1. CENTRAL CLINICAL LABORATORY
FLAGS AND TROUBLESHOOTS
– 3 PART DIFFERENTIAL CELL COUNTERS
DR. PRASAD P. SHENOY
CENTRAL CLINICAL LABORATORY
PANAJI – GOA

2. COMMON INSTRUMENT IN A HEMATOLOGY LABORATORY
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)

3. 3 PART DIFFERENTIAL CELL COUNTER
HYDRODYNAMIC FOCUSSING
ELECTRICAL IMPEDENCE
VOLUMETRIC METERING
COLORIMETRY (Hb)

4. PARTICLE 2 – 20 fl: PLATELET
3 PART DIFFERENTIAL CELL COUNTER
RBC AND PLATELET COUNTED IN ONE CHAMBER
PARTICLE > 35 fl: RBC
PARTICLE 2 – 20 fl: PLATELET
HEMOGLOBIN AND WBC COUNT IN SECOND CHAMBER

5. 3 PART DIFFERENTIAL CELL COUNTER
DIRECTLY MEASURED PARAMETERS AND HISTOGRAMS
HEMOGLOBIN CONCENTRATION
WBC COUNT
RBC COUNT
PLATELET COUNT
WBC HISTOGRAM
RBC HISTOGRAM
PLATELET HISTOGRAM

6. PARAMETERS DERIVED FROM HISTOGRAMS
3 PART DIFFERENTIAL CELL COUNTER
PARAMETERS DERIVED FROM HISTOGRAMS
LYMPHOCYTE PERCENTAGE
MID-SIZE CELL PERCENTAGE
GRANULOCYTE PERCENTAGE
MCV
RDW
MPV
PDW

7. CALCULATED PARAMETERS
3 PART DIFFERENTIAL CELL COUNTER
CALCULATED PARAMETERS
LYMPHOCYTE #
MID-SIZED CELL #
GRANULOCYTE #
HEMATOCRIT
MCH
MCHC
PCT

8. 3 PART DIFFERENTIAL CELL COUNTER
MANUAL DIFFERENTIAL COUNT REMAINS A DEFINITIVE TOOL FOR COMPLETE HEMATOLOGIC ANALYSIS
PERIPHERAL BLOOD SMEAR REVIEW IS
MANDATORY

9. FLAG SIGNAL TO THE OPERATOR
INDICATES A SIGNIFICANT ABNORMALITY IN THE ANALYSED SAMPLE / ANALYSER ITSELF

10. QUESTIONABLE RESULT
SAMPLE RELATED
ANALYSER RELATED ?
TROUBLESHOOTING

11. TROUBLESHOOTING SYSTEMATIC APPROACH
ISOLATE A SOURCE OF A PROBLEM AND FIX IT
THROUGH A PROCESS OF ELIMINATION
FIX THE MOST OBVIOUS / EASIEST PROBLEM FIRST

12. QC QUESTIONABLE RESULT ANALYSER RELATED SAMPLE RELATED SAMPLE RELATED
QC IS
OUT OF RANGE
ANALYSER RELATED
QC ACCEPTABLE
SAMPLE RELATED

13. ANALYSER RELATED ERRORS
ELECTRONIC (HARDWARE / SOFTWARE)
PRESSURE / HYDRAULIC
REAGENT

14. 3 PART DIFFERENTIAL CELL COUNTER
FLAGS ARE FEW
OPERATOR MUST BE ALERT

15. NORMOCYTIC NORMOCHROMIC
Hb: g/dL
RBC: x 106 / uL
HCT: %
MCV: fl
MCH: pg
MCHC: g/dL
RDW: %
RULE OF 3
NORMOCYTIC NORMOCHROMIC

16. WBC : x 103 / uL
Lymph#: x 103/uL
Mid# : x 103/uL
Gran# : x 103/uL
Lymph%: %
Mid% : %
Gran%: %
PLT : x 103 / uL
MPV : fL
PDW :
PCT : %

17. 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

18. CASE: 1 20 years / Female Breathlessness, easy fatiguability
Lack of concentration, giddiness

19. MICROCYTIC HYPOCHROMIC ANEMIA
Hb: L g/dL
RBC: L x 106 / uL
HCT: L %
MCV: L fl
MCH: L pg
MCHC: L g/dL
RDW: H %
WBC: x 103 / uL
PLT: H x 103 /ul
MICROCYTIC HYPOCHROMIC ANEMIA
IDA
THALASSEMIA
ANEMIA OF CHRONIC DISORDERS

21. If M. I. < 13: Thalassemia
MENTZER’S INDEX (M. I.)
M. I . = MCV / RBC
If M. I. > 13: IDA
If M. I. < 13: Thalassemia

22. Suggestive of Iron deficiency Anemia Adv: Sr. Iron, TIBC, Ferritin
= 17.8
Suggestive of Iron deficiency Anemia
Adv: Sr. Iron, TIBC, Ferritin
Iron: ug/dL
TIBC: ug/dL
% Transferrin: %
Ferritin : ng/mL

