CBC Interpretation

Dr. Saifeldein M. A. E.
MBBS, MMSC-PATH, MMSC-HEMA
Consultant of Hematopathology
Laboratory & Blood Bank Department
MCH-Najran

04/19/2020 1
 OBJECTIVES
- To have an idea about the hematology analyzers.
- To know the different types of CBC data presentation.
- To be able to interpret CBC reports.
- To recognize common blood disorders.
- To be updated about the new CBC parameters.
- To know when to request hematology consultation.
- To know what is the next step or test to be requested.
04/19/2020 2
 Introduction
Complete blood count is the most useful and informative single
test; which consists of RBC, WBC, and Platelets indices.
Hematology analyzers lay out these indices in form of crude numeric data,
intensity graphs and histograms.
CBC is used for:
• Screening.
• Diagnosis of hematological and systemic disorders.
• Follow up.
• Disease monitoring and effect of treatment.
• Routine
04/19/2020
base-line investigation. 3
 Crude Data

04/19/2020 4
 Flagging System
Parameters Validation
• Abnormalities of cells are signaled by certain ‘asterisk’ on CBC report.
• Every instrument has its own flagging system.

04/19/2020 5
 Interpretive Messages (IP)

• IP denotes abnormalities on CBC that may need verification. Seen at the

bottom end of the report.
• Indicators that may appear after the data:
• @ : Data is outside the linearity limit.
• * : Data is doubtful.
• + or – :Data is outside the reference limits.
• ---- : Data does not appear due to analysis error or abnormal sample.
• ++++ : Data exceeds display limit.

04/19/2020 6
04/19/2020 7
04/19/2020 8
 HISTOGRAMS
• These are the graphical representation of numerical data of different cell
population on cell counter.
• Y axis represents the number of cells and X axis represents the cell size.
• Platelets volume is b/w 8 – 12 fl and counted b/w 2 – 25 fl.
• RBC volume is b/w 80 – 100 fl and counted b/w 25 – 250 fl.
• WBC Lower discriminator fluctuates between 30 -60 fl and upper discriminator
is fixed at 300 fl.

04/19/2020 9
 Thrombocyte histogram
• The histogram curve should lie within the lower and upper platelet
discriminator (PL & PU) and start and end on the base line.
• 1 flexible Discriminator PL 2 to 6 fl.
• 1 flexible Discriminator PU 12-30 fl.
• 1 fixed Discriminator at 12 fl.

04/19/2020 10
04/19/2020 11
 • PL flag:
• When lower discriminator exceeds preset height by 10%, Platelet count, P-
LCR and MPV will show PL flag.
• Possible causes:
• High blank value.
• Cell fragments.
• High numbers of bacteria.
• Contaminated reagent.
• Platelet aggregation.

04/19/2020 12
 PU flag:
• This occurs when UD exceeds the preset height by more than 40%.

Possible causes
• PLT clumps.
• EDTA-incompatibility.
• Clotted sample.
• Giant Platelets.
• Micro-erythrocytes.
• Fragmented or dysplastic RBC.

04/19/2020 13
 Multiple peaks (MP)

04/19/2020 14
 Platelets Parameters
Parameter Description
MPV Mean platelets volume.

PDW Platelets distribution width.

PCT Platelets crit.

MPC Mean platelets concentration.

MPM Mean platelets mass.

PCDW Platelets concentration distribution width.

P-LCR Platelets large cell ratio.

IPF Immature platelets fraction

04/19/2020 15
 Thrombocytopenia
• The primary reason for evaluating thrombocytopenia is to assess the risk of bleeding
and the presence of underlying disorders.

• PLT < 20 000 - increased risk of spontaneous bleeding.

• PLT 20 to 50000 - rarely have increased risk of spontaneous bleeding but there will be
an increased risk of bleeding from procedures.

• PLT 50 to 100,000 no increased risk of spontaneous bleeding.

• A question should be asked; Is it true thrombocytopenia?

