REFERENCE VALUES

IN HAEMATOLOGY
DR PETER OGUNDEJI
MBBS, ASSFMCPATH, FWACP

DR PETER OGUNDEJI 1
 LEARNING OUTCOMES

• AT THE END OF THE CLASS, STUDENTS WOULD BE ABLE TO

• INTERPRET HAEMATOLOGICAL TESTS AND SUGGEST
DIFFERENTIAL DIAGNOSIS
• EXPLAIN HOW CBC PARAMETERS ARE GENERATED

DR PETER OGUNDEJI 2
At the end of the class, students would be able to

Explain how cbc parameters are generated

Interpret haematological tests and

suggest differential diagnosis
DR PETER OGUNDEJI 3
 OUTLINE

• INTRODUCTION
• HAEMOGLOBIN
• RED CELL ABSOLUTE INDICES
• RETICULOCYTE COUNT
• WHITE CELL COUNT
• PLATELETS
• COAGULATIVE STUDIES
DR PETER OGUNDEJI 4
 INTRODUCTION

• HAEMATOLOGICAL INDICES ARE THE VARIOUS

INVESTIGATIONS CARRIED OUT IN THE HAEMATOLOGY
LABORATORY.
• NORMAL REFERENCE VALUES ARE OF UTMOST
IMPORTANCE IN THE CARE AND MANAGEMENT OF THE
PATIENT.

DR PETER OGUNDEJI 5
 PACKED CELL VOLUME(PCV)

• ANTICOAGULATED WHOLE BLOOD, CENTRIFUGED, PORTION

OF SPACE OCCUPIED BY PACKED CELLS
• EXPRESSED IN PERCENTAGE OR DECIMAL, NUMBER OF RED
BLOOD CELLS IN A GIVEN VOLUME OF WHOLE BLOOD
ADULT
• MALE ; 40-52%
• FEMALE ; 36-48%

NEW BORN ; 52% LOWER LIMIT

DR PETER OGUNDEJI 6
 HB CONCENTRATION

• USUALLY A THIRD OF PCV

• EXPRESSED IN G/L
• MALE ;13.5-17.5G/DL
• FEMALE ;11.5-15.5G/DL

DR PETER OGUNDEJI 7
 RCC

• RED CELL COUNT, IS THE NUMBER OF RED BLOOD CELLS IN

A STATED VOLUME OF WHOLE BLOOD
• EXPRESSED AS THE NUMBER OF CELLS PER LITRE OF
BLOOD
• FEMALE ; 3.8-5.8 X 10¹² PER L
• MALE ; 4.5-6.5 X1012 PER L

DR PETER OGUNDEJI 8
 Anaemia

Iron deficiency anaemia

Vitamin B12/ folate anaemia

Sideroblastic anaemia

Anaemia of chronic disordHaemolytic

anaemiasers
DR PETER OGUNDEJI 9
 POLYCYTHAEMIA

• CONGENITAL
• CHRONIC LUNG DISEASE
• SMOKING
• CARBON MONOXIDE
• HIGH ALTITUDE
• OBSTRUCTIVE SLEEP APNEA
• RENAL ARTERY STENOSIS
• RENAL CELL CARCINOMA
DR PETER OGUNDEJI 10
 RED CELL ABSOLUTE INDICES

• CANNOT BE MEASURED DIRECTLY

• MEASURED USING BASIC PARAMETERS
• CALCULATED AS A MEASURE OF 2 RATIOS
• MEAN CELL VOLUME (MCV)
• MEAN CELL HAEMOGLOBIN (MCH)
• MEAN CELL HAEMOGLOBIN CONCENTRATION(MCHC)

DR PETER OGUNDEJI 11
 MEAN CELL VOLUME(MCV)

• INDICATES AVERAGE VOLUME OR SIZE OF INDIVIDUAL RED CELL

• NORMAL IS 80-95FL
• PCV(LITRES)

