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FLAGS AND TROUBLESHOOTS – 3 PART DIFFERENTIAL CELL COUNTERS DR. PRASAD P. SHENOY CENTRAL CLINICAL LABORATORY PANAJI – GOA

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Presentation on theme: "FLAGS AND TROUBLESHOOTS – 3 PART DIFFERENTIAL CELL COUNTERS DR. PRASAD P. SHENOY CENTRAL CLINICAL LABORATORY PANAJI – GOA"— Presentation transcript:

1 FLAGS AND TROUBLESHOOTS – 3 PART DIFFERENTIAL CELL COUNTERS DR. PRASAD P. SHENOY CENTRAL CLINICAL LABORATORY PANAJI – GOA

2 3 PART DIFFERENTIAL CELL COUNTER COMMON INSTRUMENT IN A HEMATOLOGY LABORATORY CBC – ‘BREAD AND BUTTER’ OF HEMATOLOGY LAB RAPID, ACCURATE AND PRECISE BLOOD COUNTS (CONSISTENT)

3 3 PART DIFFERENTIAL CELL COUNTER HYDRODYNAMIC FOCUSSING ELECTRICAL IMPEDENCE VOLUMETRIC METERING COLORIMETRY (Hb)

4 3 PART DIFFERENTIAL CELL COUNTER PARTICLE > 35 fl: RBC PARTICLE 2 – 20 fl: PLATELET HEMOGLOBIN AND WBC COUNT IN SECOND CHAMBER RBC AND PLATELET COUNTED IN ONE CHAMBER

5 3 PART DIFFERENTIAL CELL COUNTER DIRECTLY MEASURED PARAMETERS AND HISTOGRAMS HEMOGLOBIN CONCENTRATION WBC COUNT RBC COUNT PLATELET COUNT WBC HISTOGRAM RBC HISTOGRAM PLATELET HISTOGRAM

6 3 PART DIFFERENTIAL CELL COUNTER PARAMETERS DERIVED FROM HISTOGRAMS LYMPHOCYTE PERCENTAGE MID-SIZE CELL PERCENTAGE GRANULOCYTE PERCENTAGE MCV RDW MPV PDW

7 3 PART DIFFERENTIAL CELL COUNTER CALCULATED PARAMETERS LYMPHOCYTE # MID-SIZED CELL # GRANULOCYTE # HEMATOCRIT MCH MCHC PCT

8 3 PART DIFFERENTIAL CELL COUNTER MANUAL DIFFERENTIAL COUNT REMAINS A DEFINITIVE TOOL FOR COMPLETE HEMATOLOGIC ANALYSIS PERIPHERAL BLOOD SMEAR REVIEW IS MANDATORY

9 FLAG SIGNAL TO THE OPERATOR INDICATES A SIGNIFICANT ABNORMALITY IN THE ANALYSED SAMPLE / ANALYSER ITSELF

10 QUESTIONABLE RESULT ANALYSER RELATED SAMPLE RELATED TROUBLESHOOTING ?

11 SYSTEMATIC APPROACH ISOLATE A SOURCE OF A PROBLEM AND FIX IT THROUGH A PROCESS OF ELIMINATION FIX THE MOST OBVIOUS / EASIEST PROBLEM FIRST

12 QUESTIONABLE RESULT ANALYSER RELATED SAMPLE RELATED QC ACCEPTABLE SAMPLE RELATED QC IS OUT OF RANGE ANALYSER RELATED QC

13 ANALYSER RELATED ERRORS ELECTRONIC (HARDWARE / SOFTWARE) PRESSURE / HYDRAULIC REAGENT

14 3 PART DIFFERENTIAL CELL COUNTER FLAGS ARE FEW OPERATOR MUST BE ALERT

15 Hb: 15.6 g/dL RBC: 5.19 x 10 6 / uL HCT: 45.9 % MCV: 88.6 fl MCH: 30.1 pg MCHC: 33.3 g/dL RDW: 12.9 % RULE OF 3 NORMOCYTIC NORMOCHROMIC

16 WBC: 7.0 x 10 3 / uL Lymph#: 1.8 x 10 3 /uL Mid#: 0.3 x 10 3 /uL Gran#: 4.9 x 10 3 /uL Lymph%: 25.9 % Mid%: 4.3 % Gran%: 69.8 % PLT: 267 x 10 3 / uL MPV: 9.5 fL PDW: 14.2 PCT: %

17 INTERFERENCES RBC FRAGMENTS, VERY SMALL RBC’s NUCLEATED RBC’s, LYSE RESISTANT RBC’s COLD AGGLUTININS HIGH LEUKOCYTE COUNTS (>50 x 10 3 /uL) GIANT PLATELETS, PLATELETS CLUMPS LIPEMIC SAMPLE CRYOGLOBULINS CLOTTED SAMPLE AIR BUBBLES

18 CASE: 1 20 years / Female Breathlessness, easy fatiguability Lack of concentration, giddiness

19 Hb: L 4.2 g/dL RBC:L 3.09 x 10 6 / uL HCT: L 15.3 % MCV:L 55.0 fl MCH: L 13.5 pg MCHC: L 24.8 g/dL RDW:H 24.5 % WBC: 5.5 x 10 3 / uL PLT:H 561 x 10 3 /ul MICROCYTIC HYPOCHROMIC ANEMIA IDA THALASSEMIA ANEMIA OF CHRONIC DISORDERS