• If not true thrombocytopenia, then what is it?

04/19/2020 16
 RED CELL FLAGS
• RL flag:
• When lower discriminator exceeds the preset height by 10 %; RBC
count, HCT, MCV, MCH and MCHC show RL flag.

04/19/2020 17
04/19/2020 18
 Possible causes of RL flag
• Giant platelets.
• Micro-erythrocytes.
• Fragmented RBCs.
• Platelet clumps.
• Due to high numbers of small RBCs the
platelet result might be false high.

04/19/2020 19
 RU flag
• Flag is seen when UD exceeds the preset height by greater than 5 %.
Possible causes of RU flag:
• Cold agglutination.
• RBC agglutination.
• Rouleaux formation.
• Leucocytosis.

04/19/2020 20
 Multiple peaks (MP)

• RDW SD shows the MP flag.

Possible causes:
• Iron deficiency anemia in recovery.
• Post transfusion.
• Extreme Leucocytosis.
• Reticulocytosis.

04/19/2020 21
 Diagnostic features of common hematological conditions

Condition Hb MCV MCH MCHC RDW RBC Plot

Normal Normal Normal Normal Normal Normal In normochromic

normocytic zone

Iron deficiency Low Low Low Normal or low High Microcytic hypochromic
anemia zone

Beta Normal or low Low Low Normal or low Normal or near Normal Clustering in hypochromic
thalassemia microcytic zone
minor

Beta Very low Low Low Low Very high Similar to iron deficiency
thalassemia
major

Non Normal High Normal Normal Normal Clustered in macrocytic

megaloblastic or low zone
macrocytosis
04/19/2020 22
 Diagnostic features of common hematological conditions

Condition Hb MCV MCH MCHC RDW RBC Plot

Megaloblastic Low High Normal Normal High Wide spread microcytic zone
anemia

Dual deficiency Low Variable Variable Variable High Histogram extends in macrocytic and
anemia microcytic zones

Blood Normal or low Variable Variable Variable High Double plot of patients and
transfusion transfused cells

Cold agglutinin Normal or low Bizzare Bizzare Bizzare Bizzare Incubate blood at 37degree
centigrade

Spherocytosis Low Normal Normal High Normal Variable population in the hype-
rchromic zone

04/19/2020 23
 Reticulocyte Indices
• RETIC. Count = 0.5% – 1.5%.
• RET-He.(30 – 36pg) Is a direct measurement of iron in the erythrocyte HGB.
• RMI Is the retics maturation index. This is determined according to the relative
amount of cellular RNA and hence it is divided into:
• 1- LFR – low fluorescence – intensity ratio. Mature retics. (85.8 _ 97.8%).
• 2- MFR – Middle fluorescence – intensity ratio. Immature cells. (1.91 _ 12.41%).
• 3- HFR – High fluorescence – intensity ratio. Most immature cells. (0.00 _ 1.9%).
• IRF – Immature reticulocytes fraction; is the sum of MFR and HFR(2.11 _ 14.14).

04/19/2020 24
04/19/2020 25
04/19/2020 26
 Shift Correction Factor
Normal reticulocyte survive 3.5 days in marrow and 1 day in peripheral
circulation at normal PCV.
Maturation days depends on the PCV as follows:

PCV% Maturation Days

45 1
35 1.5
25 2
15 2.5
04/19/2020 27
 Reticulocyte production index (RPI)
• Reticulocyte production index or corrected reticulocyte count; Is an index
corrected according to the level of anemia.
• Reticulocyte Index = Reticulocyte count x Patient’s hematocrit/ Normal
hematocrit.
• Reticulocyte production index = Reticulocyte index/Shift correction factor.
• RPI in a healthy person is between 0.5 and 2.5%. Which is the same as RI.
• RPI lower than 2 accompanied by anemia is a signal of RBC loss and
decreased production of reticulocytes.
• RPI greater than 3 accompanied by anemia suggests RBC loss but an
increased production of reticulocytes

04/19/2020 28
 WBC histogram

• The number of cells between LD and UD is WBC count.

