2. Introduction
We will discuss :
 Blood, Blood components, Blood cells,
Haematopoiesis
 CBC parameters and clinical significance
 Use in Clinical Practice
 CBC analyser, Technical aspects
 What next after analysing a CBC report
 Futuristic aspects
CBC: Basic haematologic and systemic evaluation
-It offers a comprehensive assessment of the cellular
components that circulate within the bloodstream
revealing wide range of medical conditions

3. Objectives:
Basic idea
about CBC
analyzers
Methods of
reporting
Interpretation
of CBC
parameters
Diagnostic
significance
Newer concepts
to implement in
routine practice

4. Blood: Primary functions
 Blood is a specialized body fluid
 Transporting oxygen and
nutrients to the lungs and
tissues: RBCs
 Forming blood clots to prevent
excess blood loss: Platelets
 Carrying cells (WBCs) and
antibodies (Plasma) that fight
infection
 Bringing waste products to the
kidneys and liver, which filter
and clean the blood
 Regulating body temperature

5. Blood: Components
 Plasma: a mixture of water, sugar,
fat, protein, and salts. Transport blood cells
throughout body along with nutrients, waste
products, antibodies, clotting proteins,
hormones, and proteins that help maintain
the body's fluid balance.
 Red blood cells
(Erythrocytes): Controlled by
erythropoietin. No nucleus and can easily
change shape. Contain a special protein
called haemoglobin. The percentage of whole
blood volume that is made up of red blood
cells is called the haematocrit.
 White blood cells
(Leukocytes): White blood cells
protect the body from infection
 Platelets (Thrombocytes):
Platelets are not actually cells but rather
small fragments of cells. Helps in blood

6. Blood cells and Haematopoiesis

7. Peripheral blood smear

8. Bone marrow

9. Blood cells:
Bone Marrow Cells Peripheral Blood Cells
Stem cells
Immature myeloid Precursors
Megakaryocytes
Immature erythroid precursors/
Normoblasts
Lymphocytes,
Plasma cells
Mesenchymal/Stromal cells
Adipocytes
Mature blood cells
Haemoparasites
RBCs,
Reticulocytes, Normoblasts
WBCs,
Immature precursors (Left shift),
Atypical cells/Blasts
Platelets
Haemoparasites

10. The necessity of a CBC report

11. CBC Report (LIS Generated) :

12. …XYZ of CBC
 RBC
 WBC
 Platelets

13. RBC (Eythrocyte)
Nucleated RBCs:
nRBC number
nRBC % (/100 WBC)
Reticulocyte:
Reticulocytes number
Reticulocyte % (/100 RBC)
IRF
Ret-Hb
Reticulocyte maturity indices (LFR, HFR, MFR-
Fluorescence ratio)
RPI (Reticulocyte Production Index)
FRC (Fragmented red cells)
RBCs:
Total RBC count
Hb
PCV
MCV
MCH
MCHC
RDW-SD
RDW-CV

14. RBC Count
Hb
PCV
 Anaemia
 Polycythemia

15. Polycythemia Vs Anaemia
Congenital heart disease
Heart failure
Chronic obstructive pulmonary disease (COPD)
Pulmonary fibrosis, often due to smoking
Polycythemia vera
Performance-enhancing drugs that stimulate RBC
production, such as anabolic
steroids or erythropoietin
Renal cell carcinoma
Dehydration
Kidney failure
Thyroid problems
Bleeding, either internal or external
Leukemia
Drug side effects, including chemotherapy
Deficiency of erythropoietin
Deficiencies in iron, folate, vitamin B12, or vitamin B6
Hemolysis
Pregnancy

16. MCV
A low MCV may be seen with:
Iron deficiency
Thalassemia
Anaemia of chronic disease
Sideroblastic anemia
Lead poisoning
HbC and other haemoglobin hybrids
Spherocytosis
Common causes of high MCV:
Vitamin B12 deficiency
Folate deficiency
Liver disease
Hyperglycemia, or high blood sugar
Alcohol use disorder
Hypoplastic anaemia
The MCV may be falsely high.
This can occur when red blood cells clot.
Cold agglutinin disease,
Paraproteinemias
Blood sugar is very high.