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21 MENTZER’S INDEX (M. I.) M. I. = MCV / RBC If M. I. > 13: IDA If M. I. < 13: Thalassemia

22 Suggestive of Iron deficiency Anemia Adv: Sr. Iron, TIBC, Ferritin Iron: ug/dL TIBC: ug/dL % Transferrin: % Ferritin: ng/mL M. I. = 55/3.09 = 17.8

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24 CASE: 2 23 years / Female Pregnant, 12 weeks Total Bil : 1.1 mg/dL Conjugated Bil: 0.3 mg/dL Transaminases: Normal

25 Hb: L 10.1 g/dL RBC: 4.89 x 10 6 / uL HCT: L 31.9 % MCV:L 65.0 fl MCH: L 22.8 pg MCHC: L 30.5 g/dL RDW:H 17.2 % WBC: 7.5 x 10 3 / uL PLT: 418 x 10 3 /ul

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28 M. I. = 65/4.89 = MICROCYTIC HYPOCHROMIC ANEMIA Adv: Sr. Iron, TIBC, Ferritin Hemoglobin electrophoresis

29 Hemoglobin Electrophoresis HbA = – 98.5 HbF = – 2.0 HbA2 = – 3.5 Iron: ug/dL TIBC: ug/dL % Transferrin: % Ferritin: ng/ml β Thalassemia trait with Iron deficiency

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31 CASE: 3 46 years / Female Weakness, Paresthesia No organomegaly

32 Hb: L 7.1 g/dL RBC:L 1.80 x 10 6 / uL HCT: L 21.5 % MCV:H fl MCH: H 39.4 pg MCHC: 34.0 g/dL RDW:H 20.6 % WBC: 3.8 x 10 3 / uL PLT: 127 x 10 3 /ul MACROCYTIC ANEMIA

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37 MACROCYTIC ANEMIA, FAVOUR MEGALOBLASTIC Adv: Sr. Vitamin B-12 and Folic acid Vitamin B – 946 pg/ml FOLIC ACID1.12>5.38 ng/ml MEGALOBLASTIC ANEMIA

38 THERAPEUTIC TRIAL RETICULOCYTE RESPONSE

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40 Vitamin B 12 & Folic acid deficiency Myelodysplastic syndromes Hemolytic anemias Myelophthisic anemias Aplastic anemia Chronic Liver diseases MACROCYTIC ANEMIA

41 Adv: Sr. Vitamin B-12 and Folic acid Vitamin B – 946 pg/ml FOLIC ACID 27.46>5.38 ng/ml ?

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46 MACROCYTIC ANEMIA WITH FEATURES OF DYSPLASTIC HEMATOPOIESIS BONE MARROW & CYTOGENETIC STUDIES

47 CASE: 4 63 years / Male

48 Hb: L 9.0 g/dL RBC:L 3.86 x 10 6 / uL HCT: L 27.9 % MCV:L 72.3 fl MCH: L 23.3 pg MCHC: 32.2 g/dL RDW:H 29.2 % WBC: 8.3 x 10 3 / uL PLT: 258 x 10 3 /ul DUAL PEAK M. I. = 72.3 / 3.86 = 18.73

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50 POST BLOOD TRANSFUSION

51 CASE: 5 53 years / Female ? FEVER

52 WBC: H x 10 3 / uL Lymph#: H 31.4 x 10 3 /uL Mid#: H 43.8 x 10 3 /uL Gran#: H x 10 3 /uL Lymph%: L 10.1 % Mid%: 14.1 % Gran%: H 75.8 % Hb: L 9.4 g/dL PLT:H 689 x 10 3 /uL

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55 Features compatible with a Myeloproliferative neoplasm: CHRONIC MYELOID LEUKEMIA IN CHRONIC PHASE Adv: Molecular / Cytogenetic studies for Philadelphia chromosome

56 Hb: L 9.4 g/dL RBC:L 1.77 x 10 6 / uL HCT: L 16.6 % MCV: 94.1 fl MCH: H 53.1 pg MCHC:H 56.6 g/dL RDW:H 22.3 % PLT:H 689 x 10 3 /uL HEMOGLOBIN PERFORMED BY MANUAL (CYANMETH) METHOD 8.3 g/dL 7.1 g/dL (after centrifugation)

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59 CASE: 6 63 years / Female Operated case of Ca-Ovary, on Chemotherapy, for follow up

60 Hb: 12.4 g/dL RBC: 4.57 x 10 6 / uL HCT: 35.9 % WBC: 6.7 x 10 3 / uL PLT: L 56 x 10 3 / uL MPV: H 14.5 fL PDW: H 19

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62 Giant Platelets Platelet clumps EDTA induced platelet clumping SPURIOUS THROMBOCYTOPENIA

63 Acknowledgement Dr. P. R. Malur, Dr. Anita Borges Dr. C. N. Nair, Dr. Sumeet Gujral Dr. Mona Anand, Dr. Mani Drs: Archana, Anshuman, Aditi, Sunita, Kiran, Kanchan, Manu, Sanica. Entire Staff of Hematopathology Laboratory, TMH, Mumbai Ms. Salini Gopinathan Dr. Prasad P. Shenoy Central Clinical Laboratory Panjim – Goa


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