1. Complete Blood Count
(CBC)

2. Complete Blood Count (CBC)
Panel of tests that examine different components of the blood.
CBC values
RBC count
Hemoglobin
Hematocrit
RBC indices
WBC count and differential
Platelet count

3. White Blood Count (WBC): actual number of white blood cells per volume of blood.
WBC differential: types of WBC present.
Red Blood Cells (RBC): actual number of red blood cells per volume of blood
Hemoglobin (Hb): amount of the oxygen carrying protein in the blood
Platelets (PLT): actual number of platelets per volume of blood

4. Mean Corpuscular Volume (MCV ): a measurement of the average size of RBCs
Mean Corpuscular Hemoglobin (MCH ): the average amount of oxygen-carrying hemoglobin inside a RBC
Mean Corpuscular Hemoglobin Concentration (MCHC): the average concentration of hemoglobin inside a RBC
Red Cell Distribution Width (RDW): a variation in the size of RBCs

5. The significance of CBC
Find the cause of symptoms such as fatigue, weakness, fever, bruising, or weight loss
Diagnosis of anemia
Estimation of blood loss
Diagnosis of polycythemia
Find an infection
Diagnosis of blood diseases as leukemia
Response to drug or radiation treatment
Screening before surgery
Abnormal count of certain types of cells

6. Principle
The counting of the cellular elements of the blood (erythrocytes, leukocytes, and platelets) is based on the classic method of electrical impedance.
Electrical resistant principle, which depend on the fact that blood cells are non conductive to electricity, so when they pass through electrical field they will increase the electrical resistance.
The counting chamber consists of a beaker, two electrodes with a direct current, an orifice with specified dimension; when suspended cells passes through the aperture it will increase the electrical impedance between the two electrodes, manifested as a pulse (sum of pulse= count). The pulse height indicate cell volume.

7. Performance
The aspirated whole blood specimen is divided into two aliquots and mixed with an isotonic diluent.
The first dilution is delivered to the RBC aperture bath, and the second is delivered to the WBC aperture bath.
In the RBC chamber, both the RBCs and the platelets are counted and discriminated by electrical impedance
Particles between 2 and 20 fL are counted as platelets, and those greater than 36 fL are counted as RBCs.
Red cell histograms: histograms are derived by plotting the size of each red cell on x axis and the relative number on the y axis.
They are used to determine the average size, distribution of size, and to detect sub populations.

8. Histograms

9. Hb measurement
A reagent to lyse RBCs and release hemoglobin is added to the WBC dilution before the WBCs are counted by impedance After the counting cycles are complete, the WBC dilution is passed to the hemoglobinometer for hemoglobin determination (light transmittance read at a wavelength of 535 nm).
Hemoglobin, on most automated systems, is measured as cyanmethemoglobin.
Red cells are lysed and potassium ferricyanide oxidizes hemoglobin to methemoglobin, which combines with potassium cyanide forming cyanmethemoglobin.
The brown color is measured spectrophotometrically and the corresponding hemoglobin reported.
Normal rang
Males g/dl
Females g/dl

10. Normal blood contains about 15-16 grams hemoglobin per 100 ml (dL).
Each gram of hemoglobin can carry about 1.35 ml of gaseous oxygen.
Fully saturated arterial blood will therefore contain about 20 ml of oxygen per 100 cc.
The relative amount of oxygen in the blood compared to the carrying capacity of the hemoglobin is called the oxygen saturation, and is expressed as a percentage.

12. Hematocrit
Hematocrit is the volume of the red cells as compared to the volume of the whole blood sample.
Hematocrits on the automated systems are calculated.
Calculated: (MCV)×(RBC) = Hct
Usually expressed in percentage (42%)
Males %
Females 37-47% (pregnant>33%)

13. Provides information on the amount of red blood cells (RBC) present in the blood.
Decreased levels means anemia from hemorrhage, parasites, nutritional deficiencies or chronic disease process, such as liver disease, cancer, etc.
Increased levels are often seen in dehydration or polycythemia

14. Red Blood Cell Count (RBC)
Normal value = 4.6 to 6.2 x 106 cells/L
Decreased with anemia
Increased with erythrocytotic states such as polycythemia vera, erythrocytosis of chronic hypoxia, dehydration, stress polycythemia, and thalassemia minor.

