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Title: Laboratory Diagnosis What is laboratory diagnosis


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?
  • 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?
  • 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.

5
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)

6
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
  • ___________________________________

7
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
  • ___________________________________

8
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

9
In automatic blood cell analyzer,25 items are
included together
  • WBC 4.010.0x109/L
  • LYM 0.8 4.0 x109 /L (2040)
  • MID( middle cells) monocyte, eosinocyte,
    basocyte , immature cells(rare be seen)
  • GRAN(granulocyte)2.07.8x109/L(5070)
  • RBC4.05.5x1012/L(male),3.55.0x 1012 /L
    (female)
  • HGB 120160 g/L (male), 110150 g /L (femal)

10
-
  • HCT(hematocrit)0.40.5L/L(male), 0.37 0.48
    L/L (female)
  • MCV ( mean corpuscular volume) 8295 fl
  • MCH(mean corpuscular hemoglubin) 2731 pg
  • MCHC ( mean corpuscular hemoglubin
    concentration) 320360 g/L
  • RDW ( red cell distribution width ) 11.514.5
  • PLT( platelet) 100300x109 /L
  • MPV ( mean platelet volume) 8.716.5 fl
  • PDW ( platelet distribution width) 15.821.4

11
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.

12
According to the level of Hb, anemia is divided
into four degrees in clinic
  • mild anemia Hb lt 120g/L(male) or lt
    110g/L(female)
  • medium anemia Hb lt90 g/L
  • severe anemia Hb lt60g/L
  • extreme severe anemia Hb lt30g/L

13
Physiological anemia
  • infant and children aged between 3 months to 15
    years,
  • pregnant women in middle or terminal periods of
    pregnancy,
  • elderly people.

14
Pathological anemia.
  • decrease in synthesis of red blood cell in bone
    marrow
  • increased destroy of red blood cell in peripheral
    blood
  • blood loss

15
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)

16
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

17
Blood loss --
hemorrhagic anemia
  • acute blood loss acute upper digestive tract
    bleeding , splenic rupture
  • chronic blood loss hemorrhoid, hookworm
    disease, hypermenorrhea, GI tumor

18
  • 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 Hbery-throcytosis
    polycythemia vera(PV), chronic cardiopulmonary
    diseases cor pulmonale, obstructive emphysema,
    scarcity of oxygen.

19
  • 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

20
  • 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

21
  • acute blood loss digestive tract bleeding,
  • splenic rupture
  • Acute poisoning uremia, ketoacidosis
  • Malignant blood diseases and tumor
  • leukemia, metastatic tumor

22
  • Granulocytopenia
  • leukopenia WBC lt 4 x109 /L
  • granulocytopenia
  • neutrophil granulocyte lt 1.5 x109 /L
  • agranulocytopenia
  • neutrophil granulocyte lt 0.5 x109 /L

23
  • 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

24
  • Changes of nucleus
  • nucleus shift to left
  • mild shift to left Nst gt 6 only
  • medium shift to left Nst gt 10 with meta-
  • myelocyte
  • severe shift to left Nst gt 25 with more
  • immuture cell (leukemiod reaction )
  • nucleus shift to left cab be seen in acute
    infection,
  • acute poisoning, acute hemolysis

25
  • Nucleus shift to right multi-segmented Nse
    gt3
  • 3-lobed Nse is normal segmented neutrophil in
    BP
  • nucleus shift to right can be seen
  • megaloblastic anemia
  • administration of anti-metabolic drugs

26
  • 2. lymphocyte
  • A . Lymphocytosis DC Lym gt 40
  • Virus infection infectious mononucleosis,
  • chickenpox,
  • Lymphocytic leukemia ALL, AA, lymphoma
  • GVHD or GVHR after BMT

27
  • 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,

28
  • 4. eosinophilia
  • allergic diseases, hypersensitive diseases
  • parasites infection
  • Skin diseases psoriasis
  • blood diseases CML, eosinophilic leukemia,
  • lymphoma
  • Infectious diseas scarlatina
  • Hypereosinophilic syndrome

29
5. Basophil granulocyte bosophilia CML,
basophilic leukemia,
myelofibrosis
30
Other tests for red blood cell
  • 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

