Hematology

Hematology came from the Greek words (''haima'') meaning "blood" and (''logos''), a root
commonly employed to denote a field of study.
It is the branch of internal medicine, physiology, pathology, clinical laboratory work, and
pediatrics that is concerned with the study of blood, the blood-forming organs, and blood
diseases.

History
Laboratory hematology (LH) arose after the Dutch biologist Jan Swammerdam who discovered
erythrocytes (red blood cells, RBCs) in 1658, using a primitive microscope that had been
invented shortly before by his fellow countryman and colleague scientist Anthonie van
Leeuwenhoek.
After a number of significant achievements made, such as the construction of the
hemocytometer (counting chamber), improvement of microscopes, and Paul Ehrlich ’ s invention
of histochemical staining of blood cells, which eventually led to the Romanowsky stain and its
modifications that continue to exist in our times. A real breakthrough in Laboratory Hematology
was the development of electronic blood cell counting in 1953 by Wallace Coulter. His
impedance technology eventually evolved to fully automated hematologyanalyzers for
performing a complete blood count that consists of 40 parameters.
In 1770 William Hewson describes leukocytes and some essential clotting factors and became
known as “The father of Hematology.”
Physicians who specialize in Hematology are known as hematologists. Their routine work mainly
includes the care and treatment of patients with hematological diseases, although some may
also work at a Hematology laboratory viewing blood films and bone marrow slides under the
microscope, interpreting various hematological test results.

What is blood?
 Blood is the life-maintaining fluid that circulates through the body'sheart, arteries, veins
and capillaries
 Human blood consists of about 22% solids and 78% water.

What is the function of blood?

 Blood carries nourishment, electrolytes, hormones, vitamins, antibodies, heat, and
oxygen to the body tissues
 Blood carries away waste matter and carbon dioxide from the body tissues.

What are the components of the blood?

 Plasma, in which the blood cells are suspended, including:

 Red blood cells (erythrocytes) - carry oxygen from the lungs to the rest of the body.

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  White blood cells (leukocytes) - help fight infections and aid in the immune process.
Types of WBCs:

NEUTROPHILS, EOSINOPHILS, BASOPHILS AND MONOCYTES

The term “white cells” or “leukocytes” refers to the nucleated cells of the blood—
the neutrophils, lymphocytes, monocytes, eosinophil and basophils. All these cells
play a role in defending the host against infection and other insults. Neutrophils,
monocytes, eosinophil, and basophils are phagocytes. They engulf and destroy
foreign material and damaged ells. The term “granulocytes” may be used to
particularly describe neutrophils, eosinophil and basophils.

Neutrophils

Neutrophils have a limited lifespan of around 10 hours in the blood.

Approximately half the cells are included in a normal blood count (circulating
pool) the remainder being in the “marginal pool” . the essential function of all
these cells is to enter the tissues and combat infection. This requires both
migration to the site of infection or tissue injury (chemotaxis) and the destruction
of foreign material (phagocytosis).

EOSINOPHILS

Eosinophil spend only a brief period in the blood, instead rapidly migrating to the
sobcosa of gastrointestinal, respiratory, and urinary tracts, where they serve as a
first-line defense against invading parasites. Hypereosinophillic syndrome (HES) is
a condition marked by chronic sustained blood (>6 months) and tissue
eosinophilia that leads to tissue damage. Primary(idiopathic) HES is a rare
disorder with no identifiable etymology.

BASOPHILS AND MAST CELLS

-derive from a common marrow progenitor. Mast cells unlike basophils are not
normally seen in the blood and rapidly migrate to connective tissues, where they
are relatively long lived and capable of cell division. Basophils, like eosinophils,
circulate in the blood only briefly; they rapidly enter mucosal tissues during
allergic responses.

