CBC Basics

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6/9/2010

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The complete blood count (CBC) includes the white blood cell (WBC)
count, red blood cell (RBC) count, hemoglobin, hematocrit, platelet
count, white blood cell differential, and red blood cell indices. The
reticulocyte count is also included because it is closely related to the
CBC. The WBC differential is the classification, either automated or
manually performed by a technologist, of the white blood cells. Both
the red blood cells and the white blood cells are also visually scanned
for abnormalities if the automated results indicate the need.

Cells are

also counted and identified in sources such as cerebrospinal fluid

(CSF), urine, and various other body fluids.

Hematopoiesis
It is helpful to understand the basics of cellular formation in the
human body in order to understand the value of the complete blood
count in diagnosing and monitoring disease states. There are three
types of cellular elements present in circulating blood: erythrocytes
(red blood cells, RBC), leukocytes (white blood cells, WBC), and
thrombocytes (platelets). In a healthy individual, the destruction and
production of each cell type is constant. Hematopoiesis is the term
which means production of blood cells
Cells go through various stages as they become mature and are
able to carry out their designated functions. Normally, only the
mature stages of the cells are found in the peripheral blood. In
disease states, immature and abnormal forms of the various cells may
be found. These immature and abnormal cells are noted by the
automated instrumentation in the laboratory, but the technologist
must make the final decision as to the type of cell present. The

technologist relies on his/her knowledge and experience to properly

identify the type of immature or abnormal cells found in a patients
blood. Slides of the patients blood are made, stained, and individually
studied microscopically. If the technologist questions the identification
of a cell, he/she refers the slide to the pathologist who makes the final
decision.
Before a baby is born, hematopoiesis takes place in the liver,
spleen, thymus, bone marrow, and lymph nodes. Only two weeks
after a baby is conceived, a type of red blood cell is formed in the yolk
sac. By the second month of gestational life, some leukocytes and
megakaryocytes (which form platelets) appear, and the liver and
spleen take over the function of producing cells. By the fifth month in
his/her mothers womb, the bone marrow has taken over the primary
role of hematopoesis.
Blood cells arise from hematopoietic stem cell in the bone
marrow. (These cells can repopulate the bone marrow after injury or
irradiation, which is the theory behind bone marrow transplants.)
These stem cells are thought to differentiate into red cells, various
white cell types, and platelets. These cells transform from the
primitive blast stage into the various stages of each type of cell in a
gradual manner; this often makes it difficult to absolutely state the
level of maturation of a cell seen on a blood smear. As a cell matures,
there are changes in the cytoplasm, nucleus, and cell size.
The CBC is often used in preoperative laboratory work because it
tells much about a patients health. The WBC count is one of the first
parameters affected when a persons health is not optimum. If a
patients WBC count is not normal, then the health care practitioner is
given a direction to take in administering medical advice and/or
medication.

The White Blood Cell Count

White blood cells, or leukocytes, are reported as the number of
cells per cubic millimeter (cumm) of whole blood, or as the number of
cells per microliter (ul) since a cumm is equal to a ul. A microliter is 1
x 10^(-6) liter. The normal WBC varies depending on the age of the
patient. The WBC is a good indicator of many disease states, and it is
often monitored during various therapies. It may be increased in
bacterial infections, pregnancy, and a variety of other conditions. It
may be decreased in other conditions such as hepatitis, cirrhosis of the
liver, rheumatoid arthritis, and lupus erythematosus. Leukemia may
cause the WBC to be either increased or decreased, depending on the
type and stage of the leukemia. In chemo and radiation therapy, the
WBC can drop drastically low as a result of the cells being killed. If the
WBC is too low, the patients immune system cannot work properly,
and the patient is at risk of serious infection.
The term leukocytosis refers to an increase of white blood cells
above normal, and the term leukopenia refers to a decrease of white
blood cells below normal. The WBC count responds to illness, but it
also fluctuates somewhat with exercise, stress, and anxiety. In
children, the WBC count may respond more quickly than in adults, and
their count may elevate rapidly with infection.

