RED BLOOD CELLS (RBCs) Prof. Dr. Salwa Saad

ILOs: The student should be able to: Define Erythropoiesis Recognize normal RBCs and their parameters Recognize RBCs abnormalities Define anaemias

Identify morphological types of anaemias Select appropriate investigation(s) in each anaemia (disease)‏ Integrate knowledge learnt in the course with other laboratory findings and clinical data

DEVELOPMENT

DEVELOPMENT Complete loss of basophilic material probably occurs in the bloodstream and, particularly, in the spleen after the cells have left the bone marrow. This maturation is thought to take 2–3 days, of which about 24 hours are spent in the circulation Spleen Peripheral Circulation

Normal RBCs

Reticulocyte count: Definition..... Reticulocyte count = % of reticulocytes in PB. Normally= 0.5- 2.5% Absolute count = 50- 100 x 109/L Causes of reticulocytosis:  Hemorrhage  Hemolysis  In response to hematinics Causes of reticulocytopenia:  Aplastic anemia

Polychromasia

RBCs Parameters 11.5-14% RDW 32-35% MCHC 27-32 pg MCH 78-98 fL MCV PCV M: 13-17 g/dL F: 12-16 g/dL Hb M: 4.5-5.5x1012/L F: 3.8-4.8x1012/L RBCs count Range RBCs Parameter

RBCs Abnormalities Size Shape Staining Inclusions

RBCs Abnormalities;Size: Microcytosis = diminished MCV (small RBCs)‏ Macrocytosis = Increased MCV (large RBCs)‏ Anisocytosis = variation in RBCs size

RBCs Abnormalities;Shape Poikilocytosis: variation in RBC shape Target cells: found in:  Thalassemias and other abnormal Hbs  Iron deficiency anemia  Liver diseases

RBCs Abnormalities;Shape: Spherocytes: Fully hemoglobinized small RBCs. Found in: Congenital spherocytosis Autoimmune hemolytic an. Hemolytic disease of newborn  Blood transfusion

Normal RBCs Microspherocyte Target Cell

RBCs Abnormalities; Shape Sickle cells: found in sickle disease Ovalocytes: in congenital ovalocytosis Elliptocytes: In congenital elliptocytosis

RBCs Abnormalities; Staining Hypochromia: Diminished MCH Polychromasia: in case of Increased reticulocytic count

RBCs Abnormalities; Inclusions: Malaria Heinz bodies Unstable Hb Chemical/drug poisoning G6PD def. Post-splenectomy

ANEMIA Definition: It is a decrease in Hb concentration, RBC count and/or PCV below the average normal for age and sex

ANEMIA Morphological Classification of Anemias Microcytic Hypochromic - MCV < 78 fL - MCH < 27 pg Normocytic Normochromic - MCV: 78-98 fL - MCH: 27-32 pg Macrocytic - MCV > 98 fL Causes: - Acute blood loss Hemolytic an. (ex thal.)‏ An. of chronic disorder Aplastic anemia Causes: - Iron deficiency anemia Thalassemia minor/major An. of chronic disorder Sideroblastic anemia Causes: - Megaloblastic Non Megaloblastic * Liver disease * Hemolytic anemia * Aplastic anemia

Microcytic Hypochromic Anemia D D of Microcytic Hypochromic anemia: N ↑ ↓ An. chronic Disorder ↑ HbA2 (β thal.)‏ N (α thal.)‏ Thals. trait Fe def.an. Hb electrophoresis Ring sideroblasts BM iron stores s. Ferritin TIBC s. Iron Sideroblastic an.

Microcytic Hypochromic Anemia Thalassemias: Definition: Genetically determined familial defect in globin chain synthesis  imbalance in globin chain production  abnormal erythropoiesis + hemolytic anemia β-thalassemia: Defect in β chain production: β0  total absence β+  partial ↓ Phenotypically: β-th. Major β-th. Minor α-thalassemia: Defect in α chain production: Phenotypically: Silent carrier α-th. trait Hb H Hb Barts

Microcytic Hypochromic Anemia Thalassemias: Thalassemia major: - Marked degree of microcytic hypochromic anemia - Increased serum iron, ferritin. - PB : normoblastemia, target cells, anisopoikilocytosis, reticulocytosis - Hb electrophoresis: Hb F in β thalassemia Hb H in α thalassemia

Macrocytic anemias - Aplastic an. ↓ Retics Hemolytic an. ↑ Retics Differential Diagnosis of Macrocytic anemias: - Aplastic an. ↓ Retics Hemolytic an. ↑ Retics Megaloblastic an. Liver disease Normal Retics