RBC
• DECREASED IN IRON DEFICIENCY, THALASSAMIA, LEAD
POISONING, MICROCYTIC
• INCREASED IN FOLATE /VITAMIN 12 DEFICIENCY, ALCOHOL, LIVER
DISEASE, MACROCYTIC

DR PETER OGUNDEJI 12
MEAN CELL HAEMOGLOBIN(MCH)

• INDICATES AVERAGE VOLUME OF HAEMOGLOBIN IN INDIVIDUAL

CELL
• HB(IN G/L)

RBC(CELL/L)
• NORMAL IS 27-32PG
• DECREASED IN IRON DEFICIENCY, THALASSAMIA, LEAD POISONING
• INCREASED IN ACUTE BLOOD LOSS, RENAL DISEASES, BONE
MARROW FAILURE, POST-CHEMOTHERAPY

DR PETER OGUNDEJI 13
 MEAN CELL HAEMOGLOBIN
CONCENTRATION (MCHC)
• INDICATES QUANTITY OF HAEMOGLOBIN IN A GIVEN
VOLUME OF RED CELL
• HB IN G/L
PCV IN L/L
• 32-35G/DL

DR PETER OGUNDEJI 14
 ERYTHROCYTE SEDIMENTATION
RATE (ESR)
• RATE AT WHICH RED CELLS SETTLE IN A GIVEN
ANTICOAGULATED BLOOD.
• NON SPECIFIC TEST
• NOT FOR DEFINITIVE DIAGNOSIS
• USEFUL FOR MONITORING/FOLLOW UP
MEN ; 0-7MM/HR WESTERGREN
FEMALE ; 0-15MM/HR WESTERGREN

DR PETER OGUNDEJI 15
SLIGHTLY INCREASED
• WITH AGE
• PREGNANCY
• ANAEMIA

DR PETER OGUNDEJI 16
HIGH
• ACUTE INFECTIONS
• CHRONIC INFECTIONS
• NEOPLASTIC CONDITIONS
• DEGENERATIVE/INFLAMMATORY CONDITIONS

DR PETER OGUNDEJI 17
VERY HIGH
• MULTIPLE MYELOMA
• RHEMATOID ARTHRITIS
• TUBERCULOSIS
• HIV/AIDS

DR PETER OGUNDEJI 18
 RETICULOCYTE COUNT

• RETICULOCYTES ARE IMMATURE RED CELLS AT THE

PENULTIMATE STAGE OF MATURATION.
• NORMAL COUNT IS 0.5-2%
• INDICATES ACTIVE BONE MARROW AS A RESPONSE TO
INCREASED PERIPHERAL DESTRUCTION OF RED CELL

DR PETER OGUNDEJI 19
 INCREASED

• SICKLE CELL HEMOLYTIC CRISIS

• HEAMOLYTIC ANAEMIA
• G6PD
• RECOVERY AFTER ACUTE BLOOD LOSS
• RESPONSE TO HEMATINIC TREATMENT IN CASE OF FOLIC
ACID, VITAMIN B12 AND IRON DEFICIENCIES
• NOT INCREASED IN ANAEMIA DUE TO IMPAIRED RED CELL
PRODUCTION
DR PETER OGUNDEJI 20
FEATURE/ DESCRIPTION SIGNIFICANCE OF
ABNORMALITY FEATURE/
ABNORMALITY
RBC MORPHOLOGY
Normal red cell 8 micrometer.
Stains pink red.
Central area of palor
about
1/3 of cell’s diameter

Hypochromic cells Pale staining Iron def, thallasemia ,

Increase area of palor anaemia of chronic inf,
>1/3 sideroblastic anaemia

Polychromasia Blue grey Staining of Post haemorrhage,

immature red cells haemolysis, anaemia with
(reticulocyte) effective BM response,
Larger than normal RBC ffg treatment for anaemia

DR PETER OGUNDEJI 21
Microcytosis Smaller than normal Iron def, anaemia of
RBC chronic infection,
< 6.5 thallasemia syn

