DH76 Clinical Case Analysis Report 2021

Content
Chapter One Measurement Principles and Process ....................................................................... 3

1. WBCMeasurement .......................................................................................................................... 3
1.1. Working Principle of Laser-based Flow Cytometry ............................................................ 3
1.2. Electrical Impedance Method............................................................................................... 4
1.3. Derivation of WBC-Related Parameters .............................................................................. 5
2. HGB Measurement ......................................................................................................................... 6
2.1. Colorimectric Method .......................................................................................................... 6
2.2. HGB ..................................................................................................................................... 6
3. RBC/PLT Measurement .................................................................................................................. 6
3.1. Electrical Impedance Method............................................................................................... 6
3.2. RBC...................................................................................................................................... 7
3.3. PLT ...................................................................................................................................... 8
4. IP Message Parameters ................................................................................................................... 8
5. Abnormal Flags Analysis ................................................................................................................ 9
5.1. Abnormal WBCScattergram................................................................................................. 9
5.2. Abnormal RBC Distribution .............................................................................................. 10
5.3. Abnormal PLT Distribution ................................................................................................ 11
Chapter Two Leukocytosis Case .................................................................................................... 12
1. Neutrophilia .................................................................................................................................. 12
2. Lymphocytosis .............................................................................................................................. 13
3. Monocytosis .................................................................................................................................. 15
4. Eosinophilia .................................................................................................................................. 16
Chapter Three Other Abnormalitis ............................................................................................... 18
1. Immature Cell & Left Shift ....................................................................................................... 18
2. Abnormal/Atypical Lym ........................................................................................................... 20
3. Dimorphologic .......................................................................................................................... 21
4. Microcytosis .............................................................................................................................. 22
5. Macrocytosis ............................................................................................................................. 23
6. Thrombocytosis ......................................................................................................................... 24
7. Thrombopenia ........................................................................................................................... 25
8. Abnor. PLT Distr. ...................................................................................................................... 26
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9. PLT Clump？ ............................................................................................................................ 27
Chater Four Abnormalities in the Leukocyte ............................................................................... 28

1. Case 1: Chronic Myeloid Leukemia.............................................................................................. 28
2. Case 2: Chronic Lymphocytic Leukemia ...................................................................................... 30
3. Case 3: Leukocytosis..................................................................................................................... 32
4. Case 4：Leucopenia ..................................................................................................................... 34
5. Case 5：Pulmonary Malignancy................................................................................................... 35

Chapter One Measurement Principles and Process
1. WBC Measurement
The analyzer obtains the white blood cell differential count using a semiconductor-laser-
based flowcytometry, obtains the white blood cell count/basophils count using the principle
of impedancemethod (also known as Coulter principle) and eventually calculates the
parameters relevant to whiteblood cells.
1.1. Working Principle of Laser-based Flow Cytometry
The analyzer obtains the white blood cell differential count using semiconductor–laser-
based flowcytometry.
Figure1WBC Measurement
After a predetermined volume of blood is aspirated and diluted by certain amount of

reagents and they areisinjected into the flow chamber. Surrounded with sheath fluid
(diluent), the blood cells pass throughthe center of the flow chamber in a single column at a
faster speed. When the blood cells suspendedin the diluent pass through the flow chamber,
they are exposed to a laser beam. The intensity ofscattered light reflects the blood cell size
and intracellular density. The low-angle scattered lightsignal shows cell size, while the
middle-angel and high-angle scattered light signal show intracellularinformation (nucleus
and cytoplasm information). The optical detector receives this scattered lightand converts it
into electrical pulses. Pulse data thus collected can be used to draw a
2-dimensionaldistribution (scattergram).

Figure2DIFF channel scattergram
By analyzing the DIFF channel scattergram, the analyzer presents the Lym%, Mon%, Eos%
andNeu%.
1.2. Electrical Impedance Method
BASs/WBCs are counted and sized by the Electrical Impedance method.

