Hematology

HEMATOLOG
Dula D. (B.Pharm; MSc)

Jimma University
School of Pharmacy
Introduction
2
 Hematologic cell types are originate from the

hematopoietic stem cell (bone marrow, lymph
system or blood).
 Each cell line has a defined role and unique

contribution to the overall homeostatic process.
Hematology 04/01/2021
Hematopoietic stem cell lineage
3
Complete Blood Count (CBC)
4
 CBC is one of the most commonly ordered

clinical laboratory tests.
 CBC measures;
o RBCs, Hgb, hematocrit (Hct)
o Mean cell volume (MCV), mean cell Hgb
concentration (MCHC)
o Total WBCs (with differential)
o Platelet . Hematology 04/01/2021
Complete Blood Count (CBC)
5
Red Blood Cells (Erythrocytes)
6
 RBCs are produced in the bone marrow, released

into the peripheral blood;
 circulated for approximately 120 days, and cleared
by the reticuloendothelial system.
 The primary function is to transport oxygen
linked to Hgb from the lungs to tissues.
Red Blood Cells
7
 The concentration of RBCs in the blood can be

measured to detect anemia.
 Hct and Hgb concentrations are generally used
to monitor quantitative changes in RBCs.
 Reference Range:
 Male: 4.3–5.9 × 106/µL
 Female:3.5–5 × 106/µL
Hematocrit (Hct)
8
 Hct (packed cell volume) is the percentage of

RBCs to the total blood volume.
 determined by comparing the height of the settled
RBCs to the height of the column of whole blood.
 A decrease in Hct may result from;
 bleeding
 bone marrow suppressant effects of drugs
 Chronic diseases
 genetic alterations in RBC morphology, or hemolysis
Hematocrit
9
 An increase in Hct may result from;

 Hemoconcentration
 polycythemia vera
 polycythemia secondary to chronic hypoxia
 Reference Range:
 Males: 40.7%–50.3% or 0.4–0.503
 Female: 36%–44.6% or 0.36–0.446
Hemoglobin
10
 Hgb is the major oxygen-carrying compound

contained in RBCs.
 Total Hgb concentration primarily depends on the
number of RBCs in the blood sample.
 Medical conditions that impact the number of RBCs
will also affect Hgb concentration.
 Reference Range:
 Males: 13.8–17.5 g/dL or 138–175 g/L
 Females: 12.1–15.3 g/dL Hematology
or 121–153 g/L
04/01/2021
Red Blood Cell Indices
11
 RBC indices (Wintrobe indices) are useful

in the classification of anemias.
 These indices include;
o the MCV
o the MCH
o the MCHC
Red Blood Cell Indices
12
 These indices are calculated as:

 MCV = Hct (%) x 10 / RBC (mL/µL)
= 80-97.6 (µm3)
 MCH = Hgb (g/dL) x 10 / RBC (mL/µL)
= 27-33 (pg)
 MCHC=Hgb (g/dL) x 100 / Hct (%)
=33-36 (g/dL)
MEAN CELL VOLUME (MCV)
13
 The MCV detects changes in cell size.

 A decreased MCV indicates:
 a microcytic cell, which can result from iron-deficiency
anemia or anemia of chronic inflammation.
 A increased MCV indicates:

 a macrocytic cell, which can be caused by a vitamin B12
or folic acid deficiency.
 The MCV can be normal in a patient with a “mixed”

(microcytic and macrocytic) anemia.
MEAN CELL HEMOGLOBIN (MCH)
14
 The MCHC is a more reliable index of RBC Hgb than MCH.
 MCH measures the weight of Hgb in the RBCs in a sample.
 MCHC measures concentration of the RBCs contained

within a sample.
 In normochromic anemias,
 changes in the size of RBCs (MCV) are associated with
corresponding changes in the weight of Hgb (MCH),
 but the concentration of Hgb (MCHC) remains normal.
MEAN CELL HEMOGLOBIN
15
 Thus, hypochromic refers;

 to a decrease in RBC Hgb
 reflected by reduced MCHC, and may indicate

iron-deficiency anemia.
 Hyperchromic RBCs;
 have an elevated MCHC because of the presence

of greater amounts of Hgb.
 are not commonly encountered.
Reticulocytes
16
 Typically comprise about 1% of the RBCs.

