ANNALS O F C LIN IC A L AND LABORATORY SC IEN C E, Vol. 11, No.

2
Copyright © 1981, Institute for Clinical Science, Inc.

Increased Electronic Mean Corpuscular

Volume Induced by Marked Hyperglycemia
EDWARD E. MORSE, M.D.,* GEORGE KALACHE, R.N.,f
W ILFRED GERMINO, M .D .,f and RICHARD STOCKWELL, M .D .f

Departments o f Laboratory Medicine* and Medicine, t

University o f Connecticut School o f Medicine,
Farmington, C T 06032

ABSTRACT
A very high glucose level in a diabetic was associated with an increased
electronic mean corpuscular volume (MCV). The hematocrit was falsely
high and the mean corpuscular hemoglobin concentration (MCHC) falsely
low, while the mean corpuscular hemoglobin (MCH) was normal. Blood
smears failed to corroborate the abnormal indices. Correct values could be
obtained by predilution of the blood in isotonic medium and allowing 10 to
15 m inutes for equilibration. It is suggested that glucose in the cell produces
a hyperosmolar state which results in the rapid diffusion of water into the
cells in the counter. The phenomenon is dependent on the concentration of
glucose to which the red cell is exposed. It is temperature dependent and it is
rapidly reversible.

Introduction single count with a high MCV.10 If blood

The shape of the red cell is dependent
upon a num ber of factors including the
contractile forces within the membrane
and the osmotic milieu.7 The mean cor­
puscular volume as measured electroni­
cally by the Coulter Counter is influenced
by several phenomena. Cells as they enter
the ap ertu re of th e co u n ter displace
sodium and chloride ions and create an
electronic impedance proportional to the
size of the cell.1 If cold agglutinins are
present, pairs of cells or clumps of cells
may pass through together producing a
184
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from an anemic patient with a high white
co u n t and large im m ature form s is
counted, the large white cells will influ­
ence the MCV.11 In these cases, the find­
ing of the agglutination in the blood tube
as it cools to room temperature or exami­
nation of a smear for agglutination or
large white cells will provide obvious
clues to the artifact affecting the MCV.
Recently, another phenomenon affecting
the MCV came to our attention w hen a
patient presented to the Emergency De­
partm ent with an extremely high serum
glucose.
 E L E C T R O N IC M EA N C O R P U S C U L A R V O L U M E IN D U C E D BY H Y P E R G L Y C E M IA 185
Case Report 1 2 0 -t

A 52 year old w hite m ale w ith a history of heavy

ethanol intake for two to three w eeks p resen ted in a
so m n o le n t state. H e h a d e x p e rie n c e d n a u se a ,
vom iting, and diarrhea for two days and polyuria,
polydipsia, trem ulousness and som nolence for one
day. Physical exam ination show ed a d eh y d rated
m iddle aged m ale w ith a p ulse o f 88 and a blood
pressure of 180/100 (mm Hg). H is liver was palpable
15 cm below th e costal m argin an d h e show ed
generalized m uscle wasting.
Laboratory exam ination show ed a serum glucose
o f2250 m g per dl, a serum urea nitrogen of 25 mg p er
dl, a sodium of 127 m E q pe r liter, a potassium o f 4.4
m E q per liter, a C 0 2 of 28 m E q p e r liter and a
chloride of 79 m E q p er liter. H em atologic values
show ed a w hite count of 6900 p er cu mm, a p latelet
count of 98,000, a hem atocrit o f 45 percent, a hem o­
vu i ---------- 1----------1--------- r--------- 1---------- 1----------r-
globin of 11.7 g p er dl, and a red cell count o f 3.55 ml _0 10 20 30 40 50 60
p er cu mm w ith an MCV of 128 pi. T he M CH C was Time in minutes
26 g p e r dl and th e MCH was 33 pg p e r rbc. In spite of
the indices show ing an increased cell size and a low F i g u r e 1. Effects on m ean corpuscular volume
m e a n c o rp u s c u la r h e m o g lo b in c o n c e n tra tio n , o f monosaccharide or disaccharide.
exam ination of th e blood sm ear show ed no macro-
cytosis or hypochrom ia. N either w ere agglutination
nor large w hite cells observed. A m icrohem atocrit,
perform ed because o f the d iscrepancies, was 37 dered form* was dissolved in aliquots of
percent. whole blood.
T he p atient’s course (table I) was one of rapid
im provem ent w ith th e ad m inistration of sodium Incubations were carried out at room
chloride infusion and insulin. As th e serum glucose temperature (22C) except for the experi­
retu rn ed tow ard norm al over th e next few days, the m ents on te m p eratu re effects. P e ­
MCV also returned tow ard norm al and the electronic
hem atocrit decreased to match th e m icrohem atocrit riodically, samples w ere m easured by
on day nine. Coulter Sf to determine the MCV and
To exam ine this phenom enon m ore closely, sev­
eral experim ents w ere p erfo rm ed u sin g norm al
blood in EDTA. * (R eagent G rade) B aker C hem ical Co., Phil-
lipsberg, NJ.
f C oulter Industries, Hialeah, FL.
Materials and Methods
Blood was obtained in EDTA vacutain-
ers containing ethylene diamine tetraace-
tic acid from normal laboratory personnel
or from patient samples with normal pa­
rameters. Pure glucose in powder form*
was added to blood in various concen­
trations. Similarly, pure sucrose in pow-

