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Laboratory Diagnosis. What is laboratory diagnosis? Laboratory diagnosis is such a diagnostic process in which the samples coming from patients’ blood,

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Presentation on theme: "Laboratory Diagnosis. What is laboratory diagnosis? Laboratory diagnosis is such a diagnostic process in which the samples coming from patients’ blood,"— Presentation transcript:

1 Laboratory Diagnosis

2 What is laboratory diagnosis? Laboratory diagnosis is such a diagnostic process in which the samples coming from patients’ blood, body fluid, secretion, excretion, tissues and cells are examined by using various laboratory methods to get useful data which may reflects body` s functional status, pathological changes and etiological hints.

3 Why to study laboratory diagnosis? l Laboratory diagnosis is a very important part in diagnostics. After we have finished the study of physical diagnosis and instrument examination, we might be able to judge what kind of disease this patient probably suffer from. For further diagnosis, it is still not enough if we only master physical examination. We have to depend upon some laboratory data to ensure our diagnosis.

4 How to learn laboratory diagnosis? l First, the methods used in laboratory diagnosis are more automatic and computerized. l Second, the aim is to train for clinical application. l For each test, referential values and clinical significance always should be known very well.

5 Chapter 1 Blood Test Blood routine test (BRT) l 1. content (items) of BRT l red blood cell count (RBC) l hemoglobin(HB)concentration determination l total white blood cell count (WBC) l leukocyte differential count (DC) l platelet count (PC) l 1. content (items) of BRT l red blood cell count (RBC) l hemoglobin(HB)concentration determination l total white blood cell count (WBC) l leukocyte differential count (DC) l platelet count (PC) [ ˈ pletl ɪ t]

6 Re ferential values of BRT l Table 1. Referential values for blood routine test in different age and sex l ___________________________________ l male female newborn l ___________________________________ RBC (x10 12 /L) HB (g/L) WBC (x10 9 /L) PLT (x10 9 /L ) l ___________________________________

7 Table 2 Referential values of differential count l ___________________________________ l type percent value(%) absolute value ___________________________________ N st N se LYM Mo Eo l Ba 0-1_____________0-0.1________ l neutrophil stab cell 杆状核 (Nst), neutrophil segmented cell (Nse), lymphocyte, basophil [ ˈ besəf ɪ l] granulocyte, eosinophil [ ˌ iə ˈ s ɪ nə ˌ f ɪ l] granulocyte [ ˈɡ rænjəlo ˌ sa ɪ t]

8 l neutrophil stab cell 杆状核 (Nst), neutrophil segmented cell (Nse), lymphocyte, basophil granulocyte, eosinophil [ ˌ iə ˈ s ɪ nə ˌ f ɪ l] granulocyte [ ˈɡ rænjəlo ˌ sa ɪ t] (Nst) (Nse), Immatured neutrophil Matured neutrophil transition period anti-infection leukemia Chronic myeloid leukemia Acute suppurative infection folates deficiency nucleus shift to left nucleus shift to right Image interpretation Imagery interpretation major

9 Changes of nucleus nucleus shift to left: mild shift to left: Nst > 6% only medium shift to left: Nst > 10% with meta myelocyte [metə'ma ɪ əlo ʊ sa ɪ t] 晚幼粒细胞 severe shift to left : Nst > 25% with more immuture cell (leukemiod reaction = is similar to leukemia ) nucleus shift to left can be seen in acute infection, acute poisoning, acute hemolysis

10 Nucleus shift to right: multi-segmented Nse >3% 3-lobed Nse is normal segmented neutrophil in WBC nucleus shift to right can be seen: megaloblastic anemia( folates deficiency,VitB12 deficiency) administration of anti-metabolic drugs nucleus shift to right

11 Morphology of blood cells l Red blood cell: normocyte: 6-9um ( micron ), discocyte- shape, no nucleus [ ˈ nju:kliəs] l white blood cell divided in five types: 1.neutrophilic granulocyte : neutrophil stab cell (Nst), neutrophil segmented cell (Nse), 2.lymphocyte, 3.basophil granulocyte, 4.eosinophil granulocyte,5.monocyte l Platelet: smallest cell in peripheral [pə ˈ r ɪ fərəl] blood

