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6/9/2010
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The complete blood count (CBC) includes the white blood cell (WBC)
count, red blood cell (RBC) count, hemoglobin, hematocrit, platelet
count, white blood cell differential, and red blood cell indices. The
reticulocyte count is also included because it is closely related to the
CBC. The WBC differential is the classification, either automated or
manually performed by a technologist, of the white blood cells. Both
the red blood cells and the white blood cells are also visually scanned
for abnormalities if the automated results indicate the need.
Cells are
Hematopoiesis
It is helpful to understand the basics of cellular formation in the
human body in order to understand the value of the complete blood
count in diagnosing and monitoring disease states. There are three
types of cellular elements present in circulating blood: erythrocytes
(red blood cells, RBC), leukocytes (white blood cells, WBC), and
thrombocytes (platelets). In a healthy individual, the destruction and
production of each cell type is constant. Hematopoiesis is the term
which means production of blood cells
Cells go through various stages as they become mature and are
able to carry out their designated functions. Normally, only the
mature stages of the cells are found in the peripheral blood. In
disease states, immature and abnormal forms of the various cells may
be found. These immature and abnormal cells are noted by the
automated instrumentation in the laboratory, but the technologist
must make the final decision as to the type of cell present. The
Hemoglobin
Hemoglobin is the major parameter used in diagnosing and
monitoring anemia and polycythemia. It is reported as grams/deciliter
(dl) of whole blood. The normal hemoglobin value varies with age and
gender, and there is slight variation throughout the day, with exercise,
and with altitude.
The main function of the RBC is to synthesize hemoglobin.
Hemoglobin is used to carry oxygen to tissues and to bring carbon
dioxide from the tissues to the lungs. The hemoglobin molecule is
composed of four sub-units, each containing heme and the protein
globin. Every hemoglobin molecule is able to transport four moles of
oxygen. An atom of iron is located in the center of the structure and
98% of the total, while HgbF makes up approximately 2%, and A2, 23%. The type of polypeptide chains that make up the molecule
determines the type of hemoglobin. One heme group is attached to
each polypeptide chain, linked by the iron in the heme group. The
mature red blood cell consists mainly of hemoglobin. However, the
production of heme and globin occurs mainly in the immature red
blood cell.
Abnormal hemoglobin variants create symptoms that occur in
cases such as sickle cell anemia (HgbS) and hemolytic anemia (HgbC).
Hematocrit
The hematocrit is simply the percentage of red blood cells to
whole blood. When anticoagulated whole blood is centrifuged, the
erythrocytes, leukocytes, and platelets will be forced to the bottom of
the sample. The heaviest cells (the RBCs) will go farthest to the
bottom of the tube, followed by a thin layer of WBCs and finally the
platelets on top. The liquid portion on top is called plasma. The
volume of erythrocytes is also called the packed red cell volume (PCV),
and it is expressed as a percentage of the total whole blood volume.
The hematocrit can be measured by actual percentage after
centrifuging a small capillary tube of whole blood, or it can be
performed by automated methods.
Reticulocyte Count
Reticulocyte count is a test used to determine how the bone
marrow is responding to the bodys need for RBCs. The reticulocyte is
the erythrocyte prior to becoming a mature RBC. The erythrocyte
passes through 6 stages of development, the first four stages normally
occurring only in the bone marrow: pronormoblast, basophilic
normoblast, polychromatophilic normoblast, orthochromic normoblast,
reticulocyte, and mature erythrocyte. Three to four mitotic divisions
occur between the pronormoblast and the polychromatophilic
normoblast, producing up to 16 erythrocytes from each
pronormoblast. About three days lapse between the pronormoblast
stage and the orthochromic normoblast stage. This latter stage still
contains the nucleus, though it is very condensed and incapable of
further mitosis. On about the fourth day from the pronormoblast
stage, the nucleus is extruded from the cell and a reticulocyte is
formed. Reticulocytes are slightly larger than mature erythrocytes.
They stay in the bone marrow for 2 3 more days and are then
released into the peripheral blood where they age for an additional day
before becoming mature red blood cells.
When a persons hemoglobin drops below normal, the oxygen
content of the blood drops and the oxygen tension in the kidneys is
reduced. This stimulates the kidneys to increase their production of
erythropoietin, a hormone that initiates production of red blood cells.