24. Transaminases: Normal
CASE: 2
23 years / Female
Pregnant, 12 weeks
Total Bil : 1.1 mg/dL
Conjugated Bil: 0.3 mg/dL
Transaminases: Normal

25. Hb: L g/dL
RBC: x 106 / uL
HCT: L %
MCV: L fl
MCH: L pg
MCHC: L g/dL
RDW: H %
WBC: x 103 / uL
PLT: x 103 /ul

28. MICROCYTIC HYPOCHROMIC ANEMIA Adv: Sr. Iron, TIBC, Ferritin
= 13.29
MICROCYTIC HYPOCHROMIC ANEMIA
Adv: Sr. Iron, TIBC, Ferritin
Hemoglobin electrophoresis

29. β Thalassemia trait with Iron deficiency
Iron: ug/dL
TIBC: ug/dL
% Transferrin: %
Ferritin : ng/ml
Hemoglobin Electrophoresis HbA = – 98.5 HbF = – 2.0 HbA2 = – 3.5
β Thalassemia trait with Iron deficiency

31. CASE: 3
46 years / Female
Weakness, Paresthesia
No organomegaly

32. MACROCYTIC ANEMIA Hb: L 7.1 g/dL RBC: L 1.80 x 106 / uL HCT: L 21.5 %
MCV: H fl
MCH: H pg
MCHC: g/dL
RDW: H %
WBC: x 103 / uL
PLT: x 103 /ul
MACROCYTIC ANEMIA

37. MEGALOBLASTIC ANEMIA MACROCYTIC ANEMIA, FAVOUR MEGALOBLASTIC
Adv: Sr. Vitamin B-12 and Folic acid
Vitamin B – 946 pg/ml
FOLIC ACID >5.38 ng/ml
MEGALOBLASTIC ANEMIA

38. RETICULOCYTE RESPONSE
THERAPEUTIC TRIAL
RETICULOCYTE RESPONSE

40. MACROCYTIC ANEMIA Vitamin B 12 & Folic acid deficiency
Myelodysplastic syndromes
Hemolytic anemias
Myelophthisic anemias
Aplastic anemia
Chronic Liver diseases

41. Adv: Sr. Vitamin B-12 and Folic acid
MACROCYTIC ANEMIA
Adv: Sr. Vitamin B-12 and Folic acid
Vitamin B – 946 pg/ml
FOLIC ACID >5.38 ng/ml ?

46. MACROCYTIC ANEMIA WITH FEATURES OF DYSPLASTIC HEMATOPOIESIS
BONE MARROW
&
CYTOGENETIC STUDIES

47. CASE: 4
63 years / Male

48. M. I. = 72.3 / 3.86 = 18.73 DUAL PEAK Hb: L 9.0 g/dL
RBC: L x 106 / uL
HCT: L %
MCV: L fl
MCH: L pg
MCHC: g/dL
RDW: H %
WBC: x 103 / uL
PLT: x 103 /ul
M. I. = 72.3 / 3.86
= 18.73
DUAL PEAK

50. POST BLOOD TRANSFUSION

51. CASE: 5
53 years / Female
? FEVER

52. Hb: L g/dL
PLT: H x 103/uL
WBC: H x 103 / uL
Lymph#: H x 103/uL
Mid# : H x 103/uL
Gran# : H x 103/uL
Lymph%: L %
Mid% : %
Gran%: H %

55. Features compatible with a Myeloproliferative neoplasm: CHRONIC MYELOID LEUKEMIA IN CHRONIC PHASE Adv: Molecular / Cytogenetic studies for Philadelphia chromosome

56. HEMOGLOBIN PERFORMED BY MANUAL (CYANMETH) METHOD
Hb: L g/dL
RBC: L x 106 / uL
HCT: L %
MCV: fl
MCH: H pg
MCHC:H g/dL
RDW: H %
PLT: H x 103/uL
HEMOGLOBIN PERFORMED BY MANUAL (CYANMETH) METHOD
8.3 g/dL
7.1 g/dL (after centrifugation)

59. Operated case of Ca-Ovary, on Chemotherapy, for follow up
63 years / Female
Operated case of Ca-Ovary, on Chemotherapy, for follow up

60. Hb: g/dL
RBC: x 106 / uL
HCT: %
WBC : x 103 / uL
PLT : L x 103 / uL
MPV : H fL
PDW : H 19

62. SPURIOUS THROMBOCYTOPENIA EDTA induced platelet clumping
Giant Platelets
Platelet clumps
EDTA induced platelet clumping

63. Central Clinical Laboratory
Acknowledgement
thank you
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. Shenoy
Central Clinical Laboratory
Panjim – Goa