Macrocytosis Larger than normal RBC Folate & vit B12 def,(oval
8 macrocytes) , liver dx,
alcoholism

Target cells Stains in the centre & Thallasemia, SCD, HbC

periphery with an dx , obstructive jaundice,
unstained ring in btw liver dx, post splenectomy

Sickle cells Elliptical cells with SCD ,SCA, SC/B thal,

pointed ends, crescent or HbSC
boat shaped

DR PETER OGUNDEJI 22
Anistocytosis Unequal variation in the Assoc with many
size of red cells anaemia

Poikilocytosis Significant variation in Assoc with many anaemia

the shape of red cells

Pencil cells Elongated, narrow cells Iron deficiency

Tear drop cell Cells shaped like tear Myelofibrosis,

drops extramedullary
erythropoiesis

DR PETER OGUNDEJI 23
Rouleaux Cells joined together Myelomatosis,
side by side like stacks macroglobulinaemia,
of coins inflammatory disorder,
malignancy

Nucleated red cells Precursor red cells SCD, thallasemia major,

containing nucleus other severe anaemia,
hem dx of the newborn,
leukamias, autoimmune
hemolytic anaemia

Megaloblast Larger than normal Folate and vit B12 DEF

RBC(10-20) with an
immature nucleus (fine
lacy chromatin)
cytoplasm stains blue

DR PETER OGUNDEJI 24
 WHITE BLOOD CELL(WBC)

TOTAL WHITE BLOOD CELL

• NUMBER OF WHITE CELLS IN A STATED VOLUME OF BLOOD
• 2.0-10.0 X 109/L
• 4.0-11.0 X109/L

DR PETER OGUNDEJI 25
• DECREASED COUNT – LEUCOPENIA (<2 X10 9/L)
• TYPHOID FEVER
• HIV
• HYPERSPLENISM
• APLASTIC ANAEMIA
• CYTOTOXIC OR DRUG INDUCED.

DR PETER OGUNDEJI 26
WHITE CELL DIFFERENTIAL COUNT

• ENUMERATION OF THE DIFFERENT TYPES OF WHITE CELLS

IN THE BLOOD.
• SHOWS THE PROPORTION OF THE DIFFERENT TYPES OF
WHITE CELLS PRESENT.
ABSOLUTE WHITE CELL COUNT
THIS IS OBTAINED BY MULTIPLYING THE PERCENTAGE
DIFFERENTIAL COUNT BY THE TOTAL WHITE CELL COUNT

DR PETER OGUNDEJI 27
 At birth% 6yrs% Adult% Adult ,abs

Neutrophils 37-57 45-50 45-55 3.5+-2.25

Lymphocytes 23-35 40-45 25-40 2.4+-1.75

Monocytes 4-8 1-5 1-6 0.32+-0.29

Eosinophils 1-3 1-8 1-8 0.41+-0.39

Basophils 0-1 0-1 0-1 0.005+-0.005

DR PETER OGUNDEJI 28
 NEUTROPENIA

DRUG INDUCED
• ANTI-INFLAMMATORY
• ANTI- BACTERIAL
• ANTI-CONVULSANTS
• ANTI-THYROID
• ORAL HYPOGLYCAEMICS
• PHENOTHIAZINES
• ANTI-DEPRESSANTS
DR PETER OGUNDEJI 29
• OTHER DRUGS- GOLD, PENICILLAMINE
• AUTOIMMUNE
• SYSTEMIC LUPUS ERYTHEMATOSUS
• HYPERSENSITIVITY AND ANAPHYLAXIS

DR PETER OGUNDEJI 30
INFECTIONS
• VIRAL ;HEPATITIS, INFLUENZA, HIV
• BACTERIA ; TYPHOID, TUBERCULOSIS
PART OF GENERAL PANCYTOPENIA
• BONE MARROW FAILURE
• SPLENOMEGALY