31
  • Reticulocytopenia
  • Aplastic anemia
  • leukemia

32
  • 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

33
3. Mean values of RBC Mean corpuscular volume
(MCV) MCVHct/RBC
82-95fl Mean corpuscular hemoglubin(MCH)
MCHHb/RBC 27-31pg Mean corpuscular
hemoglubin concentration
MCHCHb/Hct 320-360g/L
34
Morphological classification of
anemia Classification MCV MCH MCHC
diseases Normocytic 82-95 27-31
320-360 AA, HA, leukemia Macrocytic gt100
gt 31 320-360 MA, pernicious

anemia Microcytic lt 80 lt
27 320-260 infection, tumor,

uremia Microcytic lt 80 lt 27
lt 320 IDA, thalassemia Hypochromic

sideroblastic
anemia
35
  • 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

36
Chapter 2. Bone MarrowExamination
  • 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. Niemann-Pick
    disease

37
  • Indications
  • Fever origin unknown (FOU)
  • Cachexia
  • Hepatomegaly, splenomegaly, lymphoadenovarix
  • Abnormal in quantity and quality in peripheral
  • blood cell

38
  • Contraindication
  • Hemophilia
  • Pyogenic infection in local skin
  • Methods
  • bone marrow aspiration
  • bone marrow biopsy

39
  • Development of blood cells
  • myeloblast promyelocyte
    myelocyte metamyelocyte Nst
    Seg
  • normoblast basophilic normoblast
  • polychromatic normoblast
    orthochromatic
  • normoblast erythrocyte

40
Monoblast promonocyte
monocyte macrophage
histiocyte Megakaryoblast promega
granular Meg thrombocytogenous Meg
platelet B-lymphoblast
B-prolymphoblast B-lymphocyte
plasmablast proplasmacyte
plasmacyte
41
3. Regulation of blood cell development
  • 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

42
  • 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
  • Ration of nucleus to cytoplasma
  • from bigger to smaller

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

46
  • Oil immersion
  • Nucleated cell count () 200-500
  • Ratio of myeloid to erythroid (ME) 2-41
  • Morpholigical description of every series
  • Special cells and parasite
  • Diagnosis

47
  • Hemogram
  • Low power(LP)
  • Oil immersion len differential count 100
  • leukocyte (DC)
  • Immature cell (nucleated cell)
  • parasites

48
6. Normal myelogram and hemogram
  • 1. Myelogram
  • Normal cellularity erythrocyte nucleated cell
  • ME2-41
  • Granulocytic series is 40-60 in all nucleated
    cells
  • Erythrocytic series is 20 in all nucleated cells
  • Lymphocyte is 20 , monocyte is lt4 in all
    nucleated cells
  • Meg count is 7-35, platelet is normal
  • Other cell plasmacyte and histiocyte are rare
  • No specific cells and parasite

49
Plastic degree of
marrow Plastic degree erythrocyte
nucleated diseases Extreme
hypercellularity 11
leukemia Significant hyper- 101
leukemia, ITP,
Cellularity
plastic anemia Normal
cellularity 201
anemia, normal

myelogram Hypocellularity
501 AA,agranulocy-

topenia Extreme hypocellularity
3001 aplastic anemia
50
  • 2. Hemogram
  • DC is normal
  • No nucleated red blood cell
  • No immature white cell
  • Platelet is normal

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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)

54
1. Iron Deficiency Anemia(IDA)
  • Hemogram
  • Hb , RBC , normal RC,
  • RBC hypochromia, exaggeration of central
    pallor to from rings, anisocytosis
  • normal WBC and platelet

55
  • Myelogram
  • Significant hypercellularity
  • ME
  • Erythroid hyperplasia with small normoblast
  • Pycnotic nuclei and scanty cytoplasma
  • irregular margin

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2. Aplastic Anemia(AA)
  • Hemogram
  • pancytopenia Hb ,RBC , WBC ,PLT
  • RC lt0.005 or absolute value lt 15 x109 /L
  • RBC is normocytic

58
  • 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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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

61
  • Myelogram
  • Extreme or significant hypercellularity
  • ME
  • 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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4. Chronic Myelocytic Leukemia(CML)
  • Hemogram
  • WBC increase rxtremly
  • DC E0, Ba increas, myelocyte,
  • metamyelocyte, band cell increase
  • normal Hb, RBC or mild decrease
  • normal plt

75
  • Myelogram
  • Extreme hypercellularity
  • ME increase
  • Extreme hyperplasia of granulocyte with increas
    of myelocyte, metamyelocyte, band cell, E0, Ba
  • Normal erythroid and Megakaryocyte

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

80
  • 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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