This method is based on the measurement of changes in electrical resistance produced by a
particle, which in this case is a blood cell, suspended in a conductive diluent as it passes
through an apertureof known dimensions. An electrode is submerged in the liquid on both
sides of the aperture to createan electrical pathway. As each particle passes through the
aperture, a transitory change in theresistance between the electrodes is produced. This
change produces a measurable electrical pulse.The number of pulses thus generated is equal
to the number of particles that have passed throughthe aperture. The amplitude of each
pulse is proportional to the volume of each particle.
Figure3Electrical Impedance Method
Each pulse is amplified and compared to the internal reference voltage channel, which only
acceptsthe pulses of certain amplitude. If the pulse generated is above the WBC/BAS lower

thresholdvalue, it is counted as a WBC/BAS. The analyzer presents the WBC/BAS
histogram, where thex-coordinate represents the cell volume (fL) and the y-coordinate
represents the number of the cells.
1.3. Derivation of WBC-Related Parameters
Based on the analysis of the DIFF channel scattergram and the Lym region, Neu region,
Mon regionand Eos region, the analyzer calculates the Lym%, Mon%, Eos% and Neu%.
After WBCmeasurement, the analyzer proceeds to calculate Lym#, Neu#, Mon# and Eos#
per the followingequations while Bas# is obtained directly by the Electrical Impedance
method and expressed in109/L.
⚫ White Blood Cell count
WBC count is the number of leukocytes measured directly by counting the leukocytes
passingthrough the aperture.
⚫ Number of Basophils (Bas#)
Bas# is the number of Basophils measured directly by counting the Basophils passing
throughthe aperture.
⚫ Percentage of Basophils (BAS %)
Bas#
BAS% = WBC×100%
⚫ Percentage of Lymphocytes (Lym %)

Particles in Lym region of DIFF channel
Lym% = × 100%
Sum of all particles in DIFF channel except those in Ghost region
⚫ Percentage of Neutrophils (Neu %)

Particles in Neu region of DIFF channel
Neu% = × 100%
⚫ Percentage of Monocytes (Mon %)

Particles in Mon region of DIFF channel
Mon% = × 100%
⚫ Percentage of Eosinophils (EOS %)

Particles in Eos region of DIFF channel
EOS% = × 100%
⚫ Number of lymphocytes (Lym#)

Lym# = WBC ×Lym%
⚫ Number of Neutrophils (Neu#)

Neu#= WBC × Neu%
⚫ Number of Monocytes (Mon#)

Mon#= WBC × Mon%
⚫ Number of Eosinophils (EOS#)
EOS #= WBC × EOS%
2. HGB Measurement
HGB is determined by the colorimetric method.
2.1. Colorimectric Method
The WBC/HGB diluent is delivered to the HGB bath where it is mixed with a certain
amount of lyse, which converts hemoglobin to a hemoglobin complex that is measurable at
525 nm. An LED ismounted on one side of the bath and emits a beam of monochromatic
light with a central wavelengthof 525nm. The light passes through the sample and is then
measured by an optical sensor mountedon the opposite side. The signal is then amplified
and the voltage is measured and compared withthe blank reference reading (readings taken
when there is only diluent in the bath).
2.2. HGB
The HGB is calculated using the following equation and expressed in g/L.
Blank Photocurrent
HGB(g/𝐿) = Constant × Ln（）
Sample Photocurrent
3. RBC/PLT Measurement
The analyzer detects the red blood cell count and platelet count and their volume
distribution byimpedance method and eventually obtains the results of related parameters.
3.1. Electrical Impedance Method
RBCs/PLTs are counted and sized by the Electrical Impedance method. This method is
based on themeasurement of changes in electrical resistance produced by a particle, which
in this case is a bloodcell, suspended in a conductive diluent as it passes through an
aperture of known dimensions. Anelectrode is submerged in the liquid on both sides of the
aperture to create an electrical pathway. Aseach particle passes through the aperture; a
transitory change in the resistance between theelectrodes is produced. This changeproduces
a measurable electrical pulse. The number of pulsesthus generated is equal to the number of

particles that passed through the aperture. The amplitudeof each pulse is proportional to the
volume of each particle.
Figure4Counting Principle
Each pulse is amplified and compared to the internal reference voltage channel, which only
accepts thepulses of certain amplitude. If the pulse generated is above the RBC/PLT lower
threshold value, itis counted as a RBC/PLT. The analyzer presents the RBC/PLT histogram,
where the x-coordinaterepresents the cell volume (fL) and the y-coordinate represents the
number of the cells.
3.2. RBC
⚫ Red Blood Cell count

