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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 , 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.
Why to study laboratory diagnosis?
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 .
How to learn laboratory diagnosis?
First, the methods used in laboratory diagnosis are more automatic and computerized.
Second , the aim is to train for clinical application .
For each test, referential values and clinical significance always should be known very well.
Chapter 1 Blood Test Blood routine test (BRT)
1. content (items) of BRT red blood cell count (RBC) hemoglobin(HB)concentration determination total white blood cell count (WBC) leukocyte differential count (DC) platelet count (PC)
1. content (items) of BRT red blood cell count (RBC) hemoglobin(HB)concentration determination total white blood cell count (WBC) leukocyte differential count (DC) platelet count (PC)
Rferential values of BRT Table 1. Deferential values for blood routine test in different age
and sex ___________________________________ male female newborn
___________________________________
RBC 4.0-5.5 3.5-5.0 6.0-7.0 HB 120-160 110-150 170-200 WBC 4-10 4-10 15-20 PLT 100-300 100-300 ___________________________________
Table 2 Referential values of differential count
___________________________________ type percent value(%) absolute value ___________________________________ N st 1-5 0.04-0.5 N se 50-70 2-7 LYM 20-40 0.8-4 Mo 3-8 0.12-0.8 Eo 0.5-5 0.02-0.5 Ba 0-1 0-0.1 ___________________________________
Morphology of blood cells
Red blood cell: normocyte: 6-9um, discocyte- shape, no nucleus
white blood cell divided in five types: neutrophilic granulocyte : neutrophil stab cell (Nst), neutrophil segmented cell (Nse), lymphocyte, basophil granulocyte, eosinophil granulocyte
Platelet: smallest cell in peripheral blood
In automatic blood cell analyzer,25 items are included together : WBC : 4.0~10.0x109/L LYM : 0.8~ 4.0 x109 /L (20~40%) MID( middle cells) : monocyte, eosinocyte, basoc
yte , immature cells(rare be seen) GRAN(granulocyte):2.0~7.8x109/L(50~70%) RBC:4.0~5.5x1012/L(male),3.5~5.0x 1012 /L (fe
male) HGB: 120~160 g/L (male), 110~150 g /L (femal)
--
HCT(hematocrit):0.4~0.5L/L(male), 0.37~ 0.48 L/L (female)
MCV ( mean corpuscular volume): 82~95 fl MCH(mean corpuscular hemoglubin): 27~31 pg MCHC ( mean corpuscular hemoglubin concentration)
: 320~360 g/L RDW ( red cell distribution width ): 11.5~14.5% PLT( platelet): 100~300x109 /L MPV ( mean platelet volume): 8.7~16.5 fl PDW ( platelet distribution width): 15.8~21.4%
Clinical significance
Anomalies of RBC and HB 1. decrease of RBC and HB Anemia: When RBC and HB of individual i
s 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.
According to the level of Hb, anemia is divided into four degrees i
n clinic
mild anemia: Hb < 120g/L(male) or < 110g/L(female)
medium anemia : Hb <90 g/L severe anemia : Hb <60g/L extreme severe anemia: Hb <30g/L
Physiological anemia
infant and children aged between 3 months to 15 years,
pregnant women in middle or terminal periods of pregnancy,
elderly people.
Pathological anemia.
decrease in synthesis of red blood cell in bone marrow
increased destroy of red blood cell in peripheral blood
blood loss
Decrease in synthesis of red blood cell in bone marrow
disorder of hemopoiesis in bone marrow: aplastic anemia
infiltration of bone marrow by tumorous cell: leukemia, multiple myeloma , lymphoma , metastatic tumor
deficiency of hemopoietic materials or factors: iron deficiency anemia(IDA), megaloblastic anemia (folic acid deficiency)
Destroy of RBC in peripheral blood -- hemolytic anemia
Hereditory disease : hereditory sphrocytosis (HS) , G6PD deficiency, thalassmia , Hb disease
Acquired anomalies : hemolysis by immunological , physical, chemical , biological and mechanical factors
Blood loss -- hemorrhagic anemia
acute blood loss : acute upper digestive tract bleeding , splenic rupture
chronic blood loss : hemorrhoid, hookworm disease, hypermenorrhea, GI tumor
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(PV), chronic cardiopulmonary diseases: cor pulmonale, obstructive emphysema, scarcity of oxygen.