The Red Blood Cell Count

The red blood cells, or erythrocytes, are reported as the number
of cells per microliter of whole blood. The normal RBC varies
according to age and gender, and somewhat to physical exercise and

daily fluctuations. The RBC count is increased in a few disease states

and in conditions such as dehydration and increase in altitude. More
significantly, however, is the decrease in the RBC count due to
anemia, bleeding, and many other disorders.
As in the WBC count, care must be taken to send a good
specimen to the laboratory for analysis. Clots greatly affect the
accuracy of the RBC count, artificially decreasing the count which
indicates a disease state that the patient may not actually have. This
may mislead to the misdiagnosing the patient and subsequently
offering the wrong treatment to the patient.
The RBC count is also often used in preoperative laboratory work
because it can indicate if a patient is physiologically strong enough to
undergo surgery. An abnormal RBC count may indicate an underlying
cause of a symptom, or it may be the symptom of an underlying
cause.

Hemoglobin
Hemoglobin is the major parameter used in diagnosing and
monitoring anemia and polycythemia. It is reported as grams/deciliter
(dl) of whole blood. The normal hemoglobin value varies with age and
gender, and there is slight variation throughout the day, with exercise,
and with altitude.
The main function of the RBC is to synthesize hemoglobin.
Hemoglobin is used to carry oxygen to tissues and to bring carbon
dioxide from the tissues to the lungs. The hemoglobin molecule is
composed of four sub-units, each containing heme and the protein
globin. Every hemoglobin molecule is able to transport four moles of
oxygen. An atom of iron is located in the center of the structure and

binds to the oxygen. Iron is carried to the RBC by a blood plasma

protein called transferrin. Most of this iron is used in the synthesis of
heme.
There are three types of hemoglobin found in the normal adult
hemoglobin A, F, and A2.

Hemoglobin A makes up approximately 95-

98% of the total, while HgbF makes up approximately 2%, and A2, 23%. The type of polypeptide chains that make up the molecule
determines the type of hemoglobin. One heme group is attached to
each polypeptide chain, linked by the iron in the heme group. The
mature red blood cell consists mainly of hemoglobin. However, the
production of heme and globin occurs mainly in the immature red
blood cell.
Abnormal hemoglobin variants create symptoms that occur in
cases such as sickle cell anemia (HgbS) and hemolytic anemia (HgbC).

Hematocrit
The hematocrit is simply the percentage of red blood cells to
whole blood. When anticoagulated whole blood is centrifuged, the
erythrocytes, leukocytes, and platelets will be forced to the bottom of
the sample. The heaviest cells (the RBCs) will go farthest to the
bottom of the tube, followed by a thin layer of WBCs and finally the
platelets on top. The liquid portion on top is called plasma. The
volume of erythrocytes is also called the packed red cell volume (PCV),
and it is expressed as a percentage of the total whole blood volume.
The hematocrit can be measured by actual percentage after
centrifuging a small capillary tube of whole blood, or it can be
performed by automated methods.

Like the hemoglobin, the hematocrit is used to monitor anemic

conditions. It is decreased in anemia and increased in forms of
polycythemia. .

Reticulocyte Count
Reticulocyte count is a test used to determine how the bone
marrow is responding to the bodys need for RBCs. The reticulocyte is
the erythrocyte prior to becoming a mature RBC. The erythrocyte
passes through 6 stages of development, the first four stages normally
occurring only in the bone marrow: pronormoblast, basophilic
normoblast, polychromatophilic normoblast, orthochromic normoblast,
reticulocyte, and mature erythrocyte. Three to four mitotic divisions
occur between the pronormoblast and the polychromatophilic
normoblast, producing up to 16 erythrocytes from each
pronormoblast. About three days lapse between the pronormoblast
stage and the orthochromic normoblast stage. This latter stage still
contains the nucleus, though it is very condensed and incapable of
further mitosis. On about the fourth day from the pronormoblast
stage, the nucleus is extruded from the cell and a reticulocyte is
formed. Reticulocytes are slightly larger than mature erythrocytes.
They stay in the bone marrow for 2 3 more days and are then
released into the peripheral blood where they age for an additional day
before becoming mature red blood cells.
When a persons hemoglobin drops below normal, the oxygen
content of the blood drops and the oxygen tension in the kidneys is
reduced. This stimulates the kidneys to increase their production of
erythropoietin, a hormone that initiates production of red blood cells.
An increased number of red blood cells are then produced and the rate