17. Iron deficiency anaemia
VS
Thalassemia

18. MCH
 A measurement of the amount of hemoglobin in red blood
cells.
 An MCH level below 27 picograms/cell is considered
abnormally low. Anemia is the most common reason for this.
 An MCH level above 31 picograms/cell is considered
abnormally high.
The average hemoglobin concentration in a given volume of
red blood cells.
MCHC
Possible causes of low MCHC include:
Iron deficiency (with or without anemia)
Lead poisoning
Thalassemias (beta thalassemia, alpha thalassemia, and
thalassemia intermedia)
Sideroblastic anemia
Anemia of chronic disease
Causes of a high MCHC with anemia include:
Autoimmune hemolytic anemia
Hereditary spherocytosis
Severe burns
Liver disease
Hyperthyroidism
Sickle cell disease (homozygous)
Hemoglobin C disease

19. RDW SD(Fl)
RDW CV (%),
 The red cell distribution width
(RDW) measures how equal
your red blood cells are in size
and shape.

20. Normal RDW/low MCV
-Anaemia of chronic disease
-Thal Minor
-HbE trait
Normal RDW/High MCV
-Aplastic anaemia
-Chronic liver disease
-Chemotherapy/antivirals
Normal RDW/Normal MCV
-Anaemia of chronic disease
-Acute blood loss
High RDW/Normal MCV
-Early iron def, vit B12 or Folate
Defi
-Dimorphic anaemia
SCD
CLD
MDS
High RDW/Low MCV
-Iron Deficiency
- Sickle-B-Thal
High RDW /High MCV
Anaemia caused by vitamin B12
and folate deficiency
Immune Haemolytic anaemia
MDS
Mixed anaemias
Myelofibrosis

21. Nucleated RBCs
nRBC number
nRBC % (/100 WBC) Hemoglobinopathies
Brisk hemolysis
Rapid blood loss
Other conditions of hematopoietic stress such as sepsis
Damage or stress to bone marrow, for example in:
Chronic myeloid leukemia
Acute leukemia
Myelodysplastic syndromes
Chemotherapy
Myelophthisic conditions, including:
Metastatic cancer to bone marrow
Bone marrow fibrosis
LEUKOERYTHROBLASTI
C BLOOD PICTURE

22. Reticulocyte
 Reticulocytes number
 Reticulocyte % (/100 RBC)
 IRF
 Ret-Hb
 Reticulocyte maturity indices
(LFR, HFR, MFR)
 RPI (Reticulocyte Production Index)
Reticulocytes are "adolescent" red blood cells that have
just been released from the bone marrow into the
circulation
Reticulocyte Count (Percent):
= Number of Reticulocytes / Number of Red Blood Cells
The normal range for the reticulocyte count without
anaemia is:
Adults: 0.5 to 1.5%
Newborns: 3 to 6%

23. Corrections and RPI
 Corrected Reticulocyte Count (CRC): First Correction
 Corrected Reticulocyte Count (Percent)
= Absolute Reticulocyte Count x Patient's hematocrit /
Normal Hematocrit
For severe anemia (hemoglobin less than 12 or hematocrit
less than 36), a second correction is needed.
The reticulocyte
prodanahaemoglobinemiauction index (RPI)
takes into account the fact that
reticulocytes will be present in the blood
for a longer period of time. More than 2
days.
Reticulocyte Production Index :
= Corrected Reticulocyte Count /Maturation Correction(In
days).

24. The maturation correction depends on the
level of anemia:
1 day: for a hematocrit of 36 to 45 or
hemoglobin of 12 to 15
1.5 days: for a hematocrit of 16 to 35, or
hemoglobin of 8.7 to 11.9
2 days: for a hematocrit of 16 to 25, or
hemoglobin of 5.3 to 8.6
2.5 days: for a hematocrit less than 15, or
hemoglobin less than 5.2
An RPI of less than or equal
to 2 means the bone
marrow is not responding
as expected
(hypoproliferative anemia)
An RPI of more than 2 or 3
means the bone marrow is
trying to compensate for
the anemia
(hyperproliferative anemia)

