Evaluation of Peripheral blood

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Evaluation of Peripheral blood

• Huang Jinwen
• Sir Run Run Shaw Hospital

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Automated hematology instrumentation
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WBC differential Advia 2120
Neutrophils
Monocytes
Neutrophils (pink) and eosinophils (yellow)
containing the most perox activity are found to
the right. Cells with little or no perox cluster
to the left, such as lymphocytes/basophils (blue)
and large unstained cells (blasts, variant and
atypical lymphocytes, light blue). Monocytes
(green) contain a small amount of perox and are
located between the neutrophils and large
unstained cells. Noise is indicated in the lower
left hand corner (white).
cell size
Lymphocytes
eosinophils
peroxidase
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Red cell size distribution curves in hereditary
sideroblastic anemia
A broad population of red cells, varying markedly
in size, with the majority of the cells being
microcytic.
Presence of two populations of red cells
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Comparison between automated optical and
immunologic platelet counts
The majority of the data points well outside of
the 95 percent confidence limits are above the
best-fit line, suggesting that the optical method
is more prone to overestimate platelet counts
than the immunologic method in this range.
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Optimal area for review
Suboptimal blood smear
Normal peripheral blood smear
Rouleaux in myeloma
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Definition and mechanisms of leukocytosis and
neutrophilia
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WBC Count

• The normal limit in adults 4.400 to 11.0. (4.0
  to 10.0) x109/L
• Leukocytosis NL 2SD, orgt 11.0 x109/L
• Hyperleukocytosis or leukemoid reaction gt 50.0
  x109/L
• Neutrophilic leukocytosis gt11.0 x109/L,
  ANCgt7,700 x109/L
• ANC WBC x percent (PMNs  bands) 100

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Neutrophilic leukocytosis

• It commonly seen in
• It can also occur in
• Neutrophilia

Infection, Stress, Smoking, Pregnancy,
Following exercise.
Chronic myeloproliferative disorders, Chronic
myeloid leukemia
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Lymphocytic leukocytosis

• WBC 11.0 X109/L, an absolute lymphocyte count gt
  4.8 X109/L .
• Infectious mononucleosis and pertussis
• Lymphoproliferative disorders, such as the acute
  and chronic lymphocytic leukemias

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Monocytic leukocytosis

• WBCgt 11.0 x109/L, an absolute monocyte gt 0.8
  x109/L.
• Acute and chronic monocytic variants of leukemia
• Acute bacterial infection or tuberculosis
• Monophilia.

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Eosinophilic and basophilic leukocytosis

• WBCgt11.0 x109/L, an absolute eosinophil gt 0.45
  x109/L or basophil gt0.2 x109/L
• Eosinophilic leukocytosis can be seen in
• Basophilic leukocytosis is a distinctly unusual
  condition,

Chronic leukemia, Solid tumors, Infection with
parasites, Allergic reactions, Following
treatment with IL-2
Basophilic or Mast cell variants of acute or
chronic leukemia
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Regulation of neutrophil counts
PMN development
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Detection of infection or inflammation
band count 20
cytoplasmic vacuoles
left-shift
Dohle bodies, Toxic granulation
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The leukocyte alkaline phosphatase score

• LAP is high in
• LAP is low in

Infection Inflammation Polycythemia vera
Chronic myeloid leukemia Paroxysmal nocturnal
hemoglobinuria
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Definitions of neutropenia

• Mild neutropenia ANC 1.0 1.5 X109/L
• Moderate neutropenia ANC 0.500 1.0 X109/L
• Severe neutropenia ANC lt 0.5 X109/L

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Neutropenia and hospitalization for infection
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Etiology of isolated neutropenia

• Acquired neutropenias
• Postinfectious neutropenia
• Drug-induced neutropenia and agranulocytosis
• Primary immune disorders
• Hypersplenism
• Bone marrow disorders
• Congenital neutropenias
• Myeloperoxidase deficiency

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NIH grading of hematologic toxicity of
chemotherapy
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Fever in the neutropenic adult patient with cancer
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Risk Factors of Fever

• A rapid decline in ANC or ANC lt0.1 X109/L
• Prolonged duration of neutropenia (gt7 to 10
  days)
• Leukemic induction
• Cancer not under control
• Comorbid illnesses requiring hospitalization
• Use of central venous catheters
• Disruption of mucosal barriers
• Use of monoclonal antibodies

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INFECTIONS IN FEBRILE NEUTROPENIA

• A majority of patients had occult bacterial
  infections
• An infectious source identified in 30
• Bacteremia documented 25
• 80 of identified infections arised from
  patients
• own endogenous flora.

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• Symptoms and a physical examination daily

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Laboratory studies

• CBC with differential, transaminases, bilirubin,
  amylase and electrolytes, a chest radiograph,
  and cultures.
• Two or more blood cultures, sputum Gram stain and
  culture, and urine Gram stain and culture.
• Pulmonary infiltrates frequently can not produce
  sputum a more invasive approach including
  bronchoscopy or open lung biopsy.
• Lumbar puncture is not usually recommended.

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Blood cultures

• One set /day for a stable fever pattern.
• Two or three sets initially and to wait 48 to 72
  hours to repeat blood cultures.

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Chest radiographs
Findings are often minimal or absent
even in patients with pneumonia. Findings
may develop along with an increase
in symptoms as the neutropenia begins
to resolve.
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Chest CT scanning
CT should be ordered for the
patients with pulmonary symptoms.
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Empiric antimicrobials

• None clearly superior antibiotics.
• Coverage targeted at Gram negative bacilli,
  especially P. aeruginosa.
• Aminoglycosides and fluoroquinolones exhibit
  concentration-dependent killing
• Beta-lactams exhibit time-dependent killing

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Addition of vancomycin

• Hypotension, mucositis, skin or catheter site
  infection, history of MRSA colonization, or
  recent quinolone prophylaxis.
• Clinical deterioration or persistent fever
  despite empiric antibiotics.
• Withdrawal of empiric vancomycin after 72 hours
  without improvement of events or culture negative.

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Addition of antifungal drugs

• Antifungal therapy is routinely added at
• 5 to 7 days
• Undiagnosed fungal infection is present
• in many patients.

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Documented antimicrobial

• Optimal coverage for this organism and should
  ideally be bactericidal.
• Broad empiric coverage for the possibility of
  other pathogens.

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" Stepdown"

• Initially with parenteral therapy, then
  switched
• to an oral regimen.
• Stepdown used successfully by
• experienced centers even in patients at
• increased risk.

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Scoring index for identification of low-risk
febrile neutropenic patients at time of
presentation with fever

• Characteristic
  score
• Extent of illness
• No symptoms
  5
• Mild symptoms
  5
• Moderate symptoms
  3
• No hypotension
  5
• No chronic obstructive pulmonary disease
  4
• Solid tumor or no fungal infection
  4
• No dehydration
  3
• Outpatient at onset of fever
  3
• Age lt 60 year
  2
• Highest theorhetical score is 26. A risk index
  score of 21 indicates that the patient is likely
  to be at low risk for complications and morbidity.

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Colony stimulating factors

• CSF reported to decrease the duration of
• neutropenia, fever, and hospitalization.
• CSF have not been shown to decrease mortality.
• These agents should not be used routinely for
• patients with fever and neutropenia.
• It may be appropriate to consider their use in
• critically ill patients.

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THANKS