RBC (1012/L) is the number of erythrocytes measured directly by counting the
erythrocytespassing through the aperture.
⚫ Mean Corpuscular Volume
Based on the RBC histogram, this analyzer calculates the mean corpuscular volume
(MCV) andexpresses the result in fL.
⚫ Hematocrit (HCT), Mean Corpuscular Hemoglobin (MCH), Mean
CorpuscularHemoglobinConcentration (MCHC).
This analyzer calculates the HCT (%), MCH (pg) and MCHC (g/L) as follows, where
the RBC isexpressed in 1012/L, MCV in fL and HGB in g/L.
RBC × MCV
HCT =
10

HGB
MCH =
RBC
HGB
MCHC = × 100
HCT
⚫ Red Blood Cell Distribution Width Coefficient of Variation (RDW-CV)
Based on the RBC histogram, this analyzer calculates the CV (Coefficient of
Variation, %) of theerythrocyte distribution width.
⚫ Red Blood Cell Distribution Width Standard Deviation (RDW-SD)
RDW-SD (RBC Distribution Width – Standard Deviation, fL) is obtained by
calculating thestandard deviation of the red blood cell size distribution.
3.3. PLT
⚫ Platelet count (PLT count, 109/L)

PLT is measured directly by counting the platelets passing through the aperture.
⚫ Mean Platelet Volume (MPV, fL)
Based on the PLT histogram, this analyzer calculates the MPV.
⚫ Platelet Distribution Width (PDW)
PDW is the geometric standard deviation (GSD) of the platelet size distribution. Each PDW
resultis derived from the platelet histogram data and is reported as 10(GSD).
⚫ Plateletcrit (PCT)
This analyzer calculates the PCT as follows and expresses it in %, where the PLT is
expressedin 109/L and the MPV in fL.
PLT × MPV
PCT =
10000
⚫ Platelet-Large Cell Count (P-LCC, 109/L)
P-LCC is measured directly by counting the large platelets passing through the aperture.
⚫ Platelet-Large Cell Ratio (P-LCR)
P − LCC
P − LCR = × 100%
PLT
4. IP Message Parameters
FlagType Message Judgment method

WBC Leucopenia WBC<2.50×109/L（or % setting）
Abnormal Leucocytosis WBC>18.00×109/L（or % setting）
Neutropenia NEU#<1.00×109/L（or % setting）
Neutrophilia NEU#>11.00×109/L（or % setting）
Lymphopenia LYM#<0.80×109/L（or % setting）
Lymphocytosis LYM#>4.00×109/L（or % setting）
Monocytosis MON#>1.50×109/L（or % setting）
Eosinophilia EOS#>0.70×109/L（or % setting）
Basophilia BAS#>0.20×109/L（or % setting）
WBC Abn.WBCscattergram Judged from DIFF scattergrams
Suspicious Left Shift? Judged from DIFF scattergrams
Immature Cell? Judged from DIFF scattergrams
Abnor./Atypical Lym? Judged from DIFF scattergrams
RBC Lyse Resistant? Judged from DIFF scattergrams
RBC Erythrocytosis RBC>6.5×1012/L
Abnormal Anisocytosis RDW-CV>22% or RDW-SD>64fl
Hypochromia MCHC<290g/L
Microcytosis MCV<70fl
Macrocytosis MCV>110fl
Anemia HGB<90g/L
RBC Abnor. RBC Distr. Arithmetic calculation and numerical comparison
Suspicious Dimorphologic Based on gap between the high and low points and
shape ofdistribution peak.
Iron Deficiency? Arithmetic calculation and numerical comparison
HGB Abn./Interfere? Arithmetic calculation and numerical comparison
RBC Clump? Arithmetic calculation and numerical comparison
PLT Thrombopenia PLT<60×109/L
Abnormal Thrombocytosis PLT>600×109/L
PLT Abnor. PLT Distr. Arithmetic calculation and numerical comparison
Suspicious PLT Clumps? Judged from DIFF scattergrams
5. Abnormal Flags Analysis
5.1. Abnormal WBCScattergram
Flag rules：Cell subgroups borderlines are blurring in DIFF channel. Boundary particles
reach a certain number trigger rules

⚫ Normal WBC Scattergram ⚫ Abnormal WBC Scattergram
5.2. Abnormal RBC Distribution
5.2.1. Abnormal Distribution
Flag rules：Histogram distribution does not accord with normal distribution of blood sample
⚫ Normal RBCDistr. ⚫ Abnormal RBCDistr.
5.2.2. Dimorphologic
Flag rules：More than one peak on RBC distribution
⚫ Double-peak RBC distribution

5.3. Abnormal PLT Distribution
Flag rules：RBC/PLTboundary is blurring（PLT-UP>25%）.
⚫ Normal PLTDistr. ⚫ Abnormal PLTDistr.

