FLAGS AND TROUBLESHOOTS

3 PART DIFFERENTIAL CELL COUNTERS

DR. PRASAD P. SHENOY
CENTRAL CLINICAL LABORATORY PANAJI GOA
drpshenoy@gmail.com

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 PART DIFFERENTIAL CELL COUNTER

HYDRODYNAMIC FOCUSSING ELECTRICAL IMPEDENCE VOLUMETRIC METERING COLORIMETRY (Hb)

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

3 PART DIFFERENTIAL CELL COUNTER

DIRECTLY MEASURED PARAMETERS AND HISTOGRAMS HEMOGLOBIN CONCENTRATION WBC COUNT

RBC COUNT
PLATELET COUNT WBC HISTOGRAM RBC HISTOGRAM PLATELET HISTOGRAM

3 PART DIFFERENTIAL CELL COUNTER

PARAMETERS DERIVED FROM HISTOGRAMS

LYMPHOCYTE PERCENTAGE
MID-SIZE CELL PERCENTAGE GRANULOCYTE PERCENTAGE

MCV
RDW MPV PDW

3 PART DIFFERENTIAL CELL COUNTER

CALCULATED PARAMETERS LYMPHOCYTE # MID-SIZED CELL #

GRANULOCYTE #
HEMATOCRIT MCH MCHC PCT

3 PART DIFFERENTIAL CELL COUNTER

MANUAL DIFFERENTIAL COUNT REMAINS A DEFINITIVE TOOL FOR COMPLETE HEMATOLOGIC ANALYSIS
PERIPHERAL BLOOD SMEAR REVIEW IS

MANDATORY

FLAG

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

QUESTIONABLE RESULT

ANALYSER RELATED

SAMPLE RELATED

?
TROUBLESHOOTING

TROUBLESHOOTING
SYSTEMATIC APPROACH ISOLATE A SOURCE OF A PROBLEM AND FIX IT

THROUGH A PROCESS OF ELIMINATION

FIX THE MOST OBVIOUS / EASIEST PROBLEM FIRST

QUESTIONABLE RESULT

ANALYSER RELATED

SAMPLE RELATED

QC
QC ACCEPTABLE

QC IS OUT OF RANGE

SAMPLE RELATED

ANALYSER RELATED

ANALYSER RELATED ERRORS

ELECTRONIC (HARDWARE / SOFTWARE)

PRESSURE / HYDRAULIC REAGENT

3 PART DIFFERENTIAL CELL COUNTER

FLAGS ARE FEW

OPERATOR MUST BE ALERT

Hb: RBC: HCT: MCV:

15.6 5.19 45.9 88.6

g/dL x 106 / uL % fl pg g/dL %

MCH: 30.1 MCHC: 33.3 RDW: 12.9

RULE OF 3

NORMOCYTIC NORMOCHROMIC

WBC :

7.0

x 103 / uL x 103/uL x 103/uL x 103/uL

Lymph#: 1.8 Mid# : 0.3 4.9

Gran# :

Lymph%: 25.9 % Mid% : Gran%: PLT MPV : : 4.3 %

69.8 % 267 9.5 x 103 / uL fL

PDW :
PCT :

14.2
0.183 %

INTERFERENCES
RBC FRAGMENTS, VERY SMALL RBCs NUCLEATED RBCs, LYSE RESISTANT RBCs COLD AGGLUTININS HIGH LEUKOCYTE COUNTS (>50 x 103/uL)

GIANT PLATELETS, PLATELETS CLUMPS

LIPEMIC SAMPLE CRYOGLOBULINS CLOTTED SAMPLE AIR BUBBLES

CASE: 1

20 years / Female
Breathlessness, easy fatiguability

Lack of concentration, giddiness

Hb:

L 4.2

g/dL x 106 / uL %

RBC: L 3.09 HCT: L 15.3

MCV: L 55.0
MCH: L 13.5 MCHC: L 24.8

fl
pg g/dL

RDW: H 24.5

MICROCYTIC HYPOCHROMIC ANEMIA IDA THALASSEMIA ANEMIA OF CHRONIC DISORDERS

WBC: 5.5 PLT: H 561

x 103 / uL x 103 /ul

MENTZERS INDEX (M. I.)