Laboratory Findings in Megaloblastic anemia Macrocytic anemias Laboratory Findings in Megaloblastic anemia Pancytopenia PB: ovalocyte macrocytes, anisopoikilocytosis,, hyper segmented neutrophils Hypercellular marrow with megaloblastic changes Decrease s. B12 & folate. Positive antiparietal cell Abs & intrinsic factor Abs in pernicious an. Therapeutic trials: Giving B12 & folate and testing the response by reticulocyte count on the 3rd day & peak on 7th day

Laboratory Findings in Megaloblastic anemia Macrocytic anemias Laboratory Findings in Megaloblastic anemia

Normocytic Normochromic Anemia Differential Diagnosis : - Aplastic an. ↓ Retics Anemia of chronic disorder Normal Retics Hemolytic Anemia Acute Hge ↑ Retics

Normocytic Normochromic Anemia Hemolytic Anemia Definition: It is anemia due to increased rate of RBCs destruction.

Normocytic Normochromic Anemia Hemolytic Anemia: Laboratory evidence of hemolysis: - ↑ indirect bilirubin - ↑ reticulocyte count (polychromasia)‏ - ↑ urine urobilinogen - BM erythroid hyperplasia - Absent haptoglobin. + - Hemoglobinemi & Hemoglobinuria in I.V hemolysis

Polycythemia Definition: Classification: Primary or secondary (usually d.t. hypoxia) Lab Findings: Hb, RBCs count, PCV increased ( RBCs) - erythrocytosis Normal pO2 - low pO2 TLC - normal TLC Platelets - normal platelets Uric acid - normal NAP score Vitamin B1 - increased erythtropoietin Neutrophil alkalin phosphatase Decreased serum erythropoietin

Case Study

To reach proper diagnosis, 3 basic questions should be answered: Is the patient anemic ? A: Hb level 2. What is the type of anemia? A: RBCs parameters: MCV; MCH 3. What is the cause of anemia? A: CBC ; cell morphology; reticulocytic count; other confirmatory tests

Case 1 Male child, 7ys old, C/O weakness, easy fatigue, underweight CBC: TLC: 12,000/ul (5,000- 15,000)‏ Hb: 8g/dL (11- 14) RBC: 2.50 million/ul (4- 5.2) PCV: 24% (35- 45) MCV: 55 fl (78- 98) MCH: 22pg (27- 32) MCHC: 30% (30-35)‏ Plat: 200,000/ul Blood Film: Eosinophilia

Case 2 Pregnant female, 30 ys old, C/O weakness, fatigue CBC: TLC: 3,900/ul (4,000- 10,000)‏ Hb: 9 (12- 16)‏ RBC: 3.00 (3.80- 4.80) MCV: 105 (78- 98)‏ MCH: 29 (27- 32) MCHC: 35 (30- 35)‏ Plat: 50,000/ul Blood Film: retics: 0.5%; macrocytes, ovalocytes, hypersegmented neutrophils

Case 3 Male infant, 4 months old, presented by jaundice, splenomegaly CBC: TLC: 10,000/ul (6,000- 18,000)‏ Hb: 8.0 g/dL (9.5- 13.5) RBC: 3.50 million/ul (3.00- 4.60) MCV: 88 fl (88- 93) MCH: 28 pg (25- 35) MCHC: 36% (30- 36)‏ Plat: 400,000/ul Blood Film: Spherocytes and polychromatic cells Chemistry: Total bilirubin: 3 mg/dL, Direct bilirubin: 0.2 mg/dL

Female patient, 18 years old, presented with renal troubles, skin rash & jaundice Case 4 CBC: TLC: 15,000/ul (4,000- 10,000)‏ Hb: 7 g/dL (12- 16) RBC: 2.30 million/ul (3.80- 4.80) MCV: 90 fl (78- 98)‏ MCH: 30 pg (27- 32)‏ Plat: 180,000/ul Blood Film: Polychromasia, microspherocytes, normoblastemia, fragmented cells, neutrophilia Chemistry: Total bilirubin: 4 mg/dL, Direct bilirubin: 0.3 mg/dL

Male patient, 50 years old, treated for joint pain 2 yrs ago. Case 5 CBC: TLC: 8,000/ul (4,000- 10,000)‏ Hb: 9 g/dL (13- 18) RBC: 3.80 million/ul (4.50- 5.50)‏ MCV: 76 fl (78- 98)‏ MCH: 25 pg (27- 32)‏ Plat: 250,000/ul

Male patient, 18 years old, in routine preoperative investigation. Case 6 CBC: TLC: 6,000/ul (4,000- 10,000)‏ Hb: 11 g/dL (13- 18)‏ RBC: 5.50 million/ul (4.50- 5.50)‏ MCV: 68 fl (78- 98)‏ MCH: 22 pg (27- 32)‏ RDW: 14.0 (11.5- 14.0)‏ Plat: 300,000/ul

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