TABLE I

Patient Course

Day 1 2 4 9
Glucose 2250 536 492 264
MCV 128 108 105 100
Electronic hematocrit 45 -- -- 31
Manual hematocrit 37 -- -- 31

F i g u r e 2. H yperosm olar red b lo o d cells ex­

MCV = Mean corpuscular volume posed to isoton.
 M O R SE, K A L A C H E , G E R M IN O , A ND S T O C K W E L L
20 30
Time in minutes
other parameters. Glucose was measured
by kinetic method using hexokinase on
the Dupont ACA. |
J D upont Instrum ents, W ilmington, D E.
F i g u r e 4. Normal red blood cells in glucose
containing plasm a (20 mg p er ml) incubated at dif­
ferent tem peratures.
F ig u r e 3. N o rm al re d
b lo o d c e lls in h ig h g lu ­
cose m ed iu m .
— i-
40 50 60
Results
Incubation of normal red blood cells
with glucose 20 mg per ml (2000 mg per
dl) for one hour produced an increase in
MCV from 93 to 114. Longer incubations
produced little change thereafter. Incuba­
tion of normal red blood cells with sucrose
in equimolar concentrations 40 mg per ml
(4000 mg per dl) for one hour or more
produced no change in MCV (figure 1).
The effect was easily reversed by diluting
the glucose containing blood 1 to 200 in
isotonic saline diluent* for 10 to 15 min­
utes (figure 2).
The increase in MCV was related to the
concentration of glucose in w hich the
cells were incubated from 500 to 2000 mg
per dl (figure 3), and a greater increase in
MCV was observed at higher tempera­
tures (figure 4).
Discussion
These results demonstrate that an in­
crease in electronically measured MCV is
produced by a high ambient glucose level
* Isoton, C oulter Industries, H ialeah, FL. (Actual
proportions 44.7 to 10 ml isoton using o f C oulter S.)
 E L E C T R O N IC M E A N C O R P U S C U L A R V O L U M E IN D U C E D BY H Y PE R G L Y C E M IA
either in vivo or in vitro, which is readily
reversed by reducing the glucose concen­
tration. Patients with serum glucose con­
centrations in the range of 1000 to 3000 mg
per dl probably have red blood cells with a
high intracellular glucose and a hyper­
osmolar state.2,8 Our studies suggest the
MCV changes are directly related to the
concentration of glucose in the serum, are
temperature and time dependent, and are
easily reversible.
The mechanism is not entirely depend­
ent upon metabolic activity since it is not
completely inhibited by cooling to 4°C. It
is not yet certain whether the change in
the electronic MCV is due to intracellular
glucose causing rapid uptake of water dur­
ing dilution and counting in the Coulter S
or d ue to m em brane b o u n d glucose
excluding ions from the vicinity of the
membrane or some combination of both.
A number of studies have shown that
glucose and water are rapidly taken up by
the red blood cell.2,3,6,12 Rapid loss of glu­
cose and water from the hyperosmolar
in tra c e llu la r space has b e e n w ell
documented.2 The rapid reversal of this
phenomenon when red cells are diluted
in isotonic medium indicates an easy leak
of glucose from or through the cell mem­
brane must occur.
The recent evidence that membrane
proteins can be non-enzymatically glyco­
sylated in diabetics9 and that specific re­
ceptors exist4,5 suggest that some glucose
may bind to the external membrane of the
cell displacing sodium and chloride ions
in the im m ediate environm ent of the
cells. Such displacement could possibly
give the appearance of a large cell (in­
creased MCV) in a measuring device de­
pendent upon electronic impedance.
High serum glucose in diabetics must
be added to the growing list of causes for
an ele v a te d MCV as d e te rm in e d by
187
C o u lter C o u n ter. T he co m p u teriz ed
hematocrit will be falsely high, and the
MCHC falsely low, while the MCH will
be normal in patients with serum glucose
around 1000 mg per dl. Correct values can
be determ ined by manual methods or by
diluting in isotonic medium for 10 to 15
minutes prior to determining the values
electronically. Further work is necessary
to define this phenomenon more accu­
rately.
References
1. C o u l t e r C o u n t e r M a n u a l : H ialeah, FL,
C oulter Electronics, Inc., 1979, p. 25.
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G.: T he m echanism of the effect o f iso and
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3. H a l t o n , D. M.: D-glucose transport in eryth­
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Philadelphia, J. B. L ippincott Co., 1969, p. 240.
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F.: N onenzym atic glycosylation of erythrocyte
m em brane proteins. J. Clin. Invest. 65:896-
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11. U npublished observations by authors.
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C arbohydrate M etabolism and Its Disorders.
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