - 5                    >20 Polychromatophilia, adult         0 - 1       2 - 5                    >20 Polychromatophilia, infant        1 - 6                        >50 Howell-Jolly (HoJo) body           none     1 -  2        3 - 5               >10 Pappenheimer body (siderocyte) none     1 - 2        3 - 5                >10

70. RBC abnormalities Severe hemolysis Nucleated rbc’s
Schistocytes: helmet cells, triangle cells, bite cells
Spherocytes (immune mediated)
acanthocytes

71. RBC Inclusions Howell-Jolly bodies
Nuclear remnants not extruded from mature erythrocytes
Indicate splenic hypofunction
Seen in
Post-splenectomy
Leukemia
Hemolytic
thalassemia

72. RBC Inclusions Basophilic stippling
Caused by aggregated ribosomes in rbc
Seen in
Thalassemia
Lead intoxication /heavy metal

73. WBC abnormalities Toxic changes Toxic granules Dohle bodies
Dark blue cytoplasmic inclusions
Seen in neutrophils
Seen in : infection, burns, MDS, pregnancy
Vacuolations

74. Toxic granules

75. DOHLE BODIES remnants of free ribosomes of RER
Single or multiple, blue, grayish-blue, or greenish inclusions.

76. Vacuolization

77. QUIZ SHOW

78. What is most likely diagnosis ?
10 year old with Hb 80, WBC 9 plt 350. On co-tri for repeated UTI. MCV MCH Retic ct
What is most likely diagnosis ?
Fe deficiency
Megaloblastic anemia
Diamond Blackfan Anemia
Hemolytic anemia

79. Answer B
MEGALOBLASTIC
ANEMIA
(Prob 2 folate def)

80. The ff is a cause of thrombocytosis
A. Immune thrombocytopenic purpura
B. Pregnancy
C. Iron deficiency anemia
D. Renal failure

81. Iron deficiency anemia
ANSWER C
Iron deficiency anemia

82. Compute absolute retic count
Hb 45 RBC 1.5 x 1012 / L
Retic count: 0.016

83. ANSWER
24,000 / uL

84. 4/4 Quiz show Which presents as a microcytic anemia B-thalassemia
Hemolytic Anemia
Aplastic Anemia
Anemia 2 blood loss

85. ANSWER A
B- Thalassemia

86. Which is the pbs of px with vit B12 deficiency?

87. Answer 7

88. Which is pbs of px with iron deficiency?1 2

89. Answer 1

90. The End