INTERPRETATION OF

CBC

DR. Anand Raj

Tutor
Department of Pathology
PMCH
CBC
 A complete blood count is a series of tests used
to evaluate the composition and concentration
of the various components of the blood.
 Most informative single investigation which can
serve both as a screening as well as prognostic
tool for various diseases.
 CBC PARAMETERS
RED CELL WHITE CELL PLATELET
PARAMETERS PARAMETERS PARAMETERS
1.TOTAL RBC COUNT 1.TOTAL WBC COUNT 1.PLATELET COUNT
2.HAEMOGLOBIN 2.DIFFERENTIAL 2.MEAN PLATELET
3.HAEMATOCRIT COUNT VOLUME
4.MCV 3.PDW
5.MCH
6.MCHC
7.RDW
8.RETICULOCYTE
COUNT
METHODS FOR CBC
1.MANUAL METHOD –
Cell counting is done by hemocytometer

2.AUTOMATIC METHOD-
• Cell counting is done with automated cell counters
MANUAL COUNTING
 Manual count is performed with the
Neubauer’s chamber.
 A Neubauer’s chamber is a modified
glass slide with nine 1*1mm ruled
areas ,which when covered with
coverslip contains 0.1 mcl of blood.
 The squares at the corners are used
for counting WBCs, whereas the
central square is used for RBC and
platelet count.
MANUAL COUNTING
WBC COUNT
• Diluting fluid:lyses RBCs
• Dilution of blood :1:20
• Dilution factor :20
• Squares counted:4 corner squares
• Total area counted : 4mm square
• Count per mm cube :no. of cells
counted/total volume in mm
cube*dilution factor
• If N = no.of cells counted in 0.1 mcl,
N*20/0.1*4=N*50
PLATELET COUNT
• Diluting fluid : lyses RBCs
• Dilution of blood :1:100
• Dilution factor :100
• Squares counted :central large square
• Total area counted:1 mm square
• Count per mm cube :no. of cells
counted / total volume in mm cube
*dilution factor
• If N=no. of cells counted in 0.1 mcl,
N*100/0.1=N*1000
MANUAL COUNTING
▪ Advantages of manual counting:
▪ Comments on cell morphology can be made
▪ Giant platelets and platelet clumps can be identified.
▪ Disadvantages of manual counting:
▪ Difficulty in cell identification: Mostly between lymphocyte, monocytes, band
cells
▪ Cell distribution error : increased cell concentration along edges
▪ Statistical sampling errors
▪ Requires lot of time and labour
AUTOMATED CELL COUNTERS
PRINCIPLES OF CELL COUNTERS
1.ELECTRICAL
IMPEDENCE
PRINCIPLE:
 Blood cells are bad conductors of
electricity.
 When passed through a narrow
orifice causes change in
resistance.
 The magnitude of change is
measured as cell size and the
number of changes as number
of particles.
 PRINCIPLES CONTD…
2.VCS principle

 Volume – direct current measures the size of

the leukocytes based upon the amount of
current it displaces in isotonic diluent
 Conductivity – HF radio waves measures
conductivity of the cells.
 Scatter – laser light beam evaluates the
surface feature, structure, shape, granularity
and reflectivity
VCS TECHNOLOGY

 DIFFERENTIAL SCATTEROGRAM
a:(NEUT+BASO,EO,LYMPH,MONO)AS DISTINCT
CLUSTERS,b:BASOPHILS APPEAR AS A DISTINCT CLUSTER
 PRINCIPLES CONTD….
3.Optical light Scatter
principle:
 when the cells pass in a single file,
infront of a light source ;light is
scattered by the cells passing through
the light beam.
 the scattered light is detected by a
photomultiplier or photodiode,which
converts it into electrical impulses that
are accumulated and counted.
PRINCIPLES CONTD…..
4.FLOURESCENCE AND FLOW CYTOMETRY:
 PRINCIPLES CONTD…
5.PEROXIDASE STAINING:
 Cells are stained with peroxidase reagent and
analyzed for size and peroxidase stain
intensity.
 Eosinophils –strong stain
 Neutrophils – medium stain
 Monocytes – weak stain
 Lymphocytes and basophils –no staining
(Basophils are separated from other WBCs by
specific cell lysing agents)
 Large unstained cells (LUC)