15. MCV Mean cell volume MCV is average size of RBC MCV = Hct x 10
RBC (millions)
If fL, normal range, RBCs considered Normocytic
If < 80 fL are Microcytic
If > 100 fL are Macrocytic
Not reliable when have marked anisocytosis

16. MCH MCH is average weight of hemoglobin per RBC. MCH = Hgb x 10
RBC (millions)

17. MCHC MCHC is average hemoglobin concentration per RBC MCHC = Hgb x 100
Hct (%)
If MCHC is normal, cell described as Normochromic
If MCHC is less than normal, cell described as Hypochromic
There are no Hyperchromic RBCs

18. RDW An index of RBC size variation
May be used to quantitate the amount of anisocytosis on peripheral blood smear
Normal range is 11.5% to 14.5% for both men and women.
MPV: The MPV is a measure of the average volume of platelets in a sample and is analogous to the erythrocytic MCV.
Pct : analogues to HCT for RBCs

19. Use of RBC indices in differential diagnosis can provide picture of what is occurring clinically.
If anemia caused be bone marrow failure, requires information about RBC production. Information obtained from reticulocyte count. Reticulocyte count measures effective RBC production.
As study different anemias, will learn morphology.

20. Red Cells Histogram
Noramal red cell histogrem dispays cells form ( ) fl
( fl ) flag may be due 1- RBCs fragments 2- WBCs fragments 3- Giant plts 4- Microcyte

21. Shift to right : - Leukemia - Macrocytic anemia - Megaloblastic anemia
Shift to left : - Microcyic anemia (IDA)
Bimodal - Cold agglutinin - IDA, megaloblastic anemia with transfusion. -Saidroblastic anemia.
Trimodal Anemia with transfusion

22. Platelet Count Normal Range = 150 to 450 x 103 cells/L Thrombocytosis
inflammatory disorders
myeloproliferative states
acute blood loss
hemolytic anemias
carcinomatosis
status post-splenectomy
exercise etc.

23. Thrombocytopenia
Production defects such as aplastic anemia, marrow replacement, megaloblastic and severe iron deficiency anemias, uremia etc.
Consumption defects with autoimmune thrombocytopenias, DIC, hypersplenism, massive hemorrhage and many severe infections.

24. Plts histogram Normal Rang (2-20 fl) (0-2) 1- Air Babbles 2- Dust
Over 20 fl 1- Microcyte 2- Scishtocyte 3- WBCs fragments
4- Giant Plts 5- Clumped plts

33. Reticulocytes
Useful in determining response and potential of bone marrow.
Reticulocytes are non-nucleated RBCs that still contain RNA.
Visualized by staining with supravital dyes, including new methylene blue; RNA is precipitated as dye-protein complex.
Normal range is % of all erythrocytes.
If bone marrow responding to anemia, should see increases in Retic count.
Newborns have higher Retic count than adults until second or third week of life.

34. Reticulocytes

43. Sickle cells (Dreprnocytes)

49. A variation in erythrocyte distribution such as rouleaux formation or agglutination

50. White Blood Cell Count (WBC)
The white blood cell differential count determines the number of each type of white blood cell, present in the blood. 
It can be expressed as a percentage (relative numbers of each type of WBC in relationship to the total WBC) or as an absolute value (percentage x total WBC). Of these, the absolute value is much more important than the relative value.
There are five basic white blood cell types:
Neutrophils
Eosinophils
Basophils
Lymphocytes
Monocytes
Each WBC cell type has its' own unique features.

53. Neutrophils Polymorphonuclear Neutrophils
These are the most common of the WBCs and serve as the primary defense against infection. The typical response to infection or serious injury is an increased production of neutrophils.

54. Bands/Stabs
Early in the response to infection, immature forms of neutrophils will be seen. These are call Stab or Band cells.
The presence of these immature cells is called a "shift to the left" and can be the earliest sign of a WBC response, even before the WBC becomes elevated.

55. Eosinophils
These cells play a role in allergic disorders and in combating parasitic infections.
Elevations in eosinophil counts are associated with:
Allergic reactions
Parasite infections
Chronic skin infections
Some cancers
Decreases in eosinophil
counts are associated with:
Stress
Steroid exposure
Anything that may suppress WBC production generally

56. Basophils
These cells can digest bacteria and other foreign bodies (phagocytosis) and also have some role in allergic reactions.
Elevations in basophil counts are associated with:
Some cancers
Some allergic reactions
Some infections
Radiation exposure
Diminished basophil
counts are associated with:
Stress reactions
Hyperthyroidism
Prolonged steroid expo

57. Monocytes
These cells respond to inflammation, infection and foreign bodies by ingesting and digesting the foreign material.
Increased monocyte counts are associated with:
Recovery from an acute infection
Viral illness
Parasitic infections
Collagen disease
Some cancers
Decreased monocyte
counts are associated with:
HIV infection
Rheumatoid arthritis
Steroid exposure

58. Lymphocytes
These cells play both an immediate and delayed role in response to infection or inflammation.
Increased numbers of lymphocytes are seen in:
Most viral infections
Some bacterial infections
Some cancers
Graves' disease
Decreased numbers of
lymphocytes are seen in:
Steroid exposure
Immunodeficiency
Renal failure
Lupus

59. White Blood Cell Count (WBC)
The lysing reagent also cause WBCs membrane collapse aruond the nucleus , so the counter actually measuring the nuclear size.
Cells lies between
(35-90 fl) are considered lymphocyte.
( fl) are considered MID cells
( fl) are neutrophile.

