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Basis for automated cell counts is the concentration analysis of corpuscular peripheral
blood components per defined volume. The performance spectrum in the class of
automated compact systems (for example, Sysmex KX-21 or Sysmex K-4500) also
includes a pre-differentiation of white blood cells, in addition to the eight parameters
of the CBC. Based on this trimodal pre-differentiation, a lot of information is provided
for the interpretation of results and indications of abnormalities. Deviations from
normal ranges are detected – such as, for example, an increased or reduced white
blood cell count.
Such abnormal values require more precise clarifications, and, respectively, a micro-
scopic differentiation to detect and identify haematologic diseases. Initial information
about the reason for an abnormal white blood cell count is provided by a classification
of white blood cells into three separate subpopulations which is called a pre-differenti-
ation and which immediately provides important information to the examiner. These
are results on the differential blood count, especially regarding the percentage of
lymphatic and myeloid white blood cell in the total white blood cells count. With
a careful interpretation of all parameters, pre-differentiation allows the detection of
normal blood samples and the results can be transmitted without delay to the treating
physician. Samples are considered ‘normal’ when their analysis results are within the
reference ranges and if the ordering physician did not request further haematologic
examination. Accordingly, pre-differentiation will bring about a reduction of the number
of differential blood counts so that pathological and suspicious blood counts can be
concentrated on. Without a specific problem at issue, it is entirely sufficient to separate
white blood cells into lymphocytes and neutrophils. Any suspicion of a viral or inflam-
matory disease can thus also be confirmed or disproved.
Monocytes present the largest population in the peripheral blood with a diameter of
approx. 20 μm and are shrunk the most. The effect on eosinophils and basophils is also
relatively major, so that these three populations find themselves in one mixed popula-
tion. The lyse reagent’s influence is most minor for lymphocytes and it is also minor
for neutrophils. The x-axis of the WBC histogram indicates cell size in femtolitres.
This cell size in the WBC histogram does not show the actual volume of the white
blood cells presented since the measuring signals following lysis treatment are no
longer in relation to the volume of native white blood cells.
Histogram interpretation
All measured pulses are shown in the volume distribution curve. Red blood cells are
lysed in the separate WBC channel so as not to interfere with the white blood cells.
Platelets are separated from the white blood cells by means of the lower discriminator
(threshold value LD = lower discriminator) so that only white blood cells are actually
shown. The volume distribution curve should be located within the two discriminators
(LD + UD) and not only begin at the base line but also end there. If a deviation from the
base line occurs, the analyser provides a corresponding warning message to indicate
required follow-up actions. The various deviations are explained in the following text.
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WBC Histogram Interpretations of 3-Part Differentiation 3
Fig. 2 ‘WL’ warning due to interference on Fig. 3 erythroblasts and one lymphocyte
lower discriminator
In case of a ‘WL’ warning, the WBC count value should be checked since it might have
a false increase due to the effect of one of the above-mentioned interference factors.
The most frequent cause for such an interference are platelets aggregates. These
aggregates affect the WBC result because the analyser cannot differentiate between
aggregates and white blood cells. In this case, however, the platelets histogram also
suggests the presence of aggregates which can also be seen in the manual differential
blood count. To obtain a correct result, it is necessary to take another blood sample.
Fig. 5 ‘WU’ warning on upper discriminator Fig. 6 ‘T2’ alarm. ‘T1’ was found, but not ‘T2’
T1 and T2 flags
Aside from the two delimiting discriminators, so-called ‘valley discriminators’ are addi-
tionally used. These discriminators seperate the white blood cells into the three popu-
lations. The two valley discriminators ‘T1’ or ‘T2’ are flexible in certain areas; i. e. they
can largely adjust to the sample. With certain abnormalities of the sample, a reliable
separation of the populations through valley discriminators will not be possible. In
this case, the equipment generates flag ‘T1’ or ‘T2’ (Fig. 6). When a ‘T1’ or ‘T2’ flag is set,
the pre-differentiation values should not be used because the populations have not
been precisely separated from each other. Here, clarification is recommended through
manual differential blood count. However, the total WBC count is correct if no ‘WL’
or ‘WU’ warning has been generated.
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WBC Histogram Interpretations of 3-Part Differentiation 5
F1 F2 F3
Summary
The above described warning messages enable the user to detect positive samples
and to react with follow-up actions because of the warnings. Morphological changes –
mostly preliminary stages or abnormalities of the myeloid and lymphatic cell series –
require manual differentiation. Pre-differentiation information will reduce the rate of
microscopic differentiation to clinically relevant cases. Working time can thus be saved
without loss of quality.