M. I . = MCV / RBC
If M. I. > 13: IDA

If M. I. < 13: Thalassemia

M. I. = 55/3.09 = 17.8

Suggestive of Iron deficiency Anemia Adv: Sr. Iron, TIBC, Ferritin

Iron: TIBC: 12.30 563 37 - 145 ug/dL 215 - 535 ug/dL 13 - 45 % 13 - 150 ng/mL

% Transferrin: 3.23 Ferritin : 1.80

CASE: 2
23 years / Female
Pregnant, 12 weeks

Total Bil : 1.1 mg/dL

Conjugated Bil: 0.3 mg/dL

Transaminases: Normal

Hb: RBC: HCT:

L 10.1 4.89 L 31.9

g/dL x 106 / uL %

MCV: L 65.0
MCH: L 22.8 MCHC: L 30.5

fl
pg g/dL

RDW: H 17.2

WBC: PLT:

7.5 418

x 103 / uL x 103 /ul

M. I. = 65/4.89 = 13.29

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

Iron:

21.40

37 - 145 ug/dL

TIBC:

405.10

215 - 535 ug/dL

13 - 45 % 13 - 150 ng/ml

% Transferrin: 5.28 Ferritin : 8.19

Hemoglobin Electrophoresis
HbA HbF HbA2 = 93.7 = 0.9 = 4.8 94.3 98.5 0.2 2.0 1.5 3.5

Thalassemia trait with Iron deficiency

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

Hb:

L 7.1

g/dL x 106 / uL %

RBC: L 1.80 HCT: L 21.5

MCV: H 119.9
MCH: H 39.4 MCHC: 34.0

fl
pg g/dL

RDW: H 20.6

WBC: PLT:

3.8 127

x 103 / uL x 103 /ul

MACROCYTIC ANEMIA

MACROCYTIC ANEMIA, FAVOUR MEGALOBLASTIC

Adv: Sr. Vitamin B-12 and Folic acid

Vitamin B-12 113.23 211 946 pg/ml

FOLIC ACID

1.12

>5.38 ng/ml

MEGALOBLASTIC ANEMIA

THERAPEUTIC TRIAL RETICULOCYTE RESPONSE

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

MACROCYTIC ANEMIA Adv: Sr. Vitamin B-12 and Folic acid

Vitamin B-12

874.89

211 946 pg/ml

FOLIC ACID

27.46

>5.38 ng/ml

MACROCYTIC ANEMIA WITH FEATURES OF DYSPLASTIC HEMATOPOIESIS

BONE MARROW & CYTOGENETIC STUDIES

CASE: 4
63 years / Male

Hb:

L 9.0

g/dL x 106 / uL %

RBC: L 3.86 HCT: L 27.9

M. I. = 72.3 / 3.86 = 18.73

MCV: L 72.3
MCH: L 23.3 MCHC: 32.2

fl
pg g/dL

RDW: H 29.2

WBC: PLT:

8.3 258

x 103 / uL x 103 /ul

DUAL PEAK

POST BLOOD TRANSFUSION

CASE: 5
53 years / Female

? FEVER

Hb: PLT:

L 9.4 H 689

g/dL x 103/uL

WBC: H 310.6
Lymph#: H 31.4 Mid# : H 43.8

x 103 / uL
x 103/uL x 103/uL

Gran# : H 235.6 x 103/uL

Lymph%: L 10.1 Mid% : 14.1 % %

Gran%:

H 75.8

Features compatible with a Myeloproliferative neoplasm:

CHRONIC MYELOID LEUKEMIA IN CHRONIC PHASE Adv: Molecular / Cytogenetic studies for Philadelphia chromosome

Hb:

L 9.4

g/dL

RBC: L 1.77
HCT: MCV: L 16.6 94.1

x 106 / uL
% fl

MCH: H 53.1
MCHC:H 56.6 RDW: H 22.3 PLT: H 689

pg
g/dL % x 103/uL

HEMOGLOBIN PERFORMED BY MANUAL (CYANMETH) METHOD 8.3 g/dL 7.1 g/dL (after centrifugation)

CASE: 6
63 years / Female

Operated case of Ca-Ovary, on Chemotherapy, for follow up

Hb: RBC: HCT:

12.4 4.57 35.9

g/dL x 106 / uL %

WBC :
PLT MPV

6.7

x 103 / uL
x 103 / uL fL

: L 56 : H 14.5

PDW : H 19

SPURIOUS THROMBOCYTOPENIA

Giant Platelets Platelet clumps EDTA induced platelet clumping

Acknowledgement
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