12 In automatic blood cell analyzer, 25 items are included together : l WBC : 4.0~10.0x10 9 /L l LYM : 0.8~ 4.0 x10 9 /L (20~40%) l MID( middle cells) : monocyte, eosinocyte, basocyte, immature cells(rare be seen) l GRAN(granulocyte):2.0~7.8x10 9 /L(50~70%) l RBC:4.0~5.5x10 12 /L(male),3.5~5.0x10 12 /L (female) l HGB: 120~160 g/L (male), 110~150 g /L (female)

13 - l HCT(hematocrit):0.4~0.5L/L(male),0.37~0.48L/L(female) l MCV ( mean corpuscular volume): 82~95 fl l MCH(mean corpuscular hemoglubin): 27~31 pg l MCHC ( mean corpuscular hemoglubin concentration): 320~360 g/L PLT( platelet): 100~300 x 10 9 /L l MPV ( mean platelet volume): 8.7~16.5 fl l PDW ( platelet distribution width): 15.8~21.4% RBC can be separated by centrifugation MCH = Hb/RBC thickness serum

14 Clinical significance l Anomalies of RBC and HB l 1. decrease of RBC and HB l Anemia: When RBC and HB of individual is lower than the referential values of the people in same age, same sex and same area. Usually, if Hb of adult male and female is lower than 120g/L or 110g/L respectively, they are considered as anemia.

15 According to the level of Hb, anemia is divided into four degrees in clinic l mild anemia: Hb < 120g/L(male) or < 110g/L(female) l medium anemia : Hb <90 g/L l severe anemia : Hb <60g/L l extreme severe anemia: Hb <30g/L

16 Physiological anemia l infant and children aged between 3 months to 15 years, l pregnant women in middle or terminal periods of pregnancy, l elderly people.

17 Pathological anemia. l decrease in synthesis [ ˈ s ɪ nθ ɪ s ɪ s] of red blood cell in bone marrow l increased destroy of red blood cell in peripheral blood l blood loss

18 Decrease in synthesis of red blood cell in bone marrow l disorder of hemopoiesis [ ˌ himəp ɔɪˈ is ɪ s] in bone marrow: aplastic anemia l infiltration of bone marrow by tumorous cell: leukemia, multiple myeloma, lymphoma, metastatic tumor 转移瘤 l deficiency of hemopoietic materials or factors: iron deficiency anemia(IDA), megaloblastic anemia (folic acid deficiency)

19 Destroy of RBC in peripheral blood -- hemolytic anemia l Hereditory disease :G-6PD deficiency, thalassmia (地中海贫血), Hb disease l Acquired [ə ˈ kwa ɪ rd] anomalies : hemolysis by immunological, physical, chemical, biological and mechanical factors

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21 [.fr æ gmən ‘ tei ʃ ən] smear: 涂片 ['m ʌ ltipl] Causes red blood cells to rupture

22 Blood loss -- hemorrhagic anemia l acute blood loss : acute upper digestive tract bleeding, splenic rupture l chronic blood loss : hemorrhoid 痔 [ ˈ h ɛ mə ˌ r ɔɪ d], hookworm disease, hypermenorrhea [ha ɪ pəmen ɒ ‘ri:ə] 月经过多, GI (gastrointestinal) tumor

23 2.Increase of RBC and Hb Comparative increase of RBC and Hb: due to the decrease of volume of plasma--severe dehydration: severe vomoting, diarrhea, severe burn Absolute increase of RBC and Hb—ery- throcytosis: polycythemia vera 真红 (PV), chronic cardiopulmonary diseases: cor pulmonale 肺心病, obstructive emphysema, scarcity of oxygen.

24 Anomalies of WBC and DC In most cases, increase and decrease of WBC is chiefly depend on the numbers of neutrophil granuiocyte in the blood. Leukocytosis: WBC is higher than 10 x10 9 /L Leukopenia: WBC is lower than 4 x10 9 /L

25 1. Neutrophil granulocyte A. granulocytosis: 5 causes leading to granulocytosis acute infection or inflammation: acute pyogenic [ ˌ pa ɪ ə'd ʒ en ɪ k] tonsilitis, acute appendicitis, hematosepsis [hi:məto ʊ ‘seps ɪ s] 败血症 damage or necrosis of tissue: severe burn, acute myocardiac infarction

26 acute blood loss: digestive tract bleeding, splenic rupture Acute poisoning: uremia, ketoacidosis Malignant blood diseases and tumor: leukemia, metastatic tumor