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 high than 10 x109 /L
•Leukopenia: WBC is lower than 4 x109 /L
1. Neutrophil granulocyte
A. granulocytosis: 5 causes leading to granulocytosis
• acute infection or inflammation: acute pyogenic
tonsilitis, acute appendicitis, hematosepsis
• damage or necrosis of tissue: severe burn, acute myocardiac infarction
•acute blood loss: digestive tract bleeding,
splenic rupture
•Acute poisoning: uremia, ketoacidosis
•Malignant blood diseases and tumor:
leukemia, metastatic tumor
B. Granulocytopenia:
• leukopenia: WBC < 4 x109 /L
• granulocytopenia:
neutrophil granulocyte < 1.5 x109 /L
• agranulocytopenia:
neutrophil granulocyte < 0.5 x109 /L
5 causes for granulocytopenia:
• Infection of bacteria and virus: typhoid, influenza,
measles
• some physical and chemical factors: drug
• autoimmune diseases: systemic lupus erythematosis (SLE),
• malignant blood diseases: aplastic anemia,leukemia
•hypersplenism
Changes of nucleus
nucleus shift to left:
• mild shift to left: Nst > 6% only
• medium shift to left: Nst > 10% with meta-
myelocyte
• severe shift to left : Nst > 25% with more
immuture cell (leukemiod reaction )
nucleus shift to left cab be seen in acute infection,
acute poisoning, acute hemolysis
Nucleus shift to right: multi-segmented Nse >3%
3-lobed Nse is normal segmented neutrophil in BP
nucleus shift to right can be seen
• megaloblastic anemia
• administration of anti-metabolic drugs
2. lymphocyte
A . Lymphocytosis: DC: Lym > 40%
•Virus infection: infectious mononucleosis,
chickenpox,
•Lymphocytic leukemia: ALL, AA, lymphoma
•GVHD or GVHR after BMT
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,
4. eosinophilia
•allergic diseases, hypersensitive diseases
•parasites infection:
•Skin diseases: psoriasis
•blood diseases: CML, eosinophilic leukemia,
lymphoma
•Infectious diseas: scarlatina
•Hypereosinophilic syndrome
5. Basophil granulocyte
bosophilia: CML, basophilic leukemia,
myelofibrosis
Other tests for red blood cellOther tests for red blood cell
1. Reticulocyte count (RC)
0.05-0.015 (0.5-1.5%)
24-84 x109 /L
Reticulocytosis: hemolytic anemia
acute hemorrhagic anemia
index of therapeutic effect:
IDA, megaloblastic anemia
•Reticulocytopenia:
Aplastic anemia
leukemia
2. Hematocrit(Hct)
0.4-0.5L/L(male), 0.37-0.48L/L(female)
• increase of Hct:
blood concentration
water loss
polycythemia(PV)
• decreas of Hct: anemia
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 320-360g/L
Morphological classification of anemia
Classification MCV MCH MCHC diseases
Normocytic 82-95 27-31 320-360 AA, HA, leukemia
Macrocytic >100 > 31 320-360 MA, pernicious
anemia
Microcytic < 80 < 27 320-260 infection, tumor,
uremia
Microcytic < 80 < 27 < 320 IDA, thalassemia
Hypochromic sideroblastic
anemia
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
Chapter 2. Bone MarrowChapter 2. Bone MarrowExaminationExamination
1. Clinical application of marrow examination Diagnosis for hematopoietic system diseases:
leukemia, myeloma, aplastic anemia, etc parasite infectious diseases: malaria, black
fever metabolic diseases: Gaucher disease. Nieman
n-Pick disease
Indications:
•Fever origin unknown (FOU)
•Cachexia
•Hepatomegaly, splenomegaly, lymphoadenovarix
•Abnormal in quantity and quality in peripheral
blood cell
Contraindication:
• Hemophilia
• Pyogenic infection in local skin
Methods:
• bone marrow aspiration
• bone marrow biopsy
2. Development of blood cells
myeloblast promyelocyte myelocyte metamyelocyte Nst Seg