 Measures the percentage of these new cells in the
circulating blood.
 An increase in the number of reticulocytes implies an
increased number of erythrocytes.
 Reticulocyte count is a good indicator of bone
marrow activity because it represents a recent
production.
Reticulocytes
17
 Appropriate treatment of anemias caused by iron,
vitamin B12, or folic acid deficiencies should result
in an increased reticulocyte count.
 Caution must be exercised in the interpretation of
reticulocyte counts.
 Changes in the number of RBCs will result in
proportional changes in the reticulocyte count.

o Adults: RR: 0.5%–1.5% of RBCs
Erythrocyte Sedimentation Rate
(ESR)
18
 The rate at which erythrocytes settle to the bottom of a test
tube through the forces of gravity and in response to fibrinogen
levels in the blood.
 is a nonspecific value and may be increased abnormally in
acute and chronic inflammatory processes.
o acute and chronic infections, neoplasms, infarction, tissue
necrosis, rheumatoid-collagen disease, dysproteinemias,
nephritis, and pregnancy.

 ESR can also be affected by non-inflammation e.g., change in
Hematology
erythrocyte size, shape, or number. 04/01/2021
Erythrocyte Sedimentation Rate
(ESR)
19
 Laboratory technique can also affect the

sedimentation rate substantially.
 Because many factors can enhance the settling rate

of RBCs.
 Moderate to marked elevation of the ESR merely

indicates an inflammatory component to a disease
state.
• RR: 0–30 mm/hour

White Blood Cells
20
 Leukocytes or WBCs comprise five different types of cells.

 Neutrophils, lymphocytes, monocytes, eosinophils, and basophils.
 The neutrophils, eosinophils, basophils, and monocytes are
formed from stem cells in the bone marrow.
 Lymphocytes are formed primarily in the lymph nodes,
thymus, spleen, and, to a lesser extent, bone marrow.
 Each WBC type has unique function.
 All WBCs contribute to host defense mechanisms.
 RR: 3.8–9.8 × 103/µL or 3.8–9.8 × 109/L

Neutrophils
21
 RR: 40%–70% of WBC
 Polymorphonuclear neutrophils, and granulocytes are synonymous with
the term neutrophil in clinical practice.
 The number of neutrophils is commonly increased during bacterial or
fungal infections;
o because these cells are essential in killing invading microorganisms.
 the bone marrow increases production of new leukocytes, there is also
an increase in the number of circulating immature neutrophils (e.g.,
bands);
 this phenomenon is commonly referred to as a “left shift,” which suggests
acute bacterial infection. Hematology 04/01/2021

Neutrophils
22
 Neutrophils are also altered by;
 noninfectious diseases (rheumatoid arthritis, IBD,
asthma, MI, or gout)
 metabolic toxic states (DKA, uremia, and eclampsia)
 physiologic response to stress (physical exercise,
childbirth).
 Drugs (epinephrine and corticosteroids)

o primarily caused by demargination from blood vessel walls.
Agranulocytosis and Absolute
Neutrophil Count (ANC)
23
 Neutropenia is defined as a neutrophil count of <2,000

cells/μL.
 Agranulocytosis refers to severe neutropenia.
o The most common causes are metastatic carcinoma,
lymphoma, and chemotherapeutic agents.
 The degree of neutropenia is often expressed by the ANC.

 The ANC is the total number of granulocytes present in
the circulating pool of WBCs.
 calculated as WBC × (% neutrophils + % bands)/100.
Agranulocytosis and ANC
24
 The risk of infection is low when the ANC exceeds

1,000/μL.
 The risk of infection increases significantly when

the ANC is <500/μL.
 The risk of developing bacteremia is increased

further as the ANC decreases to <100/μL, a
condition commonly referred to as “profound
neutropenia.”
Lymphocytes
25
 RR: 22%–44% of WBC