27 B.Granulocytopenia: leukopenia: WBC < 4 x10 9 /L granulocytopenia: neutrophil granulocyte < 1.5 x10 9 /L agranulocytopenia: neutrophil granulocyte < 0.5 x10 9 /L

28 5 causes for granulocytopenia: Infection of bacteria and virus: typhoid [ ˈ ta ɪˌ f ɔɪ d], influenza, measles [ ˈ mizəlz] some physical and chemical factors: drug (chloramphenicol, propylthiouracide, immunosuppressive agent), IE autoimmune diseases: systemic lupus erythematosis (SLE), malignant blood diseases: aplastic anemia(AA),aleukemic leukemia hypersplenism

29 2. lymphocyte A. Lymphocytosis 增多 : DC ( differential count ) : Lym > 40% Virus infection: infectious mononucleosis, chicken pox 水痘, Lymphocytic leukemia: ALL, AA, lymphoma GVHD or GVHR after BMT ( graft-versus-host disease graft bone marrow transplant GVHR :graft versus host reaction

30 B. lymphocytopenia: administration of anti-tumor drugs, prednision radiation: x-ray, r-ray, isotope 3. monocytosis: malaria, black fever, TB, subacute bacterial endocarditis(SBE) monocytic leukemia, malignant histocytosis,

31 4. eosinophilia allergic diseases, hypersensitive diseases parasites infection: Skin diseases: psoriasis blood diseases: CML ( Chronic myeloid leukemia), eosinophilic leukemia, lymphoma Infectious diseas: scarlatina [ ˌ sk ɑ rlə ˈ tinə]

32 5. Basophil granulocyte bosophilia: CML, basophilic leukemia, myelofibrosis

33 Other tests for red blood cell 1. Reticulocyte count (RC) ( %) x10 9 /L l Reticulocytosis (增多) : hemolytic anemia ( HA ) acute hemorrhagic anemia index of therapeutic effect: IDA, megaloblastic anemia ( MA) 叶酸 ( Folic acid ) IDA (iron deficient anemia )

34 Reticulocytopenia: Aplastic anemia ( AA) leukemia

35 2. Hematocrit(Hct) L/L(male), L/L(female) increase of Hct: blood concentration water loss polycythemia(PV) 红细胞增多症 decreas of Hct: anemia

36 3. Mean values of RBC Mean corpuscular volume (MCV): MCV=Hct/RBC 82-95fl Mean corpuscular hemoglubin(MCH): MCH=Hb/RBC 27-31pg Mean corpuscular hemoglubin concentration MCHC=Hb/Hct g/L

37 Morphological classification of anemia Classification MCV MCH MCHC diseases Normocytic AA, HA, leukemia Macrocytic >100 > MA, pernicious anemia ( 恶性贫血) Microcytic < 80 < infection, tumor, uremia Microcytic < 80 < 27 < 320 IDA, thalassemia hemolytic anemia(HAmegaloblastic anemia( MA)

38 4.Erythrocyte sedimentation rate(ESR) 0-15mm/h (male), 0-20mm/h (female) higher ESR: infection and inflammation: rheumatic diseases,tuberculosis malignant tumor anemia damage or necrosis of tissue globulinemia, cholesterolemia

39 Chapter 2. Bone Marrow Examination 1. Clinical application of marrow examination l Diagnosis for hematopoietic system diseases: leukemia, myeloma, aplastic anemia, etc l parasite infectious diseases: malaria, black fever l metabolic diseases: Gaucher disease. Niemann-Pick disease

40 Indications: Fever origin unknown (FOU) Cachexia Hepatomegaly, splenomegaly, lymphoadenovarix Abnormal in quantity and quality in peripheral blood cell

41 Contraindication: Hemophilia Pyogenic infection in local skin Methods: bone marrow aspiration bone marrow biopsy

42 2.Development of blood cells myeloblast promyelocyte myelocyte metamyelocyte Nst Seg normoblast basophilic normoblast polychromatic normoblast orthochromatic normoblast erythrocyte

43 Monoblast promonocyte monocyte macrophage histiocyte Megakaryoblast promega granular Meg thrombocytogenous Meg platelet B-lymphoblast B-prolymphoblast B- lymphocyte plasmablast proplasmacyte plasmacyte