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 MONOCYTES

Mature monocytes are released from the marrow into the circulation, where they
circulate with a half-life of 2-3 days before entering tissues and body fluids in
response to inflammation and infection

Lymphocytes

Lymphocytes are essential for immunity. B-lymphocytes produce antibody

against a specific antigen (humoral immunity) while T-lymphocytes are the cells
of the cell-mediated response. T-lymphocytes require antigens to be presented
by other cells including transformed monocytes termed leucocytes in the fight
against foreign invasion.

Most mature lymphocytes appear under the light microscope as cells with round
nuclei and a thin rim of agranular cytoplasm. Although B- and T-cells are not
distinguishable by their morphology, there are major differences in their mode of
maturation and function.

 Platelets (thrombocytes) - help in blood clotting.

What are the functions of blood cells?

 The primary function of red blood cells, or erythrocytes, is to carry oxygen and carbon
dioxide.
 Hemoglobin (Hgb) is an important protein in the red blood cells that carries oxygen from
the lungs to all parts of our body.
 The primary function of white blood cells, or leukocytes, is to fight infection.
 The primary function of platelets, or thrombocytes, is blood clotting.
 Platelets are much smaller in size than the other blood cells. They group together to
form clumps, or a plug, in the hole of a vessel to stop bleeding.

Where are blood cells made?

Blood cells are made in the bone marrow. The bone marrow is the spongy material in the center
of the bones that produces about 95% of the body's blood cells.
There are other organs and systems in our bodies that help regulate blood cells. The lymph
nodes, spleen, and liver help regulate the production, destruction, and differentiation

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(developing a specific function) of cells. The production and development of new cells is a
process called haematopoiesis.

Blood facts
• Approximately 8% of an adult's body weight is made up of blood.
• Females have around 4-5 litres, while males have around 5-6 litres. This difference is
mainly due to the differences in body size between men and women.
• Its mean temperature is 38 degrees Celcius.
• It has a pH of 7.35-7.45, making it slightly basic (less than 7 is considered acidic).
• Whole blood is about 4.5-5.5 times as viscous as water, indicating that it is more resistant
to flow than water. This viscosity is vital to the function of blood because if blood flows
too easily or with too much resistance, it can strain the heart and lead to severe
cardiovascular problems.
• Blood in the arteries is a brighter red than blood in the veins because of the higher levels
of oxygen found in the arteries.
• An artificial substitute for human blood has not been found.

Tests
Complete Blood Count
A complete blood count (CBC) gives important information about the kinds and numbers of
cells in the blood, especially red blood cells , white blood cells , and platelets. A CBC helps your
doctor check any symptoms, such as weakness, fatigue, or bruising you may have. A CBC also
helps him or her diagnose conditions, such as anemia, infection, and many other disorders.

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A complete blood count test usually includes:
 Red blood cells
-Red blood cell (RBC) count. Red blood cells carry oxygen from the lungs to the rest of the
body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count is
low (anemia), the body may not be getting the oxygen it needs. If the count is too high (a
condition called polycythemia), there is a chance that the red blood cells will clump together
and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry
oxygen.

-Red blood cell indices. There are three red blood cell indices: mean corpuscular volume
(MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration
(MCHC). They are measured by a machine and their values come from other measurements in a
CBC. The MCV shows the size of the red blood cells. The MCH value is the amount of
hemoglobin in an average red blood cell. The MCHC measures the concentration of hemoglobin
in an average red blood cell. These numbers help in the diagnosis of different types of anemia.
Red cell distribution width (RDW) can also be measured which shows if the cells are all the same
or different sizes or shapes.

 White Blood Cells

-White blood cell (WBC, leukocyte) count. White blood cells protect the body against
infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or
other organism causing it. White blood cells are bigger than red blood cells but fewer in
number. When a person has a bacterial infection, the number of white cells rises very quickly.
The number of white blood cells is sometimes used to find an infection or to see how the body
is dealing with cancer treatment.