of mitosis is increased, thus causing the maturation process in the

bone marrow to shorten, creating a shorter life span for the
reticulocyte in the bone marrow, which results in an increased
reticulocyte count.
The reticulocyte count thus reflects the amount of red blood cell
production taking place in the bone marrow. The normal life span of a
mature erythrocyte is 120 days, +/- 20 days, which means the bone
marrow replaces approximately 1% of the adult red blood cells daily.
The normal reticulocyte count is therefore 0.5 1.5 %. A decreased
reticulocyte count occurs in conditions in which the bone marrow is not
producing erythrocytes, such as aplastic anemia, iron deficiency
anemia, or cancer. Increased reticulocyte counts occur in hemolytic
anemias, iron deficient anemias involving iron therapy, thalassemia,
blood loss (acute and chronic), and other anemias and during
pregnancy. Newborns will have an increased reticulocyte count, but
drops within weeks after birth.

Red Blood Cell Indices

Red blood cell indices are calculated values used to help
determine the size and hemoglobin content of the red blood cells.
They can be helpful in diagnosing and differentiating anemias. The
indices are the MCV (mean corpuscular volume), MCH (mean
corpuscular hemoglobin), and MCHC (mean corpuscular hemoglobin
concentration).

MCV (mean corpuscular volume)

The MCV is calculated from the red blood cell count and the hematocrit
and measures the average size of RBC. It indicates the average
volume of the erythrocytes in femtoliters (fl = 10^-6 cubic mm). Cell
volume is considered to be microcytic (smaller than normal),
normocytic (normal), or macrocytic (larger than normal). It is
important to interpret the value for MCV along with an inspection of
the peripheral blood smear since the MCV is only a mean volume. It is
possible to have a wide variation in cell size and still have a normal
MCV. When RBC shape is abnormal, such as in sickle cell anemia, the
MCV is of doubtful value because the hematocrit is not reliable.

MCH (mean corpuscular hemoglobin)

The MCH is calculated from the hemoglobin and the red blood cell
count. It indicates the average weight of hemoglobin in the
erythrocyte in picograms (10^-12/g). It should always correlate with
the MCV and the MCHC. The MCH is directly proportional to the size of
the erythrocyte and the concentration of hemoglobin in the cell. Low
MCH values are found in microcytic anemia and in normocytic,
hypochromic red blood cells. High MCH values are found in macrocytic
anemia and may occur in spherocytosis.

MCHC (Mean corpuscular hemoglobin concentration)

The MCHC is calculated from the hemoblobin and hematocrit. It

indicates the average concentration of hemoglobin in the erythrocytes
in percentage. A low MCHC indicates hypochromia, seen in iron
deficiency anemia and thasselemia. A high MCHC indicates
hyperchromia, seen in burn patients. The MCHC should never be

above 38%. A result greater than 38% is usually due to incorrect

calculation or to abnormal agglutination of the patients red blood cells
(such as cold agglutinins) which causes a falsely decreased red blood
cell count. Conversely, the MCHC should never be below 22%. A
result less than 22% may be due to a lipemic specimen or to abnormal
hemoglobin (such as C or S) which causes an invalid hemoglobin
result.

Platelets
Platelets, or thrombocytes, originate from megakaryocytes
cytoplasm in the bone marrow. As the megakaryocyte matures, the
cytoplasm increases in amount and becomes more granular. The
granules form small clusters and the cytoplasm breaks into individual
platelets which are released into the peripheral circulation. One
megakaryocyte can produce between 2000 and 4000 platelets. As can
be seen by the formation of the platelets, they have no nucleus. When
there is damage to the endothelium, platelets form thrombi to
decrease the bleeding.
In the peripheral blood, the platelet lives 9 12 days.
Approximately 2/3 of the platelets are in the blood, while the
remaining 1/3 forms the platelet pool in the spleen. The platelets in
the spleen and blood are interchangeable.
The role of the platelet is for the purpose of hemostasis, or the
formation of blood clots to decrease bleeding. A decrease in platelets
indicates a high risk for bleeding. When the platelet count is increased,
there is a high risk for thrombosis, which can lead to a stroke, heart
attack, or pulmonary emboli.