Chapter Two Leukocytosis Case
1. Neutrophilia
Report Analysis：Neutrophilia is shown（Neu#：16.77×109/L），the brightness of light

blue zone isincreased obviously in DIFFscattergram. The number of particles
accumulated at the same position increased is indicated.The test result of Neu is 89.6%,
which matches the visual count.

Visual differential counts（%） Blood smear：
Total count 200
Neu% 86.5%
Lym% 5.0%
Mon% 4.0%
Eos% 4.5%
0.0% May-Giemsa staining（×1000）

Bas%
2. Lymphocytosis

Report Analysis：This case lymphocytosis is shown（Lym#：5.16×109/L），the
brightness of green zone is increased obviously in DIFF scattergram. The number of
particles accumulated at the same position increased is indicated.The test result of Lym
is 70.4%，which matches the visual count.
Visual differentialcounts（%） Blood smear：
Total count 200
Neu% 27.0%
Lym% 69.5%
Mon% 2.5%
Eos% 0.0%
Bas% 1.0% May-Giemsa staining（×1000）

3. Monocytosis
Report Analysis：Case of Monocytosis is shown（Mon#：1.95×109/L）

，the brightness
of purpe zone is increased obviously in DIFF scattergram. The number of particles
accumulated at the same position increased is indicated. The test result of Mon is
25.0%, which matches the visual count.

Total count 200
Neu% 59.5%
Lym% 14.0%
Mon% 25.5%
Eos% 1.0%
4. Eosinophilia

Report Analysis：The case of Eosinophilia is shown（Eos#：3.26×109/L）, the
brightness of red zone is increased obviously in DIFF scattergram. The number of
particles accumulated at the same position increased is indicated. The test result of
Mon is 39.7%, which matches the visual count.
Total count 200
Neu% 31.5%
Lym% 27.0%
Mon% 2.0%
Eos% 40.0%

Chapter Three Other Abnormalitis
1. Immature Cell & Left Shift
Report Analysis：
[1] Graphical analysis：Lots of particals appear in DIFF scattergram immature cell

zone (arrow indicated). Immature cells maybe exist.
[2] Report analysis：Test result indicated high WBC. At the same time flag “immature

cell?”，”left shift”?. At the same time high LIC# and LIC% of research parameters
also indicate high LIC. Blood smear is suggested
[3] Blood smear：RBC, PLT are fine. Lots of band neutrophils②and large immature
cell ①are visible.
Total count 200
LIC% 15.0%
Band% 56.0%
Neu% 8.0%
Lym% 18.0%
Mon% 2.5%
Eos% 0.5%
May-Giemsa staining（×1000）
Bas% 0.0%

2. Abnormal/Atypical Lym
Report Analysis：
[1] Graphical analysis：Lots of particals appear in DIFF scattergram Abnormal/Atypical

Lym zone (arrow indicated). Lym cluster and Mon cluster have poor separation.
[2] WBC Message：Abnor. /Atypical Lym?

[3] Diff analysis：Lym%、Lym # marked“？”indicated differential results may be affected
by abnormal cells. Blood smear is suggested.

Total count 200
ALY% 3.0%
Neu% 23.5%
Lym% 66.5%
Mon% 6.0%
Eos% 0.5%
Bas% 0.5%
May-Giemsa staining（×1000）
3. Dimorphologic

Report Analysis：
[1] Count result：WBC、RBC、HGB are low；
[2] RBC Message：RBC are unevenly distributed, dimorphologic, and anemia.
[3] Histrogram ： RBC histogram shows double-peak. Test results for

RDW-CVandRDW-SD are not correct. Results show“**.*”, blood smear is
suggested；Result of MCV is affected. HCT, MCV, MCHC marked“？”, review is
suggested.
4. Microcytosis
Report Analysis：
[1] Count result：RBC and PLT counts are normal. MCV value is low；