❑NOTE:this principle is used by ADVIA120

AUTOMATED CELL COUNTERS
ADVANTAGES
• No inter-observer variability
• No slide distribution errors
• Eliminate statistical error
• Many parameter are available e.g.
RDW, histogram
• More efficient and time effective
• High level of precision and accuracy
DISADVANTAGES
• False high or low values due to
clotted specimen, microcytosis
, giant platelets , platelet
clumps.
• Unable to comment on cell
morphology
▪ NOTE: however with advanced
technology analysers these
pitfalls are getting countered.
 CBC REPORT
CONSISTS OF :
 Counts i.e. numerical values
 Histograms
 Flags :signals that occur when
an abnormal result is detected
by analyzer.
 TOTAL RBC COUNT
Cells of size greater than 36 fl (36-
360fl) are counted as RBCs in
RBC/Platelet chamber in a conventional
analyser.
Normal values
• Adult (M) 4.6-6.0 million/mm3
• Adult (F) 4.2-5.0 million/mm3
 DECREASED RBC COUNT
BLOOD LOSS IMPAIRED PRODUCTION INCREASED DESTRUCTION
• Trauma • Pure red cell aplasia Intra-corpuscular
• Surgery • Pernicious anemia • Hereditary spherocytosis
• GI bleed • Megaloblastic anemia • Sickle cell anemia
• Gynecological • Iron deficiency anemia • G6PD
disturbance • Thalassemia • PNH
• Anemia of prematurity Extra-corpuscular
• Anemia of chronic • Autoimmune
disorder • Haemolytic disease of newborn
• Mismatch transfusion
• Microangiopathic
haemolytic anemia TTP,
HUS
• DIC
• Infections
 INCREASED RBC COUNT COUNT
• Polycethemia vera
• High altitude
• chronic obstructive pulmonary disease(COPD, emphysema, chronic
bronchitis),
• pulmonary hypertension,
• Hypoventilation syndrome,
• congestive heart failure
• obstructive sleep apnea,

❑In microcytic anemias rbc count decrease in proportion to hb whereas in

thalessemia rbc count is either increased or higher side of normal
• this helps in differentiating microcytic anemias from thalessemia.
 HAEMOGLOBIN
 Haemoglobin is estimated
using
cyanmethaemoglobin
method (DRABKIN’S
REAGENT).
 Hb conc. Is measured by
reading the absorbance of
cyanmethaemoglobin at
555nm in haemoglobin
chamber.
 HAEMOGLOBIN
 Newer models use SODIUM LAURYL SULPHATE instead of
drabkin’s reagent. it converts Hb into sulphated derivate and
absorbance is read at 534nm. It is cyanide free and rapid
 Normal values:
• Adult male 13.5-16.5 g/dL
• Adult female 12.0-15.5 g/dL
• Pregnant female 11.0-14.0g/dL
ANEMIA WORKUP
WHO criteria for anemia are:
• Adult males Hb<13g/dl
• Adult females Hb<12g/dl
• Infants and children upto12 yrs
Hb<11g/dl
• Pregnant woman Hb<11g/dl
GRADING :
• Mild (normal to 10.0mg/dl)
• Moderate (7-10 mg/dl)
• Severe (<7mg/dl)
 HAEMATOCRIT/PCV
• Ratio of the volume of erythrocytes
to that of the whole blood in
percentage
• Hct is measured directly by
microhematocrit centrifuge or
calculated as RBCcount/MCV.
 Rule of 3:– Hb x 3 = Hct
• Normal values
• Adult Male- 39-47%
 Adult female- 36-44%
HAEMATOCRIT CONTD….
 HIGH  LOW
• Polycythemia vera • Anemia
• Dehydration • Blood loss
• Congenital heart disease • Hemolysis
• Cor pulmonale • Bone marrow aplasia
• Smoking • Leukemia
• Haemoconcentration (Dengue) • Malnutrition
An elevated haematocrit may be due to spleen hyperfunction, and
reduced haematocrit may indicate low thymus function
RETICULOCYTES
• Reticulocyte count is done
using supravital stain using the
fact that various dyes and
flourochromes binds with RNA
of reticulocytes. Flourescent
cells are counted by flourescent
microscope or flow cytometer.
• Normal value :0.5-1.5%
 Increased reticulocyte count
• Haemolytic anemia
• Recent haemorrhage
• Thalassemia
• Pregnancy
• Response to treatment
 Decreased reticulocyte count
• Aplastic anemia
• Megaloblastic anemia
• Anemia of chronic disease
RETICULOCYTES CONTD…
 Flow cytometry classifies reticulocytes into
three maturation stages depending on their
RNA content LFR ,MFR, HFR.
 IMMATURE RETICULOCYTE
FRACTION (IRF): Sum of MFR and HFR
and is referred to as reticulocyte maturation
index
 Useful in early identification of marrow
regeneration in patients undergoing chemo or
marrow transplantation.
MEAN CORPUSCULAR VOLUME (MCV)
• Measures average volume of RBC
• MCV = haematocrit/ red cell count
▪ Normal value:79-98fl
▪ RBCs classified accordingly as
• Microcyte – MCV <79
• Macrocyte – MCV >98
• MCV <72 without heterogeneity, is a sensitive and specific predictor
of thalassemia trait
MEAN CORPUSCULAR HAEMOGLOBIN(MCH)
MCH = Haemoglobin/ red cell count
Normal range-26-37 pg