25. If the reticulocyte count is low, possible tests may
include:
Iron and iron binding capacity and/or serum ferritin
if the MCV is low or RDW high
Vitamin B12 level if the MCV is high
Bone marrow biopsy if other abnormalities are seen
on the CBC (such as an abnormal white blood cell
count or platelet count)
Blood tests to evaluate liver, kidney, and thyroid
function
If the reticulocyte count is high, potential tests may
include:
A source of bleeding if one is not obvious (such as a
colonoscopy and more)
Tests to diagnose hemolytic anemias
To look for hemoglobinopathies
Autoimmune conditions, enzyme defects such as
glucose 6 phosphate dehydrogenase deficiency
(G6PD deficiency), and others

26. IRF
Ret-Hb
Reticulocyte maturity indices
(LFR, HFR, MFR)
Raja-Sabudin RZ, Othman A, Ahmed-Mohamed KA, Ithnin A, Alauddin H, Alias H, Abdul-Latif Z, Das S,
Abdul-Wahid FS, Hussin NH. Immature reticulocyte fraction is an early predictor of bone marrow recovery
post chemotherapy in patients with acute leukaemia. Saudi Med J. 2014 Apr;35(4):346-9. PMID: 24749130.
Young Jin Yuh, Sung Rok Kim, Tae Hee Han,
Immature Reticulocyte Fraction after Iron Therapy for Iron Deficiency Anemia.,
Blood, Volume 106, Issue 11, 2005, Page 3746, ISSN 0006-4971,
https://doi.org/10.1182/blood.V106.11.3746.3746.
(https://www.sciencedirect.com/science/article/pii/S0006497119786352)

27. WBC
(Leukocytes)
 WBC count
 Differential count
 Absolute counts
 Immature granulocyte % (/100
Granulocytes)

28. WBC count
Normal WBC counts by age:
 Babies 0 to 2 weeks old: 9,000 to
30,000 cells/mm3
 Babies 2 to 8 weeks old: 5,000 to
21,000 cells/mm3
 Children 2 months to 6 years old:
5,000 to 19,000 cells/mm3
 Children 6 to 18 years old: 4,800
to 10,800 cells/mm3
 Adults: 4,500 to 11,00 cells/mm3

29. Leukocytosis:
A bacterial, fungal, or parasitic infection
Inflammatory conditions
Burns
Corticosteroid use
Cigarette smoking
Pregnancy
Leukemia
Leukopenia:
A blood or bone marrow disorder
Autoimmune disorders
Medication side effects
Chemotherapy or radiation therapy
A viral infection

30. Differential count (%)
Absolute counts
IG

31. Neutrophilia
 Infections
 Inflammation,
 Injuries, stress, and certain medications.
(The spike in neutrophils is generally short-term.)
Certain blood cancers can result in increased neutrophils .
Chronic myeloid leukemia, CNL and polycythemia vera or in variable
neutrophil counts (like primary myelofibrosis).

32. Neutropenia
 Genetic conditions: Genetic abnormalities that cause neutropenia can be passed
from parents to their biological children.
Severe congenital neutropenia.
 Infections: Viral, bacterial and parasitic infections.
Common causes include HIV, hepatitis, tuberculosis, sepsis, and Lyme disease,
among other infections.
 Cancer: Cancer and other blood and/or bone marrow disorders, including leukemia
and lymphoma, causing neutropenia.
 Medications: Cancer treatments such as chemotherapy and radiation therapy.
Medications for conditions unrelated to cancer may also cause low levels of
neutrophils.
 Nutritional deficiencies: Not having enough vitamins or minerals such as vitamin
B12, folate or copper
 Autoimmune: Antibodies that destroy healthy neutrophils. Autoimmune conditions
include Crohn's disease, lupus, and rheumatoid arthritis, HPA

33. Eosinophilia
 Allergic reactions
 Drug reactions
 Parasitic infections
 Certain cancers
A normal eosinophil count is
between 100 and 500 cells per
microliter of blood.