 These leukocytes respond to foreign antigens by
initiating the immune defense system.
 The lymphocytes circulating in blood represent
<5% of the total amount in the body.
 There are two major types of lymphocytes.
 T-lymphocytes participate in cell-mediated immune
responses.
 B-lymphocytes are responsible for humoral antibody
responses.
Lymphocytes
26
 Diseases affecting lymphocytes primarily manifest

themselves as immune deficiency disorders or as
autoimmune diseases.
 Increased numbers of lymphocytes indicates

lymphoma and viral infections.
Monocytes
27
 RR: 4%–11% of WBC

 are the precursors to macrophages and antigen-presenting
cells (dendritic cells), which are found in the body’s tissues.
 Macrophages and dendritic cells are phagocytic cells that
engulf foreign antigens or dead or dying cells.
 Monocytosis may be observed in,
o subacute bacterial endocarditis
o Malaria
o tuberculosis
o during the recovery phase of some infections 04/01/2021
Hematology
Eosinophils
28
 RR: 0%–8% of WBC
 have surface receptors that bind IgG and IgE
 can modify reactions associated with IgG and IgE-

mediated degranulation of mast cells.
 have phagocytic activity, facilitate killing of

microorganisms, initiate mast cell secretion,
protect against various parasites, and play
some role in host defense.
Eosinophils
29
 probably most commonly associated with;

§ allergic reactions to drugs
§ allergic disorders (hay fever, asthma & eczema)
§ invasive parasitic infections (hookworm,

schistosomiasis, and trichinosis)
§ collagen vascular diseases (RA, eosinophilic

fasciitis, and eosinophilic-myalgia syndrome)
§ malignancies (Hodgkin lymphoma)

Basophils
30
 RR: 0%–3% of WBC

 During infection or inflammation, basophils leave the
blood and mobilize as mast cells to the affected
site and release granules.
 These granules contain histamine, serotonin,
prostaglandins, and leukotrienes.
 Degranulation results in an increased blood flow to
the site and may compound inflammatory processes.
Basophils
31
 An increase in basophils commonly accompanies;

 allergic and anaphylactic responses
 Chronic myeloid leukemia
 Myelofibrosis
 polycythemia vera
 A decrease in the number of basophils is generally

not readily apparent.
Thrombocytes
32
 RR: 150–450 × 103/µL or 150–450 × 109/L
 Thrombocytes (platelets), are tiny fragments of cells that assist
with normal blood clotting.
 Decreased platelet counts (thrombocytopenia) may lead to
petechiae, ecchymosis, and spontaneous hemorrhage.
 Causes include;
 decreased platelet production
 dilution of blood samples secondary to blood transfusion
 sequestration secondary to hypersplenism

 DIC, infection, or systemic lupus erythematosus
Thrombocytes
33
 Elevated platelet counts (thrombocytosis) causes;

 malignancy
 rheumatoid arthritis
 iron-deficiency anemia
 loss from excessive bleeding or trauma
 polycythemia vera
 postsplenectomy syndromes
Coagulation Studies
34
 The control of bleeding depends on the formation of a
platelet plug and the formation of a stable fibrin clot.
 The formation of this clot depends on the complex
interactions of plasma proteins and clotting factors.
 coagulation studies are;

o prothrombin time (PT)
o international normalized ratio (INR)
o activated partial thromboplastin time (aPTT)

 used to monitor effectiveness &Hematology
safety of anticoagulation
04/01/2021 therapy
Activated Partial Thromboplastin
Time
35
 RR: 22–37 seconds
 aPTT measures the time it takes the body to form a clot.
 aPTT depends on;

 the activity of intrinsic pathway (factors VIII, IX, XI, & XII)
 common pathway (factors II, X, & V)
 aPTT is commonly measured to detect;

o bleeding disorders & coagulation deficiencies
o monitor unfractionated heparin therapy

Prothrombin Time
36
 RR: 10–13 seconds
 Prothrombin is converted to thrombin during the blood clotting
process.
 Thrombin formation is the critical event in the hemostatic process,
because thrombin creates fibrin results a clot formation.
 The PT test evaluates the integrity of the extrinsic and common
pathways and directly measures the activity of clotting factors VII
and X, II, and fibrinogen.
 PT is the time required for the blood to clot after a reagent (i.e.,
tissue thromboplastin). Hematology 04/01/2021

International Normalized Ratio [INR]
37
 INR is used as a standard unit to report the result of
PT test, because PT results obtained from one
reagent cannot be reliably with another reagent.
 Used to monitor both the initiation and
maintenance of warfarin.
 INR in normal individuals is 1.
 For patients on anticoagulation therapy, the target
INR is usually between 2 and 3.