Normal Values

(may very slightly according to laboratory method and/or source of

information)

White blood cell count:

Adult

4,500 10,000 cells/microliter

Newborn

9,500-35,000 cells/microliter

One year

6,000 17,000 cells/microliter.

The count continues to drop until it reaches adult levels by age 21.

Red blood cell count:

Adult females

4.2-5.4 x 10^6 cells/microliter

Adult males 4.7-6.1 x 10^6 cells/microliter

Newborn

4.0-5.9 x 10^6 cells/microliter

One year

3.7-4.9 x 10^6 cells/microliter

Children, adolescents, and adults over age 50 may have a slightly

lower RBC count.

Hemoglobin:
Adult females

14-18 grams/deciliter (g/dl)

Adult males 13 18 g/dl

Newborn

17-22 g/dl

One month 11-15 g/dl

One year

11 13 g/dl

Ten years

12 15 g/dl

Hematocrit:
Adult females

38-46%

Adult males 42-54%

Newborn

55-68%

One year

29-41%

After age 50 there may be a slight decrease in hematocrit.

MCV
Adults
Newborn

80 100 fl
95-115 fl

Two months

74-96 fl

One year

70-84 fl

Ten years

75 87 fl

MCH
Adults
Newborn

26-34 pg
31-37 pg

Two months
Ten years

25-35 pg

25 33 pg

MCHC
Adults
Newborn

31 37 %
31-37 %

Two months
Ten years

29-37 %

31-37 %

The Differential
The differential white blood cell count is performed to determine
the relative number of each type of white blood cell present in the
peripheral blood. They are ordered to determine the presence of a
specific infection, such as viral, bacterial, or parasitic, as well as

detection of allergic and drug reactions. Red and white blood cells and
platelets are examined for morphological changes.
Normal White Blood Cell Types

Neutrophils These are the largest number of cells in the
granulocytic series. They are the cell most commonly increased in
bacterial infections. The mature form of neutrophil is the
segmented neutrophil.

In normal blood there may be some of the

slightly immature form of neutrophil called the band neutrophil.

These bands are often increased when the neutrophil percentage
is high because the hematopoeitic organs release the cells more
rapidly than normal and these younger forms end up in the
peripheral circulation.

The main function of the neutrophil is to

ingest and kill invading organisms.

Eosinophil The eosinophil is also in the granulocytic series. They
are primarily tissue cells, and their half-life in blood is only about 8
hours. They usually localize in the skin, nasal membranes, lungs,
and gastrointestinal tract, and they may go back and forth from the
blood to the tissues. Eosinophils can phagocytize foreign material,
and they act as anti-inflammatory cells. They contain histaminase
which can inactivate the histamine from the mast (basophilic) cells.
They may be involved in defense against helminth parasites by
moving to the site of the parasitic infection. The cells then attach
to the surface of the parasites and release hydrolytic enzymes from
their granules. These enzymes damage the larval wall of the
parasites.

Basophils These cells are also part of the granulocytic series of
leukocytes. The basophil shows phagocytic activity. Its granules
contain serotonin, peroxidase, a vasoconstrictive histamine
compound, and heparin. They promote platelet aggregation and

adhesion. Basophils are involved in immediate hypersensitivity

reactions. If the contents of their granules are released rapidly to
the surrounding area, an anaphylactic shock reaction may occur
which may be severe, such as hyperimmune responses to toxins
and wasp or bee stings. This reaction can result in vasoconstriction
and bronchioconstriction.