[2] Histogram：RBC histogram main peak shifts to the left that indicate microcytes.
The right side of PLT histogram is higher from the horizontal coordinate,
suggesting a trailing shape. Abnormal PLT distribution is displayed by affected of
microcyte.
[3] RBC Message：Microcytosis；
[4] Manual counting：PLT：261×109/L。
5. Macrocytosis
Report analysis：
[1] Histogram：tail of RBC histogram aprears small peaks with obivious elevation
Count Result：It is obviously that RBC, HGB and HCT results are out of
propotion. While agglutination of RBC showed, multiple of RBC will be stack up
and pass counting chamber, leading to increasing of pulse and decreasing of actual
counting number. At last the total number of MCH, MCHC counting are decreased.
RBC and HCT are falsely lower. MCH and MCHC counting are increased
abnormally. The influence on WBC ad PLT is little.

[2] Blood Smear：Agglutination of RCB can be observed obviously.
6. Thrombocytosis
Report analysis：
Histogram of PLT is normal, PLT Message indicates thrombocytosis.
Blood Smear shows PLT：720×109/L. Test result is close to blood smear counting

7. Thrombopenia
Report analysis：
PLT histogram shows abnormal. PLT counting is decreased in test counting. PLT
Message indicates thrombopenia and abnormal histrogram. Blood Smear counting PLT：19
×109/L. Test counting is close to blood smear counting.

8. Abnor. PLT Distr.
Report analysis：
PLT histogram shows abnormal which the tail is slightly turned up. PLT counting is
decreased in test counting. PLT Message indicates thrombopenia and abnormal
histrogram. Blood Smear counting PLT：19×109/L. Test counting is close to blood
smear counting.
[1] Blood Smear：Thrombocyte（Arrows shows）

9. PLT Clump？
Report analysis：
[1] Graphical analysis：Scattergram distributors all are shown blue. And distribution
results are shielded.
[2] Result Analysis：PLT value is low, and “Abnor. PLT Distr.”, “PLT Clumps”
Message flags are displayed. Macroscopic agglutination was observed on the wall
of the test tube. Platelet agglutination was suspected. Suggest reviewing with fresh
blood sample.
[3] Blood smear：

Chater Four Abnormalities in the Leukocyte
1. Case 1: Chronic Myeloid Leukemia
Report analysis：
[1] Result analysis：WBC and PLT is obvisouly high, indicating anemia. Left Shift, Immature
Cell etc messages show.
[2] Graphical analysis: Immature cell area of DIFF scattergram has lots of splashes to
indicate lots of Immature Cells exist.

[3] Result analysis：Results of research parameter LIC# and LIC% are increased. Immature band
neutrophils are high.
[4] Patient：Femal, 43, Department of Hematopathology, Clinical diagnosis：Chronic Myeloid
Leukemia.
Blood smear：
Leukocyte Differential Count（n=200）
Archaeocyte 2.0% segmented 8.5%

neutrocyte
neutrophilic 4.0% Lymphocyte 3.5%

promyelocyte
neutrophilic 39.0% Monocyte 0.5%

myelocyte ① neutrophilic
myelocyte ；②
Neutrophilic 13.0% Eosinophils 1.5% Neutrophilic
metamyelocyte metamyelocyte ；③
Band neutrophils
Band 22.5% Basophilic 5.5%
neutrophils

2. Case 2: Chronic Lymphocytic Leukemia
Report analysis：
[1] Result Analysis：Instrument test shows high WBC. Lym#: 20.97×109/L. RBC is low.
Message indicates “Immature Cell”, “Lymphocytosis”.
[2] Graphical Analysis：Splashes are increased obviously in Lymphocyte area(arrow indicates)
[3] Patient ： Male ， 59 ， Department of Hematopathology ， Clinical Diagnosis ： Chronic

Lymphocytic .Leukemia
Blood smear：
Leukocyte Differential Count

（n=200）
Immature 1.5%
Lymphocyte
Segmented 5.5%
neutrocyte
Lymphocyte 92.5%
Monocyte 0.5%
Eosinophil 0.0% ① Lymphocyte；②Basket cell
Basophilic 0.0%

