Tutorial pdf - طلاب المرحلة السادسة سابقا

CASES STUDY/ DATA

INTERPRETATION

HAEMATOLOGY

FULL BLOOD COUNT

• THE ELEMENTS :

1- RBCS

2 - WBCS

3- PLATELETS

RBCS

• ELEMENTS

HB.

ERYTHROCYTE COUNT [ RBCS]
HCT

MCV
MCH  / MCHC
RDW
RETICULOCYTE
ESR

WBCS

• ELEMENTS

NEUTROPHILS

LYMPHOCYTES

MONOCYTES
EOSINOPHILS

BASOPHILS

BLAST

PLATELETS

• ELEMENTS :

INCREASE

DECREASE

NORMAL

GENERAL TOPICS

• THE IMPACT OF

HAEMOGLOBINPATHIES

• PERIMARIATAL SCREENING

ANAEMIA

• DEFINITION:

IT IS A DECREASE IN THE NUMBER OF
CIRCULATING RBCS.

• ETIOLOGY:

1-BLOOD LOSS
2- DECREASE PRODUCTION
[ MARROW FAILURE]
3- INCREASE DESTRUCTION
[ HAEMOLYSIS]

Low Hb=Anemia

MCV

Low=microcytic

Normal=normocytic

High=macrocytic

Ferritin

Fe deficient

Fe normal

Establish
cause

Anemia of
chronic disease
or
hemoglobinopathy

Reticulocyte count

high

low

Anemia of chronic disease
Renal failure
Marrow failure

Hemolysis
or blood
loss

Measure B

+ folate

Low -
Establish cause

Normal

Obvious
cause

Cause not obvious
Consider bone marrow

CASE / DISCUSSION

• 19-YEAR OLD FEMALE STUDENT

PRESENT TO THE STUDENTS HEALTH
SERVICE WITH INCREASE FATIGUE&
MALAISE.
NO BLEEDING
MENSTRUAL CYCLE NORMAL.

• P/E NAD
• WHAT IS THE NEXT STEP/S?

CBC

• HB    7
• HCT     22.8
• MCV   72
• RDW     20
• RETIC.COUNT 1.1%
• VIT. B 12 & FOLATE  NORMAL
• WBCS  5000
• PLATELETS  285000
• WHAT IS NEXT?

CONT,

• FERRITIN < 4 [ N 12- 200]
• DIAGNOSIS : [ I D A]
• TREATMENT :

A- NON- PHARM.
B- PHARM.

CONT,

IDA CRITERIA

LOW HB

LOW HCT

LOW MCV
LOW MCH

MCHC LOW / N

LOW FERRITIN

LOW FE

HIGH TIBC

HIGH RDW

CASE / DISCUSSION

• AN 18-YEAR OLD MALE DIABETIC

COLLEGE STUDENT, WHO REQUIRES
INSULIN, PRESENT TO THE STUDENTS
HEALTH SERVICE WITH A LOW GRADE
FEVER & COUGH FOR 10 DAYS DURATION.

• P/E: CRACKLES ARE HEARED ON

AUSCULTATION OF BOTH LUNGS AT THE
RIGHT BASE, BUT THERE ARE NO SIGNS
OF CONSOLIDATION.

LAB. RESULTS

CBC:

• HEMOGLOBIN :10.5

ERYTHROCYTE: 3.13 MILLION
HCT        :32
MCV          :131
MCH          :30.6
MCHC        :42.5

• WHAT ARE/ IS THE OTHER TESTS

YOU WILL REQUEST?

Cont.

• LEUKOCYTES COUNT : 11500

NEUTROPHILS COUNT: 68%
LYMPHOCYTES COUNT: 24%
MONOCYTES COUNT :7%
EOSINOPHILS COUNT:1%
BASOPHILS COUNT: 0%

• PLATELETS COUNT: NORMAL

CONT,

• VIT. B12 & FOLATE [ B 12 WAS LOW]
• DRUGS & ALCOHOL LEVEL
• SCHILLINGS TEST [ +VE]
• LFT [ GAMMA G –T]
• DD :
• COELIAC DISEASE
• DRUGS
• ALCOHOL INTAKE

CONT,

• THE FINAL DIAGNOSIS [ B12 DEF.]
• TREATMENT:

VIT B12 1000 U IM DAILY X 7 DAYS
THEN WEEKLY X 4 WEEKS
THEN MONTHLY X 4 MONTHS

Haemoglobinopathy Investigation

Usually prompted by clinical findings and/or CBC.