60. Anemia

61. Definition of Anemia
Inability of blood to supply tissues with adequate oxygen for proper metabolic function.
Usually associated with decreased levels of hemoglobin or hematocrit (packed red cell volume)
Usually associated with decreased RBCs.
Diagnosis made by patient history, physical examination, signs and symptoms, and hematological laboratory findings.
Classified as moderate (Hb 7-10 g/dl) or severe (Hb <7g/dl).
Two general forms of anemia:   Absolute Anemia (decrease in red cell mass) and Relative Anemia (increased plasma volume gives appearance of anemia).

62. RBC and Hemoglobin Production
In healthy individuals, about 1% of RBCs lost daily.
Bone marrow continuously produces RBCs to equal daily loss.
Reticulocyte count is a lab measurement of this loss.
Normal Retic count is % of circulating RBCs.
Replacement requires functioning bone marrow, normal RBC maturation and ability to release mature RBCs to peripheral blood.
Proper nutrition required (B12, Folate).  Also requires normal hemoglobin synthesis.

63. Erythropoietin levels (Epo) useful diagnostic tool.
Erythropoietin is a hormone produced in the kidney.
Levels of erythropoietin varies with oxygen tension in kidney tissues (↓ Oxygen -↑ Epo, and vice versa).
Anemic people usually respond by increasing erythropoietin levels.
Clinical Diagnosis
Made by combination of factors including: patient history, physical signs and changes in hematologic profile (CBC).
Signs and symptoms usually non-specific: fatigue, weakness, shortness of breath - especially after exertion.

64. Functional classification of Anemias
Decreased RBC production (hypoproliferative)
Defective hemoglobin synthesis
Fe deficiency
B12 deficiency
Folate deficiency
Impaired bone marrow or stem cell function, as in leukemia
Increased RBC destruction, as in sickle cell anemia or hemolytic anemia
Combination of the two (sometimes called “ineffective erythropoiesis”)

65. Decreased MCV and Decreased MCHC
Microcytic/ Hypochromic Anemia
Iron deficiency
Thalassemia
Anemia of chronic disease
Sideroblastic anemia
Lead poisoning
Increased MCV, Decreased MCHC
Macrocytic/ Normochromic Anemia
Folate deficiency
B12 deficiency
Hypothyroidism

66. Iron Deficiency Anemia
Iron metabolism
Absorption in duodenum
Transferrin transports iron to the cells.
Ferritin and hemosydrin store iron.
10% of daily iron is absorbed
Most body iron is present in hemoglobin in circulating red cells
The macrophages of the reticuloendotelial system store iron released from hemoglobin as ferritin and hemosiderin
Small loss of iron each day in urine, faeces, skin and nails and in menstruating females as blood (1-2 mg daily)

68. Thalassemias

69. Introduction
Heritable, hypochromic anemias-varying degrees of severity
Genetic defects result in decreased or absent production of mRNA and globin chain synthesis
At least 100 distinct mutations
High incidence in Asia, Africa, Mideast.

70. Globin Chains Alpha Globin 141 amino acids Coded for on Chromosome 16
Found in normal adult hemoglobin, A1 and A2
Beta Globin
146 amino acids
Coded for on Chromosome 11, found in Hgb A1
Delta Globin
Found in Hemoglobin A2--small amounts in all adults
Gamma Globin
Found in Fetal Hemoglobin
Zeta Globin
Found in embryonic hemoglobin

71. Hemoglobin Types Globin Chains Hemoglobin Type a2b2
a2d2
a2g2 b4 g4
a2b26 gluval
a2b26 glulys
Hemoglobin Type
Hgb A1—92%
Hgb A2—2.5%
Hgb F — <1%
Hgb H
Bart’s Hgb
Hgb S
Hgb C

72. Alpha Thalassemias Result from gene deletions
One deletion: Silent carrier; no clinical significance
Two deletions: a Thal trait; mild hypochromic microcytic anemia
Three deletions: Hgb H; variable severity, but less severe than Beta Thal Major
Four deletions: Bart’s Hgb;
Usually no treatment indicated
4 deletions incompatible with life
3 or fewer deletions have only mild anemia

73. Beta Thalassemias Result from Point Mutations on genes
b0-no b-globin synthesis;
b+ reduced synthesis
Disease results in an overproduction of a-globin chains, which precipitate in the cells and cause splenic sequestration of RBCs
Erythropoiesis increases, sometimes becomes extramedullary