An increased number of red blood cells are then produced and the rate
The MCV is calculated from the red blood cell count and the hematocrit
and measures the average size of RBC. It indicates the average
volume of the erythrocytes in femtoliters (fl = 10^-6 cubic mm). Cell
volume is considered to be microcytic (smaller than normal),
normocytic (normal), or macrocytic (larger than normal). It is
important to interpret the value for MCV along with an inspection of
the peripheral blood smear since the MCV is only a mean volume. It is
possible to have a wide variation in cell size and still have a normal
MCV. When RBC shape is abnormal, such as in sickle cell anemia, the
MCV is of doubtful value because the hematocrit is not reliable.
The MCH is calculated from the hemoglobin and the red blood cell
count. It indicates the average weight of hemoglobin in the
erythrocyte in picograms (10^-12/g). It should always correlate with
the MCV and the MCHC. The MCH is directly proportional to the size of
the erythrocyte and the concentration of hemoglobin in the cell. Low
MCH values are found in microcytic anemia and in normocytic,
hypochromic red blood cells. High MCH values are found in macrocytic
anemia and may occur in spherocytosis.
Platelets
Platelets, or thrombocytes, originate from megakaryocytes
cytoplasm in the bone marrow. As the megakaryocyte matures, the
cytoplasm increases in amount and becomes more granular. The
granules form small clusters and the cytoplasm breaks into individual
platelets which are released into the peripheral circulation. One
megakaryocyte can produce between 2000 and 4000 platelets. As can
be seen by the formation of the platelets, they have no nucleus. When
there is damage to the endothelium, platelets form thrombi to
decrease the bleeding.
In the peripheral blood, the platelet lives 9 12 days.
Approximately 2/3 of the platelets are in the blood, while the
remaining 1/3 forms the platelet pool in the spleen. The platelets in
the spleen and blood are interchangeable.
The role of the platelet is for the purpose of hemostasis, or the
formation of blood clots to decrease bleeding. A decrease in platelets
indicates a high risk for bleeding. When the platelet count is increased,
there is a high risk for thrombosis, which can lead to a stroke, heart
attack, or pulmonary emboli.
Normal Values
Newborn
9,500-35,000 cells/microliter
One year
The count continues to drop until it reaches adult levels by age 21.
One year
Hemoglobin:
Adult females
17-22 g/dl
11 13 g/dl
Ten years
12 15 g/dl
Hematocrit:
Adult females
38-46%
55-68%
One year
29-41%
MCV
Adults
Newborn
80 100 fl
95-115 fl
Two months
74-96 fl
One year
70-84 fl
Ten years
75 87 fl
MCH
Adults
Newborn
26-34 pg
31-37 pg
Two months
Ten years
25-35 pg
25 33 pg
MCHC
Adults
Newborn
31 37 %
31-37 %
Two months
Ten years
29-37 %
31-37 %
The Differential
The differential white blood cell count is performed to determine
the relative number of each type of white blood cell present in the
peripheral blood. They are ordered to determine the presence of a
specific infection, such as viral, bacterial, or parasitic, as well as
detection of allergic and drug reactions. Red and white blood cells and
platelets are examined for morphological changes.
Normal White Blood Cell Types
Neutrophils These are the largest number of cells in the
granulocytic series. They are the cell most commonly increased in
bacterial infections. The mature form of neutrophil is the
segmented neutrophil.
blood smear on the slide, but the burr shape may indicate
abnormal conditions such as uremia or acute blood loss.
Schistocytes These are red blood cell fragments. They occur in
hemolytic anemia, uremia, severe burns, and other conditions.
Sickle cells Red blood cells shaped like a sickle or a crescent are
due to the hemoglobin S within the cells. They are associated with
sickle cell anemia, Hemoglobin SC disease, and a form of
thalassemia.
Basophilic stippling Basophilic stippling appears as purplestaining granules in the red blood cells. The granules are clumps
of ribosomes.
some anemias.
Howell-Jolly bodies These are round nuclear fragments in the red
blood cells. They may appear in anemia and after splenectomy.
Rouleaux formation This is a situation in which erythrocytes are
arranged in stacks, similar to a roll of coins. It may be an artifact
caused by the handling of the blood, or it may be due to a high
concentration of abnormal globulins or fibrinogen. Rouleaux is
found in multiple myeloma and macroglobulinemia.
Agglutination This is clumping of the red blood cells. It is found
in patients who have a cold agglutinin or autoimmune hemolytic
anemia.
Summary
References
1.