34. Basophilia
 Polycythemia vera
 Blood cancers, Chronic myeloid leukemia
 Inflammatory bowel disease (IBD) like Crohn's disease
and ulcerative colitis
 Autoimmune disease
 Allergic reactions or inflammation related to infections
 A normal count is between 0 to 200 basophils per
microliter of blood

35. IG (%)
 At 1%-2%, the level is
considered high in evaluation of
neonatal sepsis
High IG counts can suggest :
 an infection or may point to a
bone marrow condition.
 Inflammatory diseases such as
vasculitis, affecting the blood
vessels
 Rheumatoid arthritis
 Cancer

36. Lymphocytosis
They play a key role in the immune system
 Cytomegalovirus
 Hepatitis
 Mononucleosis (caused by the Epstein Barr
virus)
 Pertussis ("whooping cough")
 Syphilis (a sexually transmitted bacterial
infection)
 Toxoplasmosis
 Tuberculosis
 Hypothyroidism
 Leukemia, Lymphomas

37. Low Lymphocyte Levels
 Aplastic anemia
 Chemotherapy
 Radiation therapy
 Immunosuppressants (drugs commonly used to
treat autoimmune diseases and prevent organ
transplant rejection)
 Malnutrition
 Hodgkin lymphoma
 Lupus
 Severe combined immunodeficiency (a rare
inherited disorder characterized by a low immune
response)
 Tuberculosis
 Typhoid fever
 HIV

38. Monocyte
 They are larger than
most blood cells.
Monocytes compose
approximately 4% to
8% of white blood
cells.
 From the bloodstream,
monocytes migrate
into different tissues,
where they
differentiate and
perform specialized
functions.
Dendritic cells: Monitor the
tissues that line the body,
identify infectious organisms
(like bacteria, viruses, and
fungi), and release chemicals
to activate an immune
response in the affected area
Macrophages: Contain
chemicals that directly destroy
pathogens (disease-causing
infectious organisms)

39. Monocytosis
Normal Levels of Monocytes and White
Cells
Per cmm Percent of
white blood
cells
Monocytes 200–800 4–8 %
The World Health Organization (WHO) defines
persistent monocytosis as an absolute
monocyte count of more than 1,000 per cu Mm,
with monocytes accounting for more than 10%
of white blood cells and persisting for longer
than three months.
Mangaonkar AA, Tande AJ, Bekele DI. Differential diagnosis and
workup of monocytosis: A systematic approach to a common
hematologic finding. Curr Hematol Malig Rep. 2021;16(3):267-275.
doi:10.1007/s11899-021-00618-4
Causes of increased monocytes include:
--Chronic infections (including tuberculosis, malaria, and
endocarditis). -Viral infections (including COVID)
-Autoimmune and inflammatory diseases
-Bone marrow recovery
-Some medications
-Due to splenectomy
-Myeloproliferative disorders
-Chronic stress

41. Platelets
 Platelet count
 Platelet distribution width (PDW)
 Mean platelet volume (MPV)
 P-LCR
 PCT
 IPF(%)
 IPF(×103)

42. Thrombocytopenia
Symptoms include:
 Nosebleeds
 Bleeding from gums
 Blood in urine or stool
 Purpura, petechiae, ecchymoses
 Easy bruising
 Heavy periods
 ICH, GI bleed
Platelet count of less than 150,000 platelets/mL, regardless
of age.

43. Isolated Vs combined
 Viruses
 Medications
 Pregnancy
 Splenomegaly
 Aplastic Anemia
 Idiopathic thrombocytopenia:
diagnosis of exclusion
 Chemotherapy
 Malignancy
 Inherited thrombocytopenia
 Thrombotic thrombocytopenic purpura

44. Thrombocytosis
 A diagnosis of thrombocytosis is made when platelets are higher than
450,000 per mcL
Primary thrombocytosis happens as a result of the bone marrow making too
many platelets.
Secondary thrombocytosis happens as a reactive process to something, such
as infection, inflammation, or iron deficiency.
Symptoms: Blood clot/ Bleeding due to defective platelet function