DR PETER OGUNDEJI 31
 NEUTROPHILIA

• BACTERIA INFECTIONS- PYOGENIC, LOCALIZED OR

GENERALIZED
• INFLAMMATION/TISSUE NECROSIS – VASCULITIS, MYOSITIS
• METABOLIC DISORDERS – URAEMIA, ECLAMPSIA, ACIDOSIS,
GOUT
• NEOPLASM – CARCINOMAS, LYMPHOMA, MELANOMA
• ASPLENIA

DR PETER OGUNDEJI 32
• DRUGS – CORTICOSTEROID THERAPY, LITHIUM
• CHRONIC MYELOID LEUKAEMIA, MYELOPROLIFERATIVE
DISEASE, POLYCYTHAEMIA VERA, MYELOFIBROSIS,
ESSENTIAL THROMBOCYTHAEMIA
• RARE INHERITED DISORDERS
• ACUTE HEMORRHAGE OR HEMOLYSIS

DR PETER OGUNDEJI 33
 LYMPHOCYTOSIS

INFECTIONS
• ACUTE; INFECTIOUS MONONUCLEOSIS, RUBELLA,
PERTUSIS, MUMPS, HIV, CYTOMEGALOVIRUS, INFECTIOUS
HEPATITIS
• CHRONIC; TUBERCULOSIS, TOXOPLASMOSIS, BRUCELLOSIS,
SYPHILIS
CHRONIC LYMPHOID LEUKAEMIA
ACUTE LYMPHOBLASTIC LEUKAEMIA
DR PETER OGUNDEJI 34
 LYMPHOPENIA

• HIV
• LEGIONELLA PNEUMOPHIIA
• SEVERE BONE MARROW FAILURE- AS PART OF
PANCYTOPENIA
• CORTICOSTEROID THERAPY
• IMMUNOSUPPRESSIVE THERAPY
• IRRADIATION

DR PETER OGUNDEJI 35
 MONOCYTOSIS

• CHRONIC BACTERIA INFECTIONS; TUBERCULOSIS,

BRUCELLOSIS, BACTERIA ENDOCARDITIS, TYPHOID
• CONNECTIVE TISSUE DISEASE ; SLE, TEMPORAL ARTERITIS
• RA
• PROTOZOAN INFECTION
• HODGKINS LYMPHOMA
• CHRONIC MYELOMONOCYTIC LEUKAEMIA

DR PETER OGUNDEJI 36
 EOSINOPHILIA

• ALLERGIC DISEASE ; ASTHMA, HAY FEVER, URTICARIA, FOOD

SENSITIVITY
• CONNECTIVE TISSUE DISEASE ; SLE ,RHEMATOID ARTHRITIS,
TEMPORAL ARTHRITIS
• PROTOZOAN INFECTIONS
• CHRONIC NEUTROPENIA
• HODGKIN LYMPHOMA
• CHRONIC MYELOMONOCYTIC LEUKAEMIA
DR PETER OGUNDEJI 37
 BASOPHILIA