-White blood cell types (WBC differential). The major types of white blood cells are
neutrophils, lymphocytes, monocytes, eosinophil, and basophils. Immature neutrophils, called
band neutrophils, are also part of this test. Each type of cell plays a different role in protecting
the body. The numbers of each one of these types of white blood cells give important
information about the immune system. Too many or too few of the different types of white
blood cells can help find an infection, an allergic or toxic reaction to medicines or chemicals, and
many conditions, such as leukemia.

 Hemoglobin
-The hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the blood cell
its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good
measure of the blood's ability to carry oxygen throughout the body.

 Hematocrit
-Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space
(volume) red blood cells take up in the blood. The value is given as a percentage of red blood
cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's

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volume is made of red blood cells. Hematocrit and hemoglobin values are the two major tests
that show if anemia or polycythemia is present.

 Platelets
-Platelet (thrombocyte) count. Platelets (thrombocytes) are the smallest type of blood cell.
They are important in blood clotting. When bleeding occurs, the platelets swell, clump together,
and form a sticky plug that helps stop the bleeding. If there are too few platelets, uncontrolled
bleeding may be a problem. If there are too many platelets, there is a chance of a blood clot
forming in a blood vessel. Also, platelets may be involved in hardening of the arteries
(atherosclerosis).

-Mean platelet volume (MPV). Mean platelet volume measures the average amount (volume)
of platelets. Mean platelet volume is used along with platelet count to diagnose some diseases.

Normal Complete Blood Count Range

Each measurement in a complete blood count has a normal range that will be noted on your
complete blood count:

White blood cell (WBC, leukocyte) count

Men and nonpregnant 5,000-10,000 WBCs per cubic millimeter (mm3) or 5.0-
women: 10.0 x 109 WBCs per liter (L)

Differential Cell Count

Adult (%) Child (%) Infant (%)

Basophils 0.1 0.06 0.07
Eosinophils 3.1 3.6 2.6
Hemocytoblasts 0.1-1.0
Lymphocytes (all stages) 2.7-24 16 49
Megakaryocrtes 0.03-0.5 0.1 0.05
Plasmacytes 0.1-1.5 0.4 0.02
Promyelocytes 0.5-8.0 1.4 0.76
Reticulum cells 0.1-2.0
Undifferentiated cells 0.0-0.1
Neutrophils, total 56.5 57.1 32.4
Metamyelocytes 9.6-24.6 23.3 11.3
Neutrophilic 10-32
Eosinophilic 0.3-3.7
Basophilic 0-0.3

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Monocytes (all stages) 0-2.7
Myeloblasts 0.1-5.0 1.2 0.62
Myelocytes 4.2-15 18.4 2.5
Neutrophilic 5.0-20
Eosinopbilic 0.1-3.0
Basophilic 0-0.5
Segmented granulocytes 6.0-12.0 12.9 3.6
Neutrophilic 7.0-30
Eosinophilic 0.2-4.0
Basophilic 0-0.7
Band cells 9.5-15.3 0 14.1
Neutrophilic 10-35
Eosinophilic 0.2-2.0
Basophilic 0-0.3
Erythroid series
Normoblasts, total 25.6 23.1 8.0
Pronormoblasts 0.2-4.0 0.5 0.1
Basophilic normoblasts 1.5-5.8 1.7 0.34
Polychromatophilic
5.0-26.4 18.2 6.9
normoblasts
Orthochromic normoblasts 3.6-21 2.7 0.54
Promegaloblasts 0
Basophilic megaloblasts 0
Polychromatic megaloblasts 0
Orthochromic megaloblasts 0

Red blood cell (RBC) count

4.5-5.5 million RBCs per microliter (mcL) or 4.5-5.5 x 1012/liter

Men:
(L)

Women: 4.0-5.0 million RBCs per mcL or 4.0-5.0 x 1012/L

Children: 3.8-6.0 million RBCs per mcL or 3.8-6.0 x 1012/L

Newborn: 4.1-6.1 million RBCs per mcL or 4.1-6.1 x 1012/L

Results continued...

