Download White Blood Cell Differential Count

White Blood Cell
Differential Count
DR. Yasir M. Khaleel
M.B.Ch.B , M.Sc.
Definition
The relative percentage of each type of
white blood cells in peripheral blood.
White Blood Cells (leucocytes) Total 4.0 – 11.0 × 10 9 /L
Absolute
Relative Percentage Average
Neutrophils 2.5 – 7.5 × 10 9 /L
50-70%
65%
Lymphocytes 1.5 – 3.5 × 10 9 /L
25-35%
30%
Monocytes 0.2 – 0.8 × 10 9 /L
2-10%
6%
Eosinophils 0.04 – 0.44 × 10 9 /L 1-5%
3%
Basophils 0.01 – 0.1 × 10 9 /L
0.4-1%
0.5%
Microscopic exam
 10× (low fold): overall smear quality,
rouleaux, agglutination or parasites
 100× (oil Len): WBC Diff, RBC
morphology
tail
body
head
Counting Area:
Observe one field and record the number of WBC according to
the different type then turn to another field in the snake-liked
direction
*avoid repeat or miss some cells
Normal peripheral blood smear
White blood cells
 There are three types of
granulocyte named
according to their staining
characteristics in blood
films. They are
neutrophils,eosinophils
and basophils.
 Mononuclear cells are
divided into lymphocytes
and monocytes.
Stab (band) neutrophil
 Diameter:12-16
 Cytoplasm : pink
 Granules : primary &
secondary
 Nucleus : dark purple blue
dense chromatin
Band form Neutrophils
 There are smaller numbers
of cells of neutrophil
lineage with nonsegmented nuclei. They are
referred to as neutrophil
band cells or band forms.
They are less mature than
segmented neutrophils.
 An increased number of
band cells is referred to as
a left shift'.
Segmented neutrophil
 Diameter: 12-16
 Cytoplasm: very pale blue
 Granules: primary
secondary
lilac-staining (purple)
 Nucleus: dark purple blue
dense heterogeneous chromatin 25 lobes
Neutrophils
• The neutrophils in the
circulating blood are
mainly mature
segmented neutrophils.
• neutrophilic because
they owe their color to
uptake of both
the acidic and the basic
components of the
stain
Eosinophil
 Diameter: 14-16
 Cytoplasm : full of granules
 Granules: large refractile
orange-red
 Nucleus: blue
dense chromatin
2 lobes like a pair of glass
Basophil
Diameter: 14-16
Cytoplasm: pink
Granules: dark blue –
black obscure nucleus
Nucleus: blue
Lymphocyte• Diameter: small 7-9
large 12-16
• Cytoplasm : rim, clear, pale blue
• Granules: small (a granular)
large (a variable number of
pinkish-purple granules)
• Nucleus: dark blue / round
chromatin
dense homogeneous
Lymphocytes divided into B(20%)
&T(70%) both of them divided
into small & large
Normal lymphocytes
 Lymphocytes are the
smallest WBC.
 They have large
condensed nucleus,
with a scanty pale blue
cytoplasm.
Monocyte
 Diameter: 14-20(are the
largest normal blood cells)
 Cytoplasm: grey blue
 Granules: dust-like lilac color
granules(purple)
 Nucleus: blue
large irregularly shaped and
folded
Samples of Blood films: 1
The red blood cells here are normal, happy RBC's.
They have a zone of central pallor about 1/3 the size
of the RBC. The RBC's demonstrate minimal
variation in size (anisocytosis) and shape
(poikilocytosis). A few small fuzzy blue platelets are
seen. In the center of the field are a band neutrophil
on the left and a segmented neutrophil on the right.
Samples of Blood films: 2
A normal mature lymphocyte is seen on the left compared
to a segmented PMN on the right. An RBC is seen to be
about 2/3 the size of a normal lymphocyte
Samples of Blood films: 3
Here is a monocyte. It is slightly larger than a lymphocyte and
has a folded nucleus. Monocytes can migrate out of the
bloodstream and become tissue macrophages under the influence
of cytokines. Note the many small smudgy blue platelets between
the RBC's.
Samples of Blood films: 4
In the center of the field is an eosinophil with a
bilobed nucleus and numerous reddish granules in
the cytoplasm. Just underneath it is a small
lymphocyte. Eosinophils can increase with allergic
reactions and with parasitic infestations.
Samples of Blood films: 5
There is a basophil in the center of the field which has a lobed
nucleus (like PMN's) and numerous coarse, dark blue granules in the
cytoplasm. They are infrequent in a normal peripheral blood smear,
and their significance is uncertain. A band neutrophil is seen on the
left, and a large, activated lymphocyte on the right.
Terms
Leucocytosis Vs
Neutrophilia Vs
Lymphocytosis Vs
Monocytosis
Vs
Eosinophilia
Basophilia
Granulocytosis
Agranulocytosis
Leucopenia k/c
Neutropenia
Lymphocytopenia
Monocytopenia
Erythrocytes Sedimentation Rate
ESR
DR. Yasir M. Khaleel
M.B.Ch.B , M.Sc.