1.MCH decreased in
 Microcytic and normocytic
anemias
2.MCH increased in
 Macrocytic anemias and infants
and newborns
3.Interference in MCH
• Marked leukocytosis
• Cold agglutinin
• Monoclonal protein in
blood
 MEAN CORPUSCULAR HAEMOGLOBIN
CONCENTRATION (MCHC)
• MCHC = haemoglobin/ haematocrit
• Normal range=32-36g/dl
 1.MCHC decreased in
 Hypochromic Microcytic Anemia
 2.MCHC increased in
 Heriditary spherocytosis
 Infant and newborns
 Autoagglutination
 3.Interference in MCHC
 most common parameter to give
spurious result as is dependant on
various parameters .
False high results if
 cold agglutinins,
 hyperlipidemia,
 hyperbilirubinemia
 RED CELL DISTRIBUTION WIDTH (RDW)
• Red cell distribution width indicates
the degree of anisocytosis.
• It is calculated from RBC histogram

• RDW is increased in iron def.

anemia but is normal in
thalessemia,similarly it is increased
in megaloblastic anemia but normal
in other causes of macrocytosis.
• NORMAL RANGE:
RDW-CV-12.8+_1.2%
RDW-SD-42.5+_3.5%
RBC HISTOGRAM
▪ RBC histogram consists of two
flexible discriminators:
• LD : 25-75 fl
• UD : 200-250 fl
• Peak of the curve gives MCV
▪ Normal red cell distribution
curve is a Gaussian curve(bell
shaped),where MCV ranges from
80-100fl.
RBC HISTOGRAM
WBC
 Cells greater than 35fl are counted as WBCs in the WBC/Hb chamber.
 Differentials are obtained according to the counters used.

3 PART DIFFERENTIAL 5 PART DIFFERENTIAL 7 PART DIFFERENTIAL

1. Granulocytes or larger 1. Neutrophils Include 5 parts plus

cells 2. Eosinophils • Large immature cells-
2. Lymphocyte or smaller 3. Basophils blast and immature
cells 4. Lymphocytes granulocytes
3. Monocytes or mid cell 5. Monocytes • Atypical lymphocytes
population
WBC COUNT
 Normal WBC count:4000-11000/ microlitre

LEUCOCYTOSIS LEUCOPENIA
1.Acute and chronic infections 1.Typhoid
2.Leukemia 2.Malaria
3.Burns 3.HIV-AIDS
4.Stress 4.Aplastic anemia
NEUTROPHILS
ABSOLUTE COUNT: 1500-7500/microlitre
NEUTROPHILLIA: ANC >7500/CUMM
1. Physiologic increase
(Demargination):
• Release of cell in marginal pool
• Stress leukocytosis
• Exercise, Seizure
• Anxiety, Epinephrine
2. Acute infections
3.Tissue injury and inflammation:
• Collagen vascular disease
• Hypersensitivity
• Burns
4.Myeloproliferative disorders:
myeloid leukemia, polycythemia vera
5.Medications: Corticosteroid, lithium
6.Misc.: Sickle cell anemia, acute
hemorrhage
NEUTROPHILS CONTD..
NEUTROPENIA:ANC<1500CUMM

