1. CBC interpretation

2. Do you know : How to evaluate anemia using MCV, RDW and RETIC count
How to assess 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 Formula (2-10 yrs old)
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

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

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

6. answer
LL: 77 fL
UL: 88.2 fL

8. 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

9. 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

10. Reticulocyte index 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 = 4.5% x .15/.45 = 1.5 % ( N = %)

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

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

13. Answer
45,000 retics / uL

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

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

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

18. 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

19. Inc MCV, Dec Retic 2. Megaloblastic disorders 3. Alcohol
Folate and Vit B 12 deficiency
Other things seen :
Hypersegmentation of PMN’s
Macroovalocytosis
Megaloblastic changes in BM
3. Alcohol
direct toxic effect on BM

20. 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

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

23. Decreased MCV Increased retic Normal /decreased retic Thalassemia
Fe deficiency
Anemia of Chronic Disease
Thalassemia trait
Sideroblastic anemia
hardest differentials !

24. Iron deficiency RDW serum Fe  MCV  anemia
Common cause in 1-3 years of age
As iron stores become depleted:
RDW serum Fe  MCV  anemia
First manifestation : RDW

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

26. 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

27. RDW HIGH ( FGHI- C ) Iron deficiency Hb H disease Fragmentation G-6PD
Chronic disease

28. Decreased MCV Increased retic Normal /decreased retic
Thalassemia
Normal /decreased retic
Fe deficiency
Anemia of Chronic Disease
Thalassemia trait
Sideroblastic anemia
hardest differentials !

29. 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

30. MCV NORMAL

31. MCV NORMAL

32. MCV NORMAL

33. Renal Disease Cause: erythropoeitin insufficiency
Serum inhibitors of erythropoeisis accumulate in uremic patients
Acanthocytosis
Shortened rbc life span
When BUN > 150 mg/dL

34. 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

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

36. THROMBOCYTOSIS Hemolytic anemia Post-splenectomy Hemorrhage Post-op
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 !

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

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

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

40. Spherocytes / acanthocytes

41. schistocytes

42. Abn RBC shapes Target cells Hypochrom ovalocyte Elliptocyte
Liver disease
Thalassemia
Iron deficiency
Post-splenectomy
Elliptocyte
Elliptocytosis
Megaloblastic anemia
Myelofibrosis
Normochrom ovalocyte
Ovalocytosis
Thalassemia
Hypochrom ovalocyte
Iron deficiency
Macrocytic ovalocyte
Megaloblastic anemia

43. Target cells/ elliptocytes

44. Abn RBC shapes Blister cell Tailed RBC Tear drop Schistocytes
Microangiopathic hemolytic anemia
Tailed RBC
Megaloblastic anemias
Iron deficiency
Tear drop
Hypersplenism
Thalassemia
Hemolytic Anemia
Schistocytes
hemolytic anemia
Hypersplenism
Megaloblastic anemia
Thalassemia
Acute Leukemia
Post severe burns

45. 1/4 point quiz show
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

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

47. 2/4 Quiz show
The ff is a cause of thrombocytosis A. Immune thrombocytopenic purpura B. Pregnancy C. Iron deficiency anemia D. Renal failure

48. Iron deficiency anemia
ANSWER C
Iron deficiency anemia

49. ¾ QUIZ show Compute absolute retic count Hb 45 RBC 1.5 x 1012 / L

50. ANSWER
24,000 / uL

51. 4/4 Quiz show Which presents as a microcytic anemia B-thalassemia
Hemolytic Anemia
Aplastic Anemia
Anemia 2 blood loss

52. ANSWER A
B- Thalassemia

53. The End