45. PDW, MPV, P-LCR
Vagdatli E, Gounari E, Lazaridou E, Katsibourlia
E, Tsikopoulou F, Labrianou I. Platelet
distribution width: a simple, practical and
specific marker of activation of coagulation.
Hippokratia. 2010 Jan;14(1):28-32. PMID:
20411056; PMCID: PMC2843567.
Tzur I, Barchel D, Izhakian S, Swarka M, Garach-Jehoshua O,
Krutkina E, Plotnikov G, Gorelik O. Platelet distribution
width: a novel prognostic marker in an internal medicine
ward. J Community Hosp Intern Med Perspect. 2019 Dec
14;9(6):464-470. doi: 10.1080/20009666.2019.1688095.
PMID: 32002150; PMCID: PMC6968671.
Khatri S, Sabeena S, Arunkumar G, Mathew M. Utility of
Platelet Parameters in Serologically Proven Dengue Cases
with Thrombocytopenia. Indian J Hematol Blood Transfus.
2018 Oct;34(4):703-706. doi: 10.1007/s12288-018-0924-2.
Epub 2018 Jan 23. PMID: 30369744; PMCID: PMC6186260.

46. IPF %
Arshad A, Mukry SN, Shamsi TS.
CLINICAL RELEVANCE OF
EXTENDED PLATELET INDICES IN
THE DIAGNOSIS OF IMMUNE
THROMBOCYTOPENIA. Acta Clin
Croat. 2021 Dec;60(4):665-674.
doi: 10.20471/acc.2021.60.04.14.
PMID: 35734488; PMCID:
PMC9196221.

47. Analysing…XYZ of CBC

48. Analysing a blood cell phenotype
 Smear morphology
 Cell size
 Cell shape
 Cell volume
 Cytoplasmic granularity
 Nucleus shape, size, chromatin
pattern
 Antigen profile (CD Markers)
membrane/nuclear

49. HaematologyAnalyzer
Technical Methods
 Electrical impedance:
For Total Count, Differential count
Early 1950s, Mr. Coulter: Invented the
patent for particle counting technology and
manufactured the first haematology
analyser
Spectrophotometry: For Hb estimation

50. Haematology Analyzer
Technical Methods
 Flow cytometry
Laser Scatter Cell structure
Laser scatter fluorescent dye
For Complex differential counts
- 5 part, 6 part, 7 part

51. Types of CBC Analyser
3-Part: Spectrophotometry, Coulter ‘s Principle,
Neutrophils, Midfraction, Lymphocytes
5-Part:Spectrophotometry, Coulter principle, Hydrodynamic focusing and Flow-cytometry (Laser scatter Cell
structure and complexity )
Neutrophils, Eosinophils, Basophils, Monocyte, Lymphocyte
6-parts:Spectrophotometry, Coulter principle, Hydrodynamic focusing and Flow-cytometry (Laser scatter
Cell structure and complexity ), Fluorescent dye
Neutrophils, Eosinophils, Basophil, Monocytes, Lymphocytes, Immature granulocytes
7-part: Above methods, Advanced Fluorescent dye
Neutrophils, Eosinophils, Basophil, Monocytes, Lymphocytes, Immature granulocytes, Atypical lymphocytes

52. 3 part:
The coulter principle,
or
The electrical impedance principle.

53. 3-part CBC analyzer

54. 5/6/7-part
CBC
analyzer

56. The
quality
control
 Internal control
 Calibration
 External control (EQAP) AIIMS, DELHI

57. CBC analysis:
Methods Vs Cost
3-5-6-7 and LIS upgradation

58. New concepts
 Morphometry AI

59. The necessity of a CBC report

60. What next after
analysing a CBC
report
 Further evaluation
 Peripheral smear study
 Pathologist/Haematol
ogist opinion
 Bone marrow
evaluation
 Haematology clinical
management

61.  CBC: The basic investigation requirement in all
clinical settings
 A Simple test providing >30 parameters to
understand the haematopoietic system status
 3-5-6-7 part depends upon the requirement
and cost affordability. LIS should be upgraded
to include the histograms and scatter plots
 Quality control is a must
 Further evaluation of an abnormal CBC report
accordingly
Cons:
1. Often requires Peripheral blood morphology evaluation
2. Preanalytic errors and FLAGs
3. Expensive and high running costs of advanced analysers