1.Decrease or ineffective 2.Increased removal from

production circulation
• Aplastic anemia • Immunological –SLE,
• Drug- Drugs
antithyroids,antipsychotics • Hypersplenism
• Deficiency –vitamin B12,
Folic acid
• Myelodysplastic syndrome
• Inherited disorder –
Kostamann synd.
EOSINOPHILS
 Absolute count:12-500 cells/microlitre
 Differential count:1-4%

EOSINOPHILIA EOSINOPENIA
• Allergic rhinitis •Usually related to increased steroids
• Asthma Cushing syndrome

•Parasitic disease
•Pulmonary Eosinophilia syndrome
•Eosinophilic leukamia
 BASOPHILS
• Absolute count: 6-200 /microloiter
• Differential count: <1-2%

• Basophilia - causes
• Hypothyroidsm
• CML
• Ulcerative colitis
• Polycythemia vera
• Chickenpox
MONOCYTES
 Absolute count:200-800/ microlitre
 Differential count:1-10%

MONOCYTOSIS MONOCYTOPENIA
1.INFECTIONS:Tuberculosis,kalazar,malaria 1.HAIRY CELL
LEUKEMIA
2.INFLAMMATORY DISEASES:SLE,
RA,Sarcoidosis,crohn’s,Ulcerative colitis 2.APLASTIC ANEMIA

3.HEMATOLOGIACAL MALIGNANCIES:AML -
M4&M5 ,CMML,HL
LYMPHOCYTES
 Absolute count: 1000-3500/microlitre in adults,
3000-9000/microlitre in children
 Differential count: 20-40%, more in children

LYMPHOCYTOSIS LYMPHOPENIA
1.CHRONIC INFECTION: 1.MARROW SUPRESSION
Tuberculosis,Syphillis,
2.HEMATOLOGICAL MALIGNANCIES: 2.DRUGS:Vinblastin,doxorubicin,
CLL,NHL,Adult T cell leukemia chloramphenicol
3.VIRAL INFECTIONS: 3.HIV-AIDS,SARS
Mumps, measles, chicken pox
WBC HISTOGRAM
BLASTS
PROMYELOCYTES,
MYELOCYTES,
METAMYELOCYTE
 CHRONIC LYMPHOCYTIC
LEUKEMIA

WBC HISTOGRAM

ACUTE MYELOID
LEUKEMIA
 PLATELET COUNT
• Cells of volume between 2 to 30fl are counted as platelets in
RBC/Platelet chamber in conventional 3part analysers,whereas in
advanced counters platelet counts may be based on rna flourescence or
presence of monoclonal antibodies CD41/CD61on flow cytometry
which gives accurate counts.
• NORMAL COUNT :1.5 -4.0 lacs/ microlitre
• THROMBOCYTOPENIA:
• Grade 1- counts is between 75,000 -150,000
• Grade 2- counts is 50,000-<75,000
• Grade 3 – 25,000 to <50,000
• Grade 4 - <25,000
THROMBOCYTOPENIA
 THROMBOCYTOSIS
Platelet count >4,50,000 is
termed as thrombocytosis
or thrombocythemia.
TYPES:
1.ESSENTIAL
THROMBOCYTHEMIA:
caused by myeloproliferative
disorders like
 CML,
 polycythemia Vera,
 primary myelofibrosis.
2.REACTIVE
THROMBOCYTOSIS: due to
secondary causes
 Infections
 Inflammatory disorders
 Acute or Chronic blood loss
 Splenectomy
 Hemolytic anemia,thalessemia
 Iron deficiency
 Rebound effect after bone
marrow supression
Mean platelet volume-MPV
• Measurement that describes the average size of the platelet in the blood.
• Indicates whether bone marrow is manufacturing platelets normallyo
• NORMAL RANGE-8 -12 fl
• change in mean platelet volume without any change in platelet count
may be early indicator of bone marrow problem
• In thrombocytopenia increased MPV indicates excessive destruction of
platelets whereas decreased MPV Indicates decreased production.
• MPV is increased in ITP,TTP,Bernard soulier syndrome,sepsis
• MPV is decreased in aplastic anemia,megaloblastic anemia
PLATELET DISTRIBUTION WIDTH (PDW)
• Compares uniformity and
heterogeneity of platelet size; as RDW
PDW is
• Normal range – 9-14 fl measured at