04/19/2020 29
04/19/2020 30
 Complete Blood Count (CBC)
Interpretation
Dr. Saifeldein Mohammed A.E
MBBS
MSC-PATHOLOGY
MSC-HEMATOLOGY
Hematopathology Consultant
Laboratory Department
MCH – NAJRAN

04/19/2020 31
04/19/2020 32
04/19/2020 33
04/19/2020 34
04/19/2020 35
 WL flag:

• Deviation of base line at lower discriminator.

• Possible causes:
• Lyses resistant RBC.
• PLT Clumps.
• EDTA-incompatibility.
• coagulated sample.
• Erythroblasts (NRBC).
• Cold agglutinates.

04/19/2020 36
 WU flag:
• The histogram curve does not match the base line at upper discriminator
due to high numbers of large particles (WBC aggregation) or if the linearity
of the white blood cell count exceeds the limit. (WBC > 100 x 10³/μl).
• Pre-dilution (e.g. 1:5) of the sample might help to obtain correct results.
• Possible cause:
• Extreme Leucocytosis.
• Rare: WBC aggregation.

04/19/2020 37
 T1 and T2 flags:
When discrimination between various cell population cannot be done due to
presence of abnormal leucocytes.

F1, F2, F3 flags:

04/19/2020 38
 Left Shift of Granulocytes
- The granulocytic “shift to left” reflects marrow response to bacterial
infection, and this is quantified as band count or immature granulocyte
count (IGC).

- IGC offers sensitivity of about 92.2%, and may be used for screening for
bacteremia.

- When IG cells are released from bone marrow , the peripheral neutrophil
count will still be in the normal or decreased range; this is called pseudo-
leucopenia which can develop upon the onset of infection.

04/19/2020 39
 New WBC Indices
MNV Mean neutrophil volume

MNC Mean neutrophil conductivity

MNS Mean neutrophil light scatter

MMV Mean monocyte volume

MMC Mean monocyte conductivity

MMS Mean monocyte light scatter

MLV Mean lymphocyte volume

MLC Mean lymphocyte conductivity

MLS Mean lymphocyte light scatter

NDW Neutrophil distribution width

40
 Criteria for Systemic Inflammatory Response
Syndrome (SIRS) and Sepsis
SIRS and sepsis are characterized by the occurrence of at least two of the
following criteria:
(1) body temperature >38°C or <36°C.
(2) heart rate >90 beats per minute.
(3) respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg.
(4) white blood cell count >12,000/ mm3, <4000/mm3, or >10% immature
(band) forms. The term sepsis is defined as an inflammatory systemic
response arising from an infection. ((Stated by American College of Chest
Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) ))

04/19/2020 41
 Differentiation between SIRS and Sepsis

The IGC discriminates between infected and non-infected

patients, with a sensitivity of 89.2% and a specificity of
76.4%, particularly within the first 48 hours after SIRS
onset.
Regarding infection, the IG count is more indicative than
other clinical parameters such as CRP, lipopolysaccharide
binding protein LBP and IL-6, which have a sensitivity of
less than 68%.
Neutrophilic band cells range is 3 to 5% of the total WBC.
04/19/2020 42
 Immature to Total Neutrophil Ratio

(IT) < 0.16:1

- [Immature cells (bands + metamyelocytes + myelocytes)

divided by the total neutrophil count (segmented

neutrophils + immature cells) ]= IT Ratio.
- Its increment or decrement may reflect the response of
the bone marrow towards an infection.
- It may also reflect the efficiency of the bone marrow
04/19/2020 43
 Grades of neutropenia
Grade Absolute Neutrophil Count
0 Within normal limits
1 >1500 - <2000
2 >1000 - <1500
3 >500 - <1000
4 <500

04/19/2020 44
Thank you

45