Hematocrit (HCT)

Men: 42%-52% or 0.42-0.52 volume fraction

Women: 36%-48% or 0.36-0.48 volume fraction

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Children: 29%-59% or 0.29-0.59 volume fraction

Newborns: 44%-64% or 0.44-0.64 volume fraction

Hemoglobin (Hgb)

Men: 14-17.4 grams per deciliter (g/dL) or 140-174 grams per liter (g/L)

Women: 12-16 g/dL or 120-160 g/L

Children: 9.5-20.5 g/dL or 95-205 g/L

Newborn: 14.5-24.5 g/dL or 145-245 g/L

In general, a normal hemoglobin level is about one-third the value of the hematocrit.

Red blood cell indices

82-98 cubic millimeters (mm3) or 82-

Mean corpuscular volume (MCV):
98 femtoliters (fL)

Mean corpuscular hemoglobin 26-34 picograms (pg) or 0.40-0.53

(MCH): femtomoles (fmol)

Mean corpuscular hemoglobin 32-36 grams per deciliter (g/dL) or 320-

concentration (MCHC): 360 grams per liter (g/L)

Red cell distribution width (RDW)

Normal: 11.5%-14.5%

Platelet (thrombocyte) count

Adults: 140,000-400,000 platelets per mm3 or 140-400 x 109/L

Children: 150,000-450,000 platelets per mm 3 or 150-450 x 109/L

Mean platelet volume (MPV)

Adults: 7.4-10.4 mcm3 or 7.4-10.4 fL

Children: 7.4-10.4 mcm3 or 7.4-10.4 fL

Blood smear

Normal: Blood cells are normal in shape, size, color, and number.

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M:E Ratio

The myeloidierythroid ratio is the ratio of white blood cells to nucleated red blood cells

Adult 6:1 to 2:1

Birth 1.85:1

2 weeks 11:1

1-2 months 5.5:1

1-20 years 2.95:1

What Abnormal Results Mean

A high RBC or hematocrit may be due to:

o Dehydration (such as from severe diarrhea)
o Kidney disease with high erythropoietin production
o Low oxygen level in the blood for a long time due to heart or lung disease
o Polycythemia Vera
o Smoking
A low RBC or hematocrit is a sign of anemia, which can result from:
o Autoimmune diseases such as lupus erythematosus or rheumatoid arthritis
o Blood loss (hemorrhage)
o Bone marrow failure (for example, from radiation, infection, or tumor)
o Chronic kidney disease
o Hemolysis (red blood cell destruction)
o Leukemia and other blood cancers
o Long-term infections such as hepatitis
o Poor diet and nutrition, causing too little iron, folate, vitamin B12, or vitamin B6
o Multiple myeloma
A lower than normal white blood cell count is called leukopenia. A decreased WBC count
may be due to:
o Autoimmune diseases (such as systemic lupus erythematosus)
o Bone marrow failure (for example, due to infection, tumor, radiation, or fibrosis)
o Disease of the liver or spleen
High numbers of WBCs is called leukocytosis. It can result from:
o Infectious diseases
o Inflammatory disease (such as rheumatoid arthritis or allergy)
o Leukemia
o Severe emotional or physical stress
o Tissue damage (such as burns)

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Low hemoglobin values may be due to:
o Anemia (various types)
o Blood loss

Increased Eosinophil
Infarcts, parasites, pneumothorax, post pneumonic effusions, rheumatic fever, rheumatoid
arthritis, and tumors.

Increased Plasma Cell

Chronic inflammation, Hodgkin's disease, and lymphoma. Atypical plasma cells may be
associated with multiple myeloma.

Decreased Glucose
Rheumatoid effusion (synovial fluid)

Increased Eosinophils
Bone marrow carcinoma, eosinophilic leukemia, hypereosinophilic
syndrome, lymphadenoma, myeloid leukemia, and pernicious anemia (relapse).