Includes:

• Hb Electrophoresis
• Quantitation of Hb A

and Hb F

• Detection of Hb H Inclusions

Other information required : patient age, ethnicity

Additional tests : serum ferritin if microcytic, occasionally molecular

studies and/or family studies

Hb A

Normal
Control

Carbonic
Anhydrase

Hb A2

Abnormal
Control

Anode

Hemoglobin Electrophoresis

at alkaline pH

Case 1

Patient

Haemoglobin Electrophoresis

(alkaline pH )

Hb C

Hb S

Moves in same position as Hb A

HbA

Anode

Haemolysate applied

Cathode

Case 1

 18 year old young man seen for medical
   examination.
 Past medical history unremarkable.
 Family of middle east descent.
 Physical examination normal

Hb

132 g/L (140-180)

MCV     66.1 fL (80-100)


Blood Film: hypochromia,

microcytosis

Case 1

Lymphocyte

CASE 1: Blood Film

Hb A

Normal
Control

Hb A

Abnormal
Control

Anode

Hemoglobin Electrophoresis

at alkaline pH

Case 1

Patient
Case 1

Case 1

Haemoglobin Electrophoresis:

Hb A 93.8 %

Hb F 1.0 %

Hb A

5.2 %

α γ

Hb A

Hb F

Diagnosis: β Thalassemia trait

Genotype αααα β

β or

β- δδ γγ

Haemoglobins Produced

Laboratory diagnosis of β Thalassemia trait made by CBC, and Hb A

>3.5%.

Serum ferritin is normal or increased.

Case Two

• A -12-Year old African boy is tested for Sickle

Cell Disease pre-operatively

• His father is known to have Sickle Cell Triat
• Results:
• HB      10.1g\dl
• RBCS      6.1X10X12\l
• MCV   65fl
• MCH     21.1pg
• MCHC   30g\dl

Cont,

• What is the next step in your investigtions ?

CONT,

• SICKLING TEST
• HB. ELECTROPHORESIS

CONT,

• SICKLING TEST WAS +VE
• IS THAT ENOUGH?

CONT,

• HB. ELECTROPHORESIS RESULT :

HBS        45%
HBA        53%
HBA2     5.2%
HBF        0%
FERRITIN LEVEL   NORMAL

Questions

• What Haemoglobinopathy does the boy

have?

• What Haemoglobinopathy would you

expect on testing the mother?

Answer

• [ Sickle- Thal]
• The mother is expected to have Thalassaemia Trait
• NB:
• Presence of Hb A exclude SCD and THAL

.MAJOR

• Presence of HbF ONLY = THAL. MAJOR
• Presence of HbS ONLY = SICKLE CELL DIS.
• Presence of HbS +HbA= Sickle trait
• Presence of HbA+ HbA2 of more than

3.5=THAL.TRAIT

• Presence of HbA + HbA2 + Hbs = Sickle- Thal

Case 3

6 year old girl from Basrah
Admitted to hospital with abdominal pain and fever.
Past history : swelling of hands and feet at age 1
        : previous episodes of abdominal pain
Physical examination:
         pallor of mucous membranes
         mild jaundice
   hepatomegaly
         no splenomegaly
         no evidence of infection
Parents healthy : OK

Case 3

84 g/L (115-155)

MCV

86.5 fL (77-95)

Blood Film - sickle cells
        erythroblasts
   Howell-Jolly bodies
        polychromasia
        target cells

Case 3

Howell Jolly
Body

Erythroblast

Abnormal

Control

Normal
Control

Patient
Case 2

Hb C

Hb S Hb F Hb A

Case 2

Case 3

Haemoglobin Electrophoresis:

Hb A 0 %

Hb S 87.0 %

Hb F 9.7 %

Hb A

3.3 %



α γ

Hb S

Hb A

Hb F

Genotype αααα β

δδ γγ

Haemoglobins Produced :

Diagnosis: Hb SS Disease

Laboratory diagnosis of sickle cell anaemia made by presence of only Hb S, Hb A

, and Hb

F on Hb electrophoresis with no Hb A, a positive sickling test and presence of sickle cells in

blood film

Case 4

Haemoglobin Electrophoresis:

Hb A 0 %

Hb A

3.5 %

Hb F 96.5 %

α γ

Hb A

Hb F

Diagnosis: β Thalassemia major

Genotype αααα - - δδ γγ

Haemoglobins Produced

Laboratory diagnosis of β thalassemia major made by CBC, absence of Hb A, with

increased Hb F. Some patients have small amounts of Hb A if some β globin chain is

produced.

Case 5

28 year old  woman
Life long history anaemia and mild jaundice.
Past history : splenectomy.
Family History :

•

Mother: life long history microcytic

hypochromic anaemia, unresponsive to iron

• Father and sister: no known history of a blood

problem.