ESR
Erythrocyte Sedimentation Rate:
Def: The distance that erythrocytes have fallen after 1 hour
in a vertical column of anti-coagulated blood under the
influence of gravity.
The most satisfactory method was provided by Westergren 1921
ESR is a non-specific test for inflammation.
It is easy to perform, widely available and inexpensive making it
a widely used screening test
Normal ESR not exclude disease
High ESR not confirm the disease unless proved by other tests.
It is also used a monitoring test for response to treatment in
conditions in which it is raised (tuberculosis, autoimmune
diseases etc (
Basics:
The ESR test is performed in the laboratory
by placing anti-coagulated blood in an
upright tube (Westegren's most often). At the
end of an hour of this, the rate of the RBC
sedimentation is measured
Factors affecting the ESR
A- Plasma related factors:
Increased in the concentration of fibrinogen and Immunoglobulins
due to inflammation and tissue injury will increase rouleaux
formation and hence the rate of sedimentation.
Plasma proteins especially fibrinogen, adhere to the red cell membranes and
neutralize the surface negative charges, promoting cell adherence and rouleaux
formation.
Any condition associated with increase in plasma fibrinogen will lead to elevated
ESR ( infection, inflammation, malignancy)
Plasma albumin retards sedimentation of RBCs .
The RBC's here have stacked together in long chains. This is known
as "rouleaux formation" and it happens with increased serum proteins,
particularly fibrinogen and globulins. Such long chains of RBC's
sediment more readily. This is the mechanism for the sedimentation
rate, which increases non-specifically with inflammation and
increased "acute phase" serum proteins.
B-The RBC related factors:
1-The size or mass of the RBC: macrocytes have faster
rate of fall so read higher ESR with macrocytic anaemia.
2- Shape of RBCs that show alterations in their
bioconcavity, like spherocytes and sickle cells (these
RBCs can’t form rouleaux), usually do not exhibit
increase rate, unless there is severe anemia.
3- RBC count :Increase red cell mass will retard the
sedimentation rate e.g. polycythemia, Vs anaemia
C-Technical factors:
1-Perpendicularity of sedimentation tube, slight deviations from
the absolute vertical can increase the result. ( False high)
2-Temperature (RT 18-25 C°) higher temperature cause false
high results due to reduction in plasma viscosity (e.g. direct sun
light)
3-Vibration cans reduce the ESR.
4- Time ( 1 hour )
5-Air bubble ( not allowed)
6- Excess or Less anti-coagulant
7- Clotted sample ( not allowed)
Reference Range
Adults < 50 years:
Females 0-20 mm/hr ; Males 0-15 mm/hr
Adults > 50 years:
Females 0-30 mm/hr ; Males 0-20 mm/hr
For older ages (Females : (Age +10)/2; Males: Age/2)
Children(<10) 0-10 mm/hr
Physiological variations
 Sex: females have higher ESR than males.
 Age: old age specially after 60 have higher ESR. Children have
lower ESR reading.
 Pregnancy and Menstruation: higher ESR
 Weight: Obesity: slightly higher ESR reading.
 Drugs: Aspirin and other NSAIDs, and cortisone may be
associated with slightly lower ESR reading, while OCP,
vitamin A and theophylline are associated with high ESR
reading
 Recent meal before the test (might) be associated with slightly
high ESR reading.
Clinical Evaluation of High ESR Reading
Slightly Elevated ESR, simply repeat the test after
1-2 months.
ESR ≥100 mm/hr is strongly associated with
serious underlying disorders like:
* Connective tissue disease,
* Infections ( specially chronic infections like TB)
* Malignancies
ESR is helpful in diagnosing two specific inflammatory diseases ,
temporal arteritis and polymyalgia rheumatica .
Some conditions with very high
ESR >100 mm/hr
- Multiple myeloma
- Connective tissue disorders - SLE, RA and other
autoimmune diseases
- Tuberculosis
- Malignancies
- Severe anemia
IMPORTANT
Erythrocyte sedimentation rate is a non-specific test and is not
diagnostic of any particular disease. It has a high sensitivity but low
specificity .Never base a diagnosis solely on an ESR value, either
normal or high .Interpretation of the result should always be along
with the patient's clinical history, examination findings and results of
other tests done.
If high ESR is encountered without any obvious reasons, patient
should be reassured and the test repeated after a reasonable time (1-2
months). There is no need to extensively search for an occult disease
without repeating it again.
Procedure
- Patient should have NO meal in the last 4 hours.
-The blood sample must be mixed with anticoagulant agent in this test.
Put 0.4 ml sodium citrate + 1.6 ml blood .
OR
Put 0.2 ml sodium citrate + 0.8 ml blood .
OR
Put 0.5 ml sodium citrate+ 2 ml blood.
1. Mix gently with out shaking for at least 2-3 minutes then put in the
graded tube and leave it stand vertically on the stand for 1 hour.
2. Read the amount of plasma that appeared without moving it .
The Result: ESR= ( ? ) mm/hr.
Thank You
Dr. Yasir M. Khaleel