• INCREASED in Essential 20% relative

height of total
thrombocythemia, Aplastic anemia, height of the
Megaloblastic anemia , CML, curve

Fragmented RBCs
• PDW is a relative good tool to
distinguish essential
thrombocythemia (PDW increase)
from reactive thrombocytosis
(PDW normal)
PLATELET HISTOGRAMS
Three major categories:
•A curve -histogram starts at
baseline but doesnot end there due
to microerythrocytes
•B curve -starts at baseline but
there is deviation from baseline at
the end due to fragmentocytes
•C curve-doesn’t start from
baseline due to giant platelets
PLATELET HISTOGRAM
EDTA
INDUCED
PLATELET
CLUMPING

HISTOGRAM NOT ENDING AT

BASELINE DUE TO
FRAGMENTOCYTES
 NEWER PARAMETERS
RED CELL WHITE CELL PLATELET
PARAMETERS PARAMETERS PARAMETERS
1. Cellular Hb concentarion 1.Immature granulocytes 1. Immature platelet fraction
mean (CHCM) 2.Abnormal lymphocytes (IPF)
2. Immature reticulocyte 3.Mean peroxidase activity 2. Reticulated platelets
fraction (IRF) index (MPXI) 3. Platelet large cell ratio
3. Reticulocyte Hb content
(CHr)
4. Hb distribution width
5. Nucleated red cells
NEWER PARAMETERS(CONTD..)
1. CELLULAR HB CONCENTRATION
MEAN(CHCM):
 Directly measured equivalent of MCHC.
 True estimate of hypochromia in IDA.
2. HB DISTRIBUTION WIDTH:
 Degree of variation in red cell hemoglobinization.
 Range-1.82 to 2.64.
 Helps in distinguishing hypochromic microcytes (due to defect in hb synthesis)
and hypochromic macrocytes which are reticulocytes
NEWER PARAMETERS(CONTD..)
3. NUCLEATED RED CELLS:
 nRBCs identified,separated & corrected WBC count obtained.
 WBCs have high fluorescence & forward scatter as compared to nRBCs

4.RETICULOCYTE HB EQUIVALENT(RET-HE):
 Hb content of freshly prepared RBCs.
 Real time information on Fe supply to erythropoiesis.
 Early detection of Fe deficiency.
 Differentiate IDA & ACD.
 Monitoring of erythropoietin & Fe therapy.
NEWER PARAMETERS(CONTD..)
7. P-LCR(PLATELET LARGE CELL RATIO):
 Indicates % of platelets with a vol >12fl.
 Normal range 15-35%
 Increased due to platelet aggregates,microerythrocytes,giant platelets.
8. RETICULATED PLATELETS /IMMATURE
PLATELET FRACTION(IPF):
 Newly produced platelets that have remains of RNA in their
cytoplasm.
 Reflects rate of thrombopoiesis.
 Increased in patients with peripheral consumption of platelets(auto-immune
thrombocytopenic purpura,thrombotic thrmbocytopenic purpura)
 Decreased in marrow failure
 NEWER PARAMETERS(CONTD..)
9.LARGE IMMATURE CELLS:
 Large cell population appears when there is presence
of blasts, promonocytes, promyelocytes, myelocytes,
metamyelocytes, prolymphocytes, and monoblasts.
10.ATYPICAL LYMPHOCYTES:
 These consists of atypical lymphocytes as well as
small blasts and plasma cells.
11.MEAN PEROXIDASE ACTIVITY
INDEX(MPAI)
 Increased in infections,AIDS,myelodysplastic
syndromes,megaloblastic anemias
 Decreased in inherited or acquired neutrophil
peroxidase deficiency.
SUMMARY
 CBC is often the initial investigation in a sick patient, but
important clinical decisions are made based on its
finding.so while interpreting cbc,its important to take the
patients clinical status into account e.g. neutrophillia in a
hospitalised patient occuring over 2-3 days is usually due to
stress/infection whereas neutrophillia sustained over
months in an apparently asymptomatic patient may be due
to a myeloproliferative neoplasm .