Lymphocytes These cells are the next largest number of white
blood cells in the peripheral blood. Their absolute number is often
increased in viral infections. The lymphocytes are vital to the
immune system. Their main function is to produce circulating
antibodies. They also have an important role to play in cellular
immunity.

Monocytes Monocytes, after they have entered tissues, are called
macrophages. Both of these cells are attracted to dead or dying
cells, and they both appear at inflammatory sites. These cells are
also phagocytic, ingesting microorganisms and tumor cells. They
help remove old red blood cells and wound debris as well as plasma
proteins and plasma lipids, and they have a role to play in iron
metabolism. They also release lysosomal enzymes into the
surrounding areas to help decompose tissue and aid the
inflammatory response.

Cellular Morphology on the Differential

Leukocytes

Toxic granulation These are cytoplasmic granules in the
neutrophil that appear in infection, drug poisoning, and burns.

Dohle bodies Single or multiple areas in the cytoplasm of the
neutrophil are called Dohle bodies. They consist of rough

endoplasmic reticulum containing RNA, and they often appear in

infections, poisoning, burns, and after chemotherapy.

Hypersegmented neutrophils Neutrophils with 6 or more
segments in their nucleus represent an abnormality in the
maturation of the cell. Most neutrophils contain 2-4 lobes, with
some having 5 lobes. When there is an increase of the percentage
of 4-5 lobed neutrophils, it will be reported. This is often the case
in pernicious anemia, folic acid deficieny, and chronic infections.

Vacuolated neutrophil When the cytoplasm degenerates and
begins to acquire holes, or as the result of phagocytosis, the
neutrophils appear to be filled with vacuoles, or vacuolated.
These cells often appear in conjunction with septicemia and severe
infection.

Smudge cells These cells are the degenerating nuclei of ruptured
leukocytes.

Enlarged platelets Platelets that are 4 7 microns in diameter
are associated with either increased platelet counts
(thrombocytosis) or decreased platelet counts (thrombocytopenia).

Giant platelets Platelets that are 7-8 microns in diameter can be
seen in myeloproliferative disorders.

Nucleated red blood cells In a normal adult peripheral blood
smear there will be no nucleated red blood cells. When the RBCs
are released from the bone marrow prematurely, possibly as a
result of increased production of red cells due to a need such as
blood loss, they will still contain their nuclei. There may be
nucleated red blood cells in newborns and this may not be
considered abnormal, depending on the rest of the blood picture.


Microcytic red blood cells Erythrocytes that are smaller than

normal are found in some anemias, including iron deficiency and
hemolytic anemia.

Macrocytic red blood cells These erythrocytes are larger than
normal and may be seen in liver disease and some anemias, such
as vitamin B12 and folic acid deficiency.

Anisocytosis This describes a situation in which the red blood
cells are various sizes.

Polychromatophilia Polychromatic red blood cells are younger
and slightly larger than normal red cells.

Spherocytes These cells may be present in hemolytic anemia,
hemolytic disease of the newborn, and hereditary spherocytosis.

Target cells These red blood cells have the appearance of a
target. This is associated with abnormal hemoglobin, liver disease,
and sickle cell anemia.

Poikilocytosis This term refers to a variation in shape of the red
blood cells.

Ovalocytes These red blood cells are oval shaped and may be
present in a variety of anemias

Elliptocytes These red blood cells are similar to ovalocytes but
have a more elliptoid, or cigar-shaped, appearance. They may also
be present in various anemias.

Teardrop red blood cells As their name indicates, these cells are
shaped like teardrops, with a pointed end. They may be found in
pernicious anemia, thalassemia, and other anemias.

Crenated red blood cells These cells are also known as burr
cells and have small projections on their outer edges, somewhat
like a burr. Crenation is sometimes an artifact due to drying of the

blood smear on the slide, but the burr shape may indicate
abnormal conditions such as uremia or acute blood loss.

Schistocytes These are red blood cell fragments. They occur in
hemolytic anemia, uremia, severe burns, and other conditions.

Sickle cells Red blood cells shaped like a sickle or a crescent are
due to the hemoglobin S within the cells. They are associated with
sickle cell anemia, Hemoglobin SC disease, and a form of
thalassemia.

