Laboratory Diagnosis.ppt by tongxiamy

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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
   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
 First, the methods used in laboratory
  diagnosis are more automatic and
 Second , the aim is to train for clinical
  application .
 For each test, referential values and clinical
  significance always should be known very
    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)
       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,
    basocyte , 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
   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
  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.
    According to the level of Hb,
     anemia is divided into four
         degrees in clinic
 mild anemia: Hb < 120g/L(male) or <
 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,
• some physical and chemical factors: drug
• autoimmune diseases: systemic lupus
erythematosis (SLE),
• malignant blood diseases: aplastic anemia,leukemia
Changes of nucleus
nucleus shift to left:
• mild shift to left: Nst > 6% only
• medium shift to left: Nst > 10% with meta-
• 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,
•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
• monocytic leukemia, malignant histocytosis,
4. eosinophilia
•allergic diseases, hypersensitive diseases
•parasites infection:
•Skin diseases: psoriasis
•blood diseases: CML, eosinophilic leukemia,
•Infectious diseas: scarlatina
•Hypereosinophilic syndrome
5. Basophil granulocyte
bosophilia: CML, basophilic leukemia,
     Other 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
 Aplastic anemia
2. Hematocrit(Hct)
  0.4-0.5L/L(male), 0.37-0.48L/L(female)
• increase of Hct:
  blood concentration
  water loss
• 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
Microcytic    < 80    < 27    320-260 infection, tumor,
Microcytic    < 80    < 27     < 320   IDA, thalassemia
Hypochromic                            sideroblastic
4. Erythrocyte sedimentation rate(ESR)
  0-15mm/h (male), 0-20mm/h (female)
  higher ESR:
• infection and inflammation: rheumatic
• malignant tumor
• anemia
• damage or necrosis of tissue
• globulinemia, cholesterolemia
     Chapter 2. Bone Marrow
1. Clinical application of marrow examination
 Diagnosis for hematopoietic system diseases:
   leukemia, myeloma, aplastic anemia, etc
 parasite infectious diseases: malaria, black
 metabolic diseases: Gaucher disease.
   Niemann-Pick disease
•Fever origin unknown (FOU)
•Hepatomegaly, splenomegaly, lymphoadenovarix
•Abnormal in quantity and quality in peripheral
blood cell
• Hemophilia
• Pyogenic infection in local skin
• 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
    3. Regulation of blood cell
 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
 from large to small, Mega is an exception,
 shape of nucleus from round to irregular,
 chromatin patten of nucleus from fine to
 nucleolus from existance to nonexistance
Ration of nucleus to cytoplasma:
 from bigger to smaller
5.Contene and step of marrow
 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
Low power(LP):
Oil immersion len: differential count 100
leukocyte (DC)
Immature cell (nucleated cell)
        6. Normal myelogram and
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
Hypocellularity               50:1            AA,agranulocy-
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
blood 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)
   Hemogram:
    Hb , RBC , normal RC,
    RBC hypochromia, exaggeration of central
    pallor to from rings, anisocytosis
    normal WBC and platelet
Significant hypercellularity
Erythroid hyperplasia with small normoblast
Pycnotic nuclei and scanty cytoplasma
irregular margin
    2. Aplastic Anemia(AA)

pancytopenia: Hb ,RBC , WBC ,PLT
RC <0.005 or absolute value < 15 x109 /L
RBC is normocytic
Hypocellularity or extreme hypocellularity,
Hematopoietic cell decrease: erythroid, myeloid
cells , meg     or absent, platelet rarely be
Non-hematoietic cell increase: lymphocyte
Reticular cell , plasmacyte
     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
Extreme or significant hypercellularity
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
WBC increase rxtremly
DC: E0, Ba increas, myelocyte,
metamyelocyte, band cell increase
normal Hb, RBC or mild decrease
normal plt
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
    Hemogram:
     normal Hb, RBC
     normal WBC and DC
     PC decreas with abnormal morphology
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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