Increased Lymphocytes
Aplastic anemia, hypoplasia of the bone marrow, infectious lymphocytosis or mononucleosis,
lymphatic leukemoid reactions, lymphocytic leukemia lymphoma, macroglobulinemia,
myelofibrosis, and viral infections.

Increased Megakaryocytes
Acute hemorrhage, aging, chronic myeloid leukemia, Hypersplenism, idiopathic
thrombocytopenia, infection , megakaryocytic myelosis, myelofibrosis, pneumonia, polycythemia
vera, and thrombocytopenia.

Increased Plasma Cells

Agranulocytosis, amyloidosis, aplastic anemia, carcinomatosis, collagen disease, hepatic
cirrhosis, Hodgkin's disease, hypersensitivity reactions, infection, irradiation, macroglobulinemia,
malignant tumor, multiple myeloma, rheumatic fever rheumatoid arthritis, serum
sickness,syphilis, and ulcerative colitis.

Increased Granulocyte
Hypoplasia of the bone marrow, infections, myelocytic leukemia myelocytic leukemoid reaction.

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What Affects the Test
Reasons you may not be able to have the test or why the results may not be helpful include:

 If the elastic band was on your arm a long time while the blood sample was taken.
 Taking medicines that can cause low platelet levels. Some examples of the many
medicines that cause low platelet levels include steroids, some antibiotics, thiazide
diuretics, chemotherapy medicines, quinidine, and meprobamate(Equanil, Miltown,
Meprospan).
 A very high white blood cell count or high levels of a type of fat (triglycerides). These can
cause falsely high hemoglobin values.
 Having an enlarged spleen, which may cause a low platelet count (thrombocytopenia) or
a low white blood cell count. An enlarged spleen may be caused by certain types of
cancer.
 Pregnancy, which normally causes a low RBC value and less often a high WBC value.
 Clumping of platelets in the test tube. This can cause a falsely low platelet count and
occurs because of the substance used in the test tube.

Cell Counts
 Counting chamber
A counting chamber, also known as hemocytometer, is a microscope slide that is
especially designed to enable cell counting. The slide has a sink in its middle; the area of
the sink is marked with a grid. A drop of a cell culture is placed in the sink. Looking at the
sample under the microscope, the researcher uses the grid to manually count the
number of cells in a certain area. The depth of the sink is predefined, thus the volume of
the counted culture can be calculated and with it the concentration of the cells.

 Plating
To quantify the number of cells in a culture, the cells can be simply plated on a petri dish
with growth medium. If the cells are efficiently distributed on the plate, it can be
generally assumed that each cell will give rise to a single colony. The colonies can then
be counted, and based on the known volume of culture that was spread on the plate, the
cell concentration can be calculated.

 Spectrophotometry
Cell cultures are turbid: they absorb some of the light and let the rest of it pass through.
The higher the cell concentration is, the higher the turbidity.Spectrophotometers are
electrical appliances that can measure turbidity very accurately. The culture is placed in a
translucent cuvette, the cuvette placed in the machine, and the turbidity measured
immediately. Simple mathematical formula help convert the detected turbidity to cell
concentration. Using spectrophotometry for measuring the turbidity of cultures is known
as turbidometry.

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  Electrical resistance
A Coulter counter is an appliance that can count cells as well as measure their volume. It
is based on the fact that cells show great electrical resistance; in other words, they
conduct almost no electricity. In a Coulter counter the cells, swimming in a solution that
conducts electricity, are sucked one by one into a tiny gap. Flanking the gap are two
electrodes that conduct electricity. When no cell is in the gap, electricity flows unabated,
but when a cell is sucked into the gap the current is resisted. The Coulter counter counts
the number of such events and also measures the current (and hence the resistance),
which directly correlates to the volume of the cell trapped.

 Flow cytometry
Flow cytometry is by far the most sophisticated and expensive method for cell counting.
In a flow cytometer the cells flow in a narrow stream in front of alaser beam. The beam
hits them one by one, and a light detector picks up the light that is reflected from the
cells.