Case 5

97 g/L (140-180)

MCV

72.1 fL (80-100)

Blood Film:   Microcytosis
        Hypochromia
        Target cells
        Fragmented cells
        Howell-Jolly bodies

Case 5

Normal
Control

Abnormal

Control

Abnormal

Control

Patient
Case 5

Case 5

HbA

HbA2

Case 5

Haemoglobin Electrophoresis:

Hb A 91.5 %

Fast moving band 8.5%

Hb A

and Hb F decreased

Hb H Preparation

Hb H inclusions
in RBCs

Case 5

α γ

Hb A

Hb F

Genotype ---α ββ δδ γγ

Haemoglobins Produced :

Hb H Disease

Hb H

Diagnosis: Hb H Disease

Laboratory diagnosis made by CBC, and presence of Hb H on Hb

electrophoresis and in the Hb H preparation.

Case 5: Family Studies

Father: Hb 139 g/L (140-180)
MCV 79 fl (80-100)

Hb Electrophoresis normal.

Hb H preparation negative

Mother: Hb 100 g/L
MCV 66 fl

Hb Electrophoresis normal.

Hb H preparation : very occasional cell
positive for Hb H inclusions

CASE SCENARIO

• A 65- YEAR OLD MAN PRESENTED

WITH H/O :

• WT. LOSS, NIGHT SWEATS & FEVER
• P/E : LYMPHADENOPATHY

HEPATOSPLENOMEGALY

• HOW CAN YOU APPROACH SUCH A

PATIENT? & WHAT INVESTIGAION/S
ARE YOU GOING TO CARRY OUT?

Blood Count

WBC x

150.0

[4-11]

Hb g/L

[120-16 0]

MCV fl

8 7

[79-98]

Plat elet s x 10

[150-450]

Neut s x 10

1.5

[2-7.5]

Lymphs x 10

130.0

[1.5-4]

Monos x 10

0 .5

[0.2-0.8]

Eos x 10

[0-0.7]

Basos x 10

[0-0.1]

Smudge cells x 10

28.0

[0]

Film Comment : appearances suggest CLL

CLL – presenting clinical features

• Chance finding
• Marrow failure
• Symptoms

– weight loss
– night sweats
– fevers

• Lymphadenopathy
• Splenomegaly, hepatomegaly

lymphocytes

‘smudge’ cells

lymphocytes

CASE SCENARIO

• A 40-YEAR OLD FEMALE PRESENTED

WITH H/O :

• WT. LOSS, NIGHT SWEATS &

MULTIPLE JOINTS PAIN.

• P/E : PALE LOOKING & BIG SPLEEN
• WHAT SORT OF INVESTIGATION/ S

ARE YOU GOING TO PERFORM ?

Blood Count

BC x 10

/ L

122.0

[4-11

]

Hb g/ L

9 8 .5

20 -16 0 ]

MCV fl

8 7

[79-9 8 ]

Plat elet s x 1

/ L

8 43

50 -450 ]

Neut s x 10

/ L

8 0 .0

[2-7.5]

Lymphs x 1

/ L

2.0

.5-4]

Monos x 10

/ L

2.0

[0 .2-0 .8 ]

Eos x 1

/ L

1.0

[0 -0 .7]

Basos x 10

/ L

5.0

[0 -0 .1

]

Blast s x 1

/ L

2.0

[0 ]

Promyelocyt es x 10

/ L

4.0

[0 ]

Myelocyt es x 1

/ L

20 .0

[0 ]

Met amyelocyt es x 10

/ L

4.0

[0 ]

Nucleat ed RBC x 1

/ L

2.0

[0 ]

Film Comment : appearances suggest CML

CML - clinical features of chronic

phase

• Peak age 20 to 40 years
• Weight loss, night sweats
• Big spleen
• Gout
• Often found by chance

neutrophils

and
precursors

basophil

blast

promyelocyte

CASE 1

A 73 year old man is to undergo surgery to repair a left inguinal hernia. He is seen for a pre-
operative medical assessment and had the following blood work done the day prior. He has

otherwise been well and is on no medications

test

result

normal range

units

leukocytes

5.2

4.0-11.0

x10

hemoglobin

14.2

14-18

g/L

MCV

84.5

80-100

platelets

140-400

x10

neutrophils

3.0

2.0-7.5

x109/L

neutrophils

1.5

1.5-4.0

x109/L

monocytes

0.6

0.2-0.8

x109/L

eosinophils

0.1

0.0-0.7

x109/L

basophils

0.0

0.0-0.1

x109/L

CASE 2

A 23 years old male is seen in the clinic because of a 2 month history of recurrent epistaxis
and increased bruising. The following result were obtained on a CBC

test

result

normal range

units

leukocytes

4 .2

4.0-11.0

x109/L

hemoglobin

14.2

140-180

g/L

MCV

84.5

80-100

RDW

13.1

11.5-14.5

platelets

140-400

x109/L

neutrophils

2.2

2.0-7.5

x109/L

neutrophils

1.6

1.5-4.0

x109/L

monocytes

0.4

0.2-0.8

x109L

eosinophils

0.1

0.0-0.7

x109/L

basophils

0.0

0.0-0.1

x109/L