Basophilic stippling Basophilic stippling appears as purplestaining granules in the red blood cells. The granules are clumps
of ribosomes.

This is found in lead poisoning, alcoholism, and

some anemias.

Howell-Jolly bodies These are round nuclear fragments in the red
blood cells. They may appear in anemia and after splenectomy.

Rouleaux formation This is a situation in which erythrocytes are
arranged in stacks, similar to a roll of coins. It may be an artifact
caused by the handling of the blood, or it may be due to a high
concentration of abnormal globulins or fibrinogen. Rouleaux is
found in multiple myeloma and macroglobulinemia.

Agglutination This is clumping of the red blood cells. It is found
in patients who have a cold agglutinin or autoimmune hemolytic
anemia.

Cerebrospinal Fluid (CSF)

A few red blood cells are often found in CSF due to
contamination of the fluid by blood vessels during the lumbar
puncture. The CSF also normally contains a few lymphocytes and
monocytes (white blood cells), the origin of which is uncertain. If a
small number of neutrophils (white blood cells) are present, their

significance depends on the clinical situation and the results of other

laboratory tests.

Urine Microscopic Examination

Cells in urine vary greatly. Normal urine may contain a few
white blood cells, bacteria, or squamous epithelial cells. (The bacteria
are generally due to urethral contamination.) Red blood cells may be
present in normal urine from females during their menses. Abnormal
cells may include transitional or renal epithelial cells, bacteria (more
than a few), yeast, trichomonas parasite, and an increase in white
blood cells. Crystals may also be present. They may or may not be
significant, depending on the type of crystal identified.
Hematuria, or blood in urine, is also indicative of UTI,
inflammation, or injury to the urinary system. Also, hematuria is also
indicative of cancers of the bladder, kidney, and prostate.

Pleural and Pericardial Fluid

Total white blood cell and red blood cell counts are of limited
diagnostic value in
pleural and pericardial fluids. However, red blood cell counts higher
than 10,000 per microliter are suggestive of malignancy, trauma, or
pulmonary infarction. Mesothelial cells form the lining of pleural and
pericardial cavities. It is sometimes difficult to distinguish these cells
from malignant cells. During inflammatory processes, mesothelial cells
proliferate and often go into serous fluid.

Summary

After studying the content of this module, nurses should gain a

better understanding of the complete blood count. They should be
able to evaluate patient situations more quickly, and they should be
able to accurately interpret laboratory descriptions. The bottom line of
the medical profession is healing, and health care professionals cannot
give medical advice or medication without a thorough understanding of
the patients condition. Laboratory tests hold a key to diagnosis and
management of illness. The more information acquired from the
complete blood count and other fluid cell counts, the faster the
diagnosis and treatment. This, in turn, results in improved health care
for the patient.

References
1.

Brown, Barbara A. (1993), Hematology, Principles, and

Procedures, 40 82.
2.
Miale, John B. (1982), Laboratory Medicine Hematology, 350
357, 379 380.
3.
Tilzer, Lowell L. (1990), Laboratory Test Handbook, 475 478.
4.
Kjeldsberg, Carl; Knight, Joseph (1986), Body Fluids, 32-42.
5.
Sandhaus, Linda M. and Meyer, P. How useful are CBC and
Reticulocytes to Reports to Clinicians? American Journal of Clinical
Pathology; 2002: 1185(2)
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Nabili, S and Shiel, W.C., Complete Blood Count (CBC)
Accessed on 3/14/10 at
www.medicinenet.com/complete_blood_count/article.htm
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Dugdale, C. and Chen, YiBen., RBC Updated 3/2/2009.
Accessed 3/14/10 on
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Campbell, Niel. Biology (8th ed) 2008 London: Pearson Edu
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Complete Blood Count American Association for Clinical
Chemistry. 2001- 2010. Last reviewed 3/2/1008. Accessed on 3/14/10
at
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10. Blood in Urine WebMd 2010. accessed 3/17/10 at
www.emedicinehealth.com/blood_in_the_urine/article_em.html