1. Evaluation of Peripheral blood
Huang Jinwen
Sir Run Run Shaw Hospital

2. Automated hematology instrumentation

3. WBC differential Advia 2120
Monocytes
Neutrophils
Neutrophils (pink) and eosinophils (yellow) containing the most perox activity are found to the right. Cells with little or no perox cluster to the left, such as lymphocytes/basophils (blue) and large unstained cells (blasts, variant and atypical lymphocytes, light blue). Monocytes (green) contain a small amount of perox and are located between the neutrophils and large unstained cells. Noise is indicated in the lower left hand corner (white).
cell size
Lymphocytes
eosinophils
peroxidase

4. Red cell size distribution curves in hereditary sideroblastic anemia
A broad population of red cells, varying markedly in size, with the majority of the cells being microcytic.
Presence of two populations of red cells

5. Comparison between automated optical and immunologic platelet counts
The majority of the data points well outside of the 95 percent confidence limits are above the best-fit line, suggesting that the optical method is more prone to overestimate platelet counts than the immunologic method in this range.

6. Optimal area for review
Suboptimal blood smear
Rouleaux in myeloma
Normal peripheral blood smear

7. Definition and mechanisms of leukocytosis and neutrophilia

8. WBC Count
The normal limit in adults: to (4.0 to 10.0) x109/L
Leukocytosis: NL + 2SD, or> 11.0 x109/L
Hyperleukocytosis or leukemoid reaction: > 50.0 x109/L
Neutrophilic leukocytosis: >11.0 x109/L, + ANC>7,700 x109/L
ANC = WBC x percent (PMNs + bands) ÷ 100

9. Neutrophilic leukocytosis
It commonly seen in
It can also occur in
Neutrophilia
Infection,
Stress,
Smoking,
Pregnancy,
Following exercise.
Chronic myeloproliferative disorders,
Chronic myeloid leukemia

10. Lymphocytic leukocytosis
WBC 11.0 X109/L, an absolute lymphocyte count > 4.8 X109/L .
Infectious mononucleosis and pertussis
Lymphoproliferative disorders, such as the acute and chronic lymphocytic leukemias

11. Monocytic leukocytosis
WBC> 11.0 x109/L, an absolute monocyte > 0.8 x109/L.
Acute and chronic monocytic variants of leukemia
Acute bacterial infection or tuberculosis
Monophilia.

12. Eosinophilic and basophilic leukocytosis
WBC>11.0 x109/L, an absolute eosinophil > 0.45 x109/L or basophil >0.2 x109/L
Eosinophilic leukocytosis can be seen in
Basophilic leukocytosis is a distinctly unusual condition,
Chronic leukemia,
Solid tumors,
Infection with parasites, Allergic reactions,
Following treatment with IL-2
Basophilic or Mast cell variants of acute or chronic leukemia

13. Regulation of neutrophil counts
PMN development

14. Detection of infection or inflammation
band count ≥20
cytoplasmic
vacuoles
left-shift
Dohle bodies,
Toxic granulation

15. The leukocyte alkaline phosphatase score
LAP is high in
LAP is low in
Infection
Inflammation
Polycythemia vera
Chronic myeloid leukemia
Paroxysmal nocturnal hemoglobinuria

16. Definitions of neutropenia
Mild neutropenia: ANC 1.0 ~1.5 X109/L
Moderate neutropenia: ANC ~1.0 X109/L
Severe neutropenia: ANC < 0.5 X109/L

17. Neutropenia and hospitalization for infection

18. Etiology of isolated neutropenia
Acquired neutropenias
Postinfectious neutropenia
Drug-induced neutropenia and agranulocytosis
Primary immune disorders
Hypersplenism
Bone marrow disorders
Congenital neutropenias
Myeloperoxidase deficiency

19. NIH grading of hematologic toxicity of chemotherapy

20. Fever in the neutropenic adult patient with cancer

21. Risk Factors of Fever ■ A rapid decline in ANC or ANC <0.1 X109/L
■ Prolonged duration of neutropenia (>7 to 10 days)
■ Leukemic induction
■ Cancer not under control
■ Comorbid illnesses requiring hospitalization
■ Use of central venous catheters
■ Disruption of mucosal barriers
■ Use of monoclonal antibodies

22. INFECTIONS IN FEBRILE NEUTROPENIA
■ A majority of patients had occult bacterial infections
■ An infectious source identified in ~ 30 %
■ Bacteremia documented ~25%
■ ~80% of identified infections arised from patients‘
own endogenous flora.

23. Symptoms and a physical examination daily

24. Laboratory studies
CBC with differential, transaminases, bilirubin, amylase and electrolytes, a chest radiograph, and cultures.
Two or more blood cultures, sputum Gram stain and culture, and urine Gram stain and culture.
Pulmonary infiltrates frequently can not produce sputum; a more invasive approach including bronchoscopy or open lung biopsy.
Lumbar puncture is not usually recommended.

25. Blood cultures One set /day for a stable fever pattern.
Two or three sets initially and to wait 48 to 72 hours to repeat blood cultures.

26. Chest radiographs minimal or absent even in patients with pneumonia.
■ Findings are often
minimal or absent
even in patients
with pneumonia.
■ Findings may
develop along
with an increase
in symptoms as
the neutropenia
begins to resolve.

27. Chest CT scanning CT should be ordered for the patients with pulmonary
symptoms.

28. Empiric antimicrobials
None clearly superior antibiotics.
Coverage targeted at Gram negative bacilli, especially P. aeruginosa.
Aminoglycosides and fluoroquinolones exhibit concentration-dependent killing
Beta-lactams exhibit time-dependent killing

29. Addition of vancomycin
Hypotension, mucositis, skin or catheter site infection, history of MRSA colonization, or recent quinolone prophylaxis.
Clinical deterioration or persistent fever despite empiric antibiotics.
Withdrawal of empiric vancomycin after 72 hours without improvement of events or culture negative.

30. Addition of antifungal drugs
■ Antifungal therapy is routinely added at
5 to 7 days
■ Undiagnosed fungal infection is present
in many patients.

31. Documented antimicrobial
Optimal coverage for this organism and should ideally be bactericidal.
Broad empiric coverage for the possibility of other pathogens.

32. " Stepdown" ■ Initially with parenteral therapy, then switched
to an oral regimen.
■ “Stepdown” used successfully by
experienced centers even in patients at
increased risk.

33. Scoring index for identification of low-risk febrile neutropenic patients at time of presentation with fever
Characteristic score
*Extent of illness
No symptoms
Mild symptoms
Moderate symptoms
*No hypotension
*No chronic obstructive pulmonary disease
*Solid tumor or no fungal infection
*No dehydration
*Outpatient at onset of fever
Age < 60 year
Highest theorhetical score is 26. A risk index score of ≥21 indicates that the patient is likely to be at low risk for complications and morbidity.

34. Colony stimulating factors
■ CSF reported to decrease the duration of
neutropenia, fever, and hospitalization.
■ CSF have not been shown to decrease mortality.
■ These agents should not be used routinely for
patients with fever and neutropenia.
■ It may be appropriate to consider their use in
critically ill patients.

35. THANKS