• MYELOPROLIFERATIVE DISORDERS ; CHRONIC MYELOID

LEUKAEMIA
• SMALLPOX
• CHICKENPOX
• ULCERATIVE COLITIS
• MYXOEDEMA

DR PETER OGUNDEJI 38
 PLATELETS

• NORMAL IN BLACKS 100-300X109/L

• THROMBOCYTOPENIA
MILD 50-99 X109/L
MODERATE 20-49 X109/L
SEVERE < 20 X109/L
• THROMBOCYTOSIS

DR PETER OGUNDEJI 39
 THROMBOCYTOPENIA

FAILURE OF PLATELETS PRODUCTION

• APLASTIC ANAEMIA
• MYELOFIBROSIS
• MULTIPLE MYELOMA
• MYELODYSPLASTIC SYNDROMES
• LEUKAEMIA
• RADIOLOGY
• MARROW INFILTRATION – CARCINOMA, LYMPHOMA
DR PETER OGUNDEJI 40
 INCREASED CONSUMPTION OF
PLATELETS
• AUTOIMMUNE
• DISSEMINATED INTRAVASCULAR COAGULOPATHY
• THROMBOTIC THROMBOCTOPENIC PURPURA
• DRUG INDUCED- HEPARIN
• INFECTIONS – HIV, MALARIA
OTHERS –ABNORMAL DISTRIBUTION OF PLATELETS, SPLENOMEGALY
MASSIVE TRANSFUSION OF STORED BLOOD TO
BLEEDING(DILUTIONAL LOSS)
DR PETER OGUNDEJI 41
BONE MARROW SUPPRESSION
• IONIZING RADIATION
• CYTOTOXIC DRUGS
• ETHANOL
• CHLORAMPHENICOL
• BENZENE
• PENICILLAMINE
DR PETER OGUNDEJI 42
 THROMBOCYTOSIS

• REACTIVE THROMBOCYTOSIS IN
SICKLERS
SURGERY
IRON DEF
• ESSENTIAL THROMBOCYTEMIA
• SPLENECTOMY
• NEPHROTIC SYNDROME
DR PETER OGUNDEJI 43
 TEST FOR COAGULATIVE
DISORDERS
• PROTHROMBIN TIME
• ACTIVATED PARTIAL THROMBOPLASTIN TIME(APTT)

DR PETER OGUNDEJI 44
 PROTHROMBIN TIME

• MEASURES FACTORS VII, X, V, PROTHROMBIN AND

FIBRINOGEN
• USED IN MONITRING ORAL ANTICOAGULANTS
• NORMAL IS 10-14S
• PROLONGED IN DEFICIENCIES OF INVOLVED CLOTTING
FACTORS
• LIVER DISEASE, WARFARIN THERAPY, DIC

DR PETER OGUNDEJI 45
 INR

• INTERNATIONAL NORMALIZED RATIO

• CALCULATED FROM PT
• BASED ON THE RATIO OF PATIENT’S PT TO A MEAN NORMAL
PT WITH CORRECTION FOR SENSITIVITY
• 0.8-1.2

DR PETER OGUNDEJI 46
 ACTIVATED PARTIAL
THROMBOPLASTIN TIME
• APTT
• MEASURES FACTORS XII,XI, IX, VIII,X, V,II, FIBRINOGEN
• NORMAL IS 30-40S
• PROLONGED IN DEFICIENCIES OF INVOLVED FACTORS
• HAEMOPHILIA

DR PETER OGUNDEJI 47
 BONE MARROW

• SAMPLES OF BONE MARROW CAN BE OBTAINED BY

ASPIRATION OR BIOPSY WITH SPECIAL NEEDLES. ASPIRATES
ARE SMEARED ON SLIDES AND STAINED WHILE BIOPSIES
ARE PROCESSED HISTOLOGICALLY.
• A DIFFERENTIAL COUNT OF THE HAEMOPOIETIC CELLS IS
THEN DONE AND THE MYELOID ERYTHROID RATIO IS ALSO
DETERMINED

DR PETER OGUNDEJI 48
• TYPICAL RBC IN THE BM.
MYELOBLASTS -0-4%
PROMYELOCYTES -0.5-5%
MYELOCYTES -10-30%
METAMYELOCYTES 10-30%
MATURE GRANULOCYTES -5-25%
LYMPHOID CELLS - 5-20%
PLASMA CELLS 0-3%
ERYTHROID PRECURSORS -5-30%
MEGAKARYOCYTES FEW -SEVERAL
DR PETER OGUNDEJI 49
 REFERENCES

• HOFFBRAND A.V. ESSENTIAL HAEMATOLOGY. WILEY-

BLACKWELL. 6TH EDITION. 2011
• DACIE AND LEWIS. PRACTICAL HAEMATOLOGY. CHURCH-
HILL LIVING STONE.6THEDITION. 2006
• J.O ADEWUYI .COMPANION TO PRACTICAL HAEMATOLOGY.
UNILORIN PRESS. 2006

DR PETER OGUNDEJI 50
DR PETER OGUNDEJI 51
•THANK

DR PETER OGUNDEJI
YOU 52