normoblast basophilic normoblast
polychromatic normoblast orthochromatic
normoblast erythrocyte
Monoblast promonocyte monocyte
macrophage histiocyte
Megakaryoblast promega granular Meg
thrombocytogenous Meg platelet
B-lymphoblast B-prolymphoblast B-lymphocyte plasmablast proplasmacyte
plasmacyte
3. Regulation of blood cell 3. Regulation of blood cell developmentdevelopment
Cytobody: from large to small,
Mega is an exception Cytoplasma: from less to more,
color from blue to pink or orange red,
granules from invisible to visible,
granules from non-specific to specific
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 nonexistanceRation of nucleus to cytoplasma: from bigger to smaller
5.Contene and step of marrow 5.Contene and step of marrow examinationexamination
Myelogram: Low power(LP):
Wright stain of marrow film
plastic degree: 5 classification
Meg count : 7-35/1.5x3cm2
ousspecial cell: metastatic tumorous cell
•Oil immersion:
Nucleated cell count (%): 200-500
Ratio of myeloid to erythroid (M:E): 2-4:1
Morpholigical description of every series
Special cells and parasite
•Diagnosis
•Hemogram:
Low power(LP):
Oil immersion len: differential count 100
leukocyte (DC)
Immature cell (nucleated cell)
parasites
6. Normal myelogram and he6. Normal myelogram and hemogrammogram
1. Myelogram Normal cellularity: erythrocyte: nucleated cell M:E=2-4:1 Granulocytic series is 40-60% in all nucleated cells Erythrocytic series is 20% in all nucleated cells Lymphocyte is 20% , monocyte is <4% in all nucleated cells Meg count is 7-35, platelet is normal Other cell: plasmacyte and histiocyte are rare No specific cells and parasite
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
2. Hemogram:
•DC is normal
•No nucleated red blood cell
•No immature white cell
•Platelet is normal
7. Characters of common bloo7. Characters of common blood diseases in microscoped diseases in microscope
Iron deficiency anemia(IDA) Aplastic anemia(AA) Acute leukemia(AL) Chronic myelocytic leukemia(CML) Idiopathic thrombocytopenia purpura(ITP)
1. Iron Deficiency Anemia(IDA) 1. Iron Deficiency Anemia(IDA)
Hemogram:
Hb , RBC , normal RC,
RBC hypochromia, exaggeration of central pallor to from rings, anisocytosis
normal WBC and platelet
•Myelogram:
Significant hypercellularity
M:E
Erythroid hyperplasia with small normoblast
Pycnotic nuclei and scanty cytoplasma
irregular margin
2. Aplastic Anemia(AA)2. Aplastic Anemia(AA)
Hemogram:
pancytopenia: Hb ,RBC , WBC ,PLT
RC <0.005 or absolute value < 15 x109 /L
RBC is normocytic
•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
3. Acute Leukemia(AL)3. Acute Leukemia(AL)
FAB classification:
acute lymphocytic leukemia: L1-L3
acute non-lymphocytic leukemia: M0-M7 Hemogram:
Hb, RBC
WBC uncertain: normal, increase, decreas
platelet:
•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
4. Chronic Myelocytic Leuke4. Chronic Myelocytic Leukemia(CML)mia(CML)
Hemogram:
WBC increase rxtremly
DC: E0, Ba increas, myelocyte,
metamyelocyte, band cell increase
normal Hb, RBC or mild decrease
normal plt
•Myelogram:
Extreme hypercellularity
M:E increase
Extreme hyperplasia of granulocyte with increas of myelocyte, metamyelocyte, band cell, E0, Ba
Normal erythroid and Megakaryocyte
5. Idiopathic Thrombocytopenic P5. Idiopathic Thrombocytopenic Purpura(ITP)urpura(ITP)
Hemogram:
normal Hb, RBC
normal WBC and DC
PC decreas with abnormal morphology
•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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