Erythrocyte Sedimentation Rate

The erythrocyte sedimentation rate (ESR), also called a sedimentation rate or Westergren ESR, is
the rate at which red blood cells sediment in a period of one hour. It is a common hematology
test, and is a non-specific measure of inflammation. To perform the test, anticoagulated blood is
placed in an upright tube, known as a Westergren tube, and the rate at which the red blood cells
fall is measured and reported in mm/h. Since the introduction of automated analyzers into the
clinical laboratory, the ESR test has been automatically performed.

Coagulation tests
Coagulation tests are usually performed in the Hematology section. They are conducted to
determine the clotting ability of the blood.

Screening tests and confirmatory assays for classic hemophilia are performed in the coagulation
area. Also, other procedures, such as platelet counts and fibrinogen assays, help to detect
coagulation problems such as disseminated intravascular coagulation (DIC) disease.

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References:
Chernecky, C. & Berger, B. Laboratory Tests and Diagnostic Procedures. (5th ed.) (pp. 100,238-
242)
Haematology by Martin R. Howard and Peter J. Hamilton (pages 4,5,6,7,8,9)
S. David Hudnall, MD, Hematology: A Pathophysiologic Approach, p. 50-58
http://www.news-medical.net/health/What-is-Hematology.aspx
Clinical Chemistry & Laboratory Medicine. Jan2013, Vol. 51 Issue 1, p119-127. 9p. 3 Charts, 1
Graph.
http://www.cc.nih.gov/ccc/patient_education/pepubs/cbc97.pdf
http://www.mayoclinic.com/health/complete-blood-count/MY00476
http://www.youtube.com/watch?v=j7PJrUFciec
https://en.wikipedia.org/wiki/Erythrocyte_sedimentation_rate
http://en.wikipedia.org/wiki/Cell_counting
Chernecky CC, Berger BJ (2008). Laboratory Tests and Diagnostic Procedures, 5th ed. St. Louis:
Saunders.
Fischbach FT, Dunning MB III, eds. (2009). Manual of Laboratory and Diagnostic Tests, 8th ed.
Philadelphia: Lippincott Williams and Wilkins.
Pagana KD, Pagana TJ (2010). Mosby’s Manual of Diagnostic and Laboratory Tests, 4th ed. St.
Louis: Mosby Elsevier.
Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier;
2011:chap 161.
Ajmani RS, Rifkind JM.Hemorheological changes during human aging. Gerontology 1998; 44 (2):
111-120
Coagulation cascade [online]. 2003 [cited 2007 Sep 9]. Available from: URL:
http://labtestsonline.org/ understanding/ analytes/ coag_cascade/ coagulation_cascade.html
Marieb EN. Human anatomy & physiology. 4th ed. Menlo Park, Calif.: Benjamin/Cummings;
1998.
Saladin KS. Anatomy and physiology - the unity of form and function. 3rd ed. New York:
McGraw-Hill; 2004.
Sherwood L. Human physiology - from cells to systems. 5th ed. Belmont, Calif: Brooks/Cole;
2004.

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Quiz:

1. It refers to the nucleated cells of the blood.

2. Also known as Platelets.
3. A type of cells that carry oxygen from the lungs to the rest of the body.
4. Where are Blood Cells made?
5. A type of WBC which have a limited lifespan of around 10 hours in the blood.
6. What is the normal cell count percentage of Basophils for Adult?
7. This test measures the average amount (volume) of platelets.
8. True or False. ESR is the rate at which red blood cells sediment in a period of one hour.
9. True or False. Coagulation Tests are performed to identify WBC concentration.
10. Who is the Father of Hematology?

Answers:

1. Leukocytes
2. Thrombocytes
3. RBC/Erythrocytes
4. Bone marrow
5. Neutrophils
6. 0.1%
7. Mean Platelet Volume
8. True
9. False
10. Jan Swammerdam

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