International Normalized Ratio [INR]
38
 the higher the INR;

 the higher the likelihood of bleeding because the
blood is taking longer to clot.
 the INR is lower;

 there is an increased risk of developing a clot.
 Many factors including medications, diet, alcohol intake,
and certain medical conditions can influence the INR.
Case study
39
 LH: a 50 year old female, is hospitalized with a sustained

high fever of 39.2°C and severe back pain.
 The results of the CBC are as follows:
 Total WBC count: 21,000/μL
 Neutrophils: 74%
 Bands: 6%
 Lymphocytes: 14.6%
 Monocytes: 8%
 Eosinophils: 1%
 Basophils: 0%
 Imaging and other blood work was ordered.
 LH is diagnosed with an abscess in her lower back and
Staphylococcus aureus bacteremia.
 How is L.H.’s laboratory report consistent with a systemic
bacterial infection? Hematology 04/01/2021
Hematologic Laboratory Values
40 Hematology 04/01/2021

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HEMATOLOG

Dula D. (B.Pharm; MSc)

 Hematologic cell types are originate from the

 Each cell line has a defined role and unique

 CBC is one of the most commonly ordered

 RBCs are produced in the bone marrow, released

 The concentration of RBCs in the blood can be

 Hct (packed cell volume) is the percentage of

 An increase in Hct may result from;

 Hgb is the major oxygen-carrying compound

 RBC indices (Wintrobe indices) are useful

 These indices are calculated as:

 MCH = Hgb (g/dL) x 10 / RBC (mL/µL)

 MCHC=Hgb (g/dL) x 100 / Hct (%)

 The MCV detects changes in cell size.

 A increased MCV indicates:

 The MCV can be normal in a patient with a “mixed”

 The MCHC is a more reliable index of RBC Hgb than MCH.

 MCH measures the weight of Hgb in the RBCs in a sample.

 MCHC measures concentration of the RBCs contained

 but the concentration of Hgb (MCHC) remains normal.

 Thus, hypochromic refers;

 reflected by reduced MCHC, and may indicate

 have an elevated MCHC because of the presence

 Typically comprise about 1% of the RBCs.

 Appropriate treatment of anemias caused by iron,

vitamin B12, or folic acid deficiencies should result

in an increased reticulocyte count.

 Caution must be exercised in the interpretation of

 Changes in the number of RBCs will result in

proportional changes in the reticulocyte count.

 The rate at which erythrocytes settle to the bottom of a test

tube through the forces of gravity and in response to fibrinogen

levels in the blood.

 is a nonspecific value and may be increased abnormally in

acute and chronic inflammatory processes.

o acute and chronic infections, neoplasms, infarction, tissue

necrosis, rheumatoid-collagen disease, dysproteinemias,

nephritis, and pregnancy.

 Laboratory technique can also affect the

 Because many factors can enhance the settling rate

 Moderate to marked elevation of the ESR merely

• RR: 0–30 mm/hour

 Leukocytes or WBCs comprise five different types of cells.

 The neutrophils, eosinophils, basophils, and monocytes are

formed from stem cells in the bone marrow.

 Lymphocytes are formed primarily in the lymph nodes,

thymus, spleen, and, to a lesser extent, bone marrow.

 Each WBC type has unique function.

 All WBCs contribute to host defense mechanisms.

 RR: 3.8–9.8 × 103/µL or 3.8–9.8 × 109/L

 RR: 40%–70% of WBC

 Polymorphonuclear neutrophils, and granulocytes are synonymous with

the term neutrophil in clinical practice.

 The number of neutrophils is commonly increased during bacterial or

 the bone marrow increases production of new leukocytes, there is also

an increase in the number of circulating immature neutrophils (e.g.,

acute bacterial infection. Hematology 04/01/2021

 Neutrophils are also altered by;

 noninfectious diseases (rheumatoid arthritis, IBD,

asthma, MI, or gout)

 metabolic toxic states (DKA, uremia, and eclampsia)

 physiologic response to stress (physical exercise,