44 3. Regulation of blood cell development l Cytobody: from large to small, Mega is an exception l Cytoplasma: from less to more, color from blue to pink or orange red, granules from invisible to visible, granules from non-specific to specific

45 l Nucleus: from large to small, Mega is an exception, shape of nucleus from round to irregular, chromatin patten of nucleus from fine to coarse. nucleolus from existance to nonexistance l Ration of nucleus to cytoplasma: from bigger to smaller

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48 5.Contene and step of marrow examination l Myelogram: l Low power(LP): Wright stain of marrow film plastic degree: 5 classification Meg count : 7-35/1.5x3cm2 ousspecial cell: metastatic tumorous cell

49 Oil immersion: Nucleated cell count (%): Ratio of myeloid to erythroid (M:E): 2-4:1 Morpholigical description of every series Special cells and parasite Diagnosis

50 Hemogram: Low power(LP): Oil immersion len: differential count 100 leukocyte (DC) Immature cell (nucleated cell) parasites

51 6. Normal myelogram and hemogram 1. Myelogram l Normal cellularity: erythrocyte: nucleated cell l M:E=2-4:1 l Granulocytic series is 40-60% in all nucleated cells l Erythrocytic series is 20% in all nucleated cells l Lymphocyte is 20%, monocyte is <4% in all nucleated cells l Meg count is 7-35, platelet is normal l Other cell: plasmacyte and histiocyte are rare l No specific cells and parasite

52 Plastic degree of marrow Plastic degree erythrocyte: nucleated diseases Extreme hypercellularity 1:1 leukemia Significant hyper- 10:1 leukemia, ITP, Cellularity plastic anemia Normal cellularity 20:1 anemia, normal myelogram Hypocellularity 50:1 AA,agranulocy- topenia Extreme hypocellularity 300:1 aplastic anemia

53 2. Hemogram: DC is normal No nucleated red blood cell No immature white cell Platelet is normal

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56 7. Characters of common blood diseases in microscope l Iron deficiency anemia(IDA) l Aplastic anemia(AA) l Acute leukemia(AL) l Chronic myelocytic leukemia(CML) l Idiopathic thrombocytopenia purpura(ITP)

57 1. Iron Deficiency Anemia(IDA) l Hemogram: Hb, RBC, normal RC, RBC hypochromia, exaggeration of central pallor to from rings, anisocytosis normal WBC and platelet

58 Myelogram: Significant hypercellularity M:E Erythroid hyperplasia with small normoblast Pycnotic nuclei and scanty cytoplasma irregular margin

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60 2. Aplastic Anemia(AA) l Hemogram: pancytopenia: Hb,RBC, WBC,PLT RC <0.005 or absolute value < 15 x10 9 /L RBC is normocytic

61 Myelogram: Hypocellularity or extreme hypocellularity, Hematopoietic cell decrease: erythroid, myeloid cells, meg or absent, platelet rarely be seen Non-hematoietic cell increase: lymphocyte Reticular cell, plasmacyte

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63 3. Acute Leukemia(AL) l FAB classification: acute lymphocytic leukemia: L1-L3 acute non-lymphocytic leukemia: M0-M7 l Hemogram: Hb, RBC WBC uncertain: normal, increase, decreas platelet:

64 Myelogram: Extreme or significant hypercellularity M:E Hyperplasia of certain line : Myeliod(M0,M1-3), monocyte(M4-5), meg(M7), lymphocyte(L1-3), erythroid(M6) Depressed erythroid and meg line

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77 4. Chronic Myelocytic Leukemia(CML) l Hemogram: WBC increase rxtremly DC: E0, Ba increas, myelocyte, metamyelocyte, band cell increase normal Hb, RBC or mild decrease normal plt

78 Myelogram: Extreme hypercellularity M:E increase Extreme hyperplasia of granulocyte with increas of myelocyte, metamyelocyte, band cell, E0, Ba Normal erythroid and Megakaryocyte

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82 5. Idiopathic Thrombocytopenic Purpura(ITP) l Hemogram: normal Hb, RBC normal WBC and DC PC decreas with abnormal morphology

83 Myelogram: Significant hypercellulerity or normal cellularity Normal myeloid, erythroid line Significant hyperplasia of Meg. Impaired maturation of Meg: Granular Meg or promeg increase Platelet producting Meg absent Platelet rarely be seen

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