3. Case 3: Leukocytosis
Report analysis：
[1] Result Analysis：Test result shows WBC is high and no differential data with low PLT.
Anemia is indicaed. “Abnor WBC”, “Leukocytosis” is showed in Message.
[2] Graphical Analysis ： Lymphocytes and Monocytes are not separated clearly in DIFF

sactergram. Large of immature Lymphocytes or Monocytes may be exsit.
[3] Patient：Male，32, Department of Hematopathology，Clinical Diagnosis：Leukocytosis
Blood Smear

（n=200）
Immature 69.0%
Lymphocyte
Segmented 20.5%
neutrocyte
Lymphocyte 9.0%
① Immature Lymphocyte
Monocyte 1.0%
Eosinophil 0.5%
Basophilic 0.0%

4. Case 4：Leucopenia
Blood Smear （%）

Total count 200
Neu%
25.5%
Lym%
65.0%
Mon%
6.0%
Eos%
3.0%
Report analysis： Bas%
0.5%
WBC total number decrease. WBC splashes in scattergram also
decrease, which is in accord with test reust. Neutrophil is less than Lymphocyte. The whole
test result is accord with blood smear.

5. Case 5：Pulmonary Malignancy
Report analysis：
[1] Result Analysis：WBC is high. Message shows “Immature Cell”.

[2] Graphical Analysis：Large splashes appear neutrophil area in DIFF scattergram (arrow
indicates). Immature granulocyte may exsit.

[3] Patient：Female，49，Minimally invasive intervention department, Clinical Diagnosis：
Pulmonary Malignancy.
Blood Smear

（n=200）
Immature 4.5%
granulocyte
Segmented 79. 0%
neutrocyte
Lymphocyte 8.0%
① neutrophilic promyelocyte ② Segmented neutrocyte
Monocyte 6.0%
Eosinophil 1.5%
Basophilic 1.0%

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Content

Chapter One Measurement Principles and Process ....................................................................... 3

Copyright ©Dymind 1page of 36

Chater Four Abnormalities in the Leukocyte ............................................................................... 28

Copyright ©Dymind 2page of 36

1.1. Working Principle of Laser-based Flow Cytometry

After a predetermined volume of blood is aspirated and diluted by certain amount of

Copyright ©Dymind 3page of 36

1.2. Electrical Impedance Method

BASs/WBCs are counted and sized by the Electrical Impedance method.

Figure3Electrical Impedance Method

Copyright ©Dymind 4page of 36

1.3. Derivation of WBC-Related Parameters

⚫ Percentage of Lymphocytes (Lym %)

⚫ Percentage of Neutrophils (Neu %)

⚫ Percentage of Monocytes (Mon %)

⚫ Percentage of Eosinophils (EOS %)

⚫ Number of lymphocytes (Lym#)

⚫ Number of Neutrophils (Neu#)

Copyright ©Dymind 5page of 36

⚫ Number of Monocytes (Mon#)

2.1. Colorimectric Method

3.1. Electrical Impedance Method

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⚫ Red Blood Cell count

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⚫ Platelet count (PLT count, 109/L)

Copyright ©Dymind 8page of 36

5. Abnormal Flags Analysis

5.1. Abnormal WBCScattergram

reach a certain number trigger rules

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5.2. Abnormal RBC Distribution

5.2.1. Abnormal Distribution

⚫ Normal RBCDistr. ⚫ Abnormal RBCDistr.

Flag rules：More than one peak on RBC distribution

⚫ Double-peak RBC distribution

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Flag rules：RBC/PLTboundary is blurring（PLT-UP>25%）.

⚫ Normal PLTDistr. ⚫ Abnormal PLTDistr.

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Report Analysis：Neutrophilia is shown（Neu#：16.77×109/L），the brightness of light

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Total count 200

0.0% May-Giemsa staining（×1000）

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Visual differentialcounts（%） Blood smear：

Total count 200

Bas% 1.0% May-Giemsa staining（×1000）

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Report Analysis：Case of Monocytosis is shown（Mon#：1.95×109/L）

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Total count 200

Bas% 0.0% May-Giemsa staining（×1000）

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Visual differential counts（%） Blood smear：

Total count 200

Bas% 0.5% May-Giemsa staining（×1000）

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[1] Graphical analysis：Lots of particals appear in DIFF scattergram immature cell

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Total count 200

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[1] Graphical analysis：Lots of particals appear in DIFF scattergram Abnormal/Atypical