Interpreting the FBC
Learning Objectives Interpreting the FBC Dr Sam Ackroyd Bradford Royal Infirmary • What is a FBC • When to do a FBC • Interpreting the FBC • What further investigations to do • When to refer • When NOT to refer • Tips and common problems What is a full blood count? THE RED CELL 4 Measuring the red blood cell Haemoglobin Hb g/L Hb RBC Lysis of red cells PCV Convert cyanmethaemoglobin MCV MCH Measure light absorption MCHC RDW 1 Packed cell volume (PCV) or Haematocrit (Hct) Red Blood Count (RBC) and MCV Impedence measure counter” Voltage proportional to MCV Male >0.52 Female >0.48 “Coulter MCV This Reticulocytes is directly measured Fluorochromes RNA “Polychromasia” Microcytic anaemia (MCV < 78) Macrocytic anaemia (MCV>100) Normocytic anaemia (MCV 79-99) CASE 1 70 year old man originally from Pakistan sees his GP with tiredness. CASES 11 He has a previous Hx of CCF and AF As part of Ix a FBC is performed 12 2 FBC Blood Film Hb 103 9.9 Platelets 322 Neutrophils 6.3 WCC Ferritin 78 (normal) MCV 62 (78-99) 13 (11 - 15) MCH 19 (27-31) MCHC 22 (32-36) RBC 6.5 (4.7 - 6.1) reticulocytes 60 (20-80) RDW 13 Re Haemoglobin Electrophoresis High Performance Liquid Chromatography (HPLC) Treatment Look out for it in all Asian patients Once diagnosed patient should be contacted by thalassaemia genetic counselling service 15 CASE 2 28 year old previously fit and well recently moved to the UK from Saudi Arabia Presents to his GP with tiredness, abdominal discomfort and weight loss On examination thin and pale No other significant findings 16 FBC Hb 71 WCC 13.2 750 Neutrophils 7.8 Eosinophils 2.6 Platelets MCV Ferritin = 6 (low) 63 (78-99) RDW 16 (11 - 15) MCH 25 (27-31) MCHC 28 (32-36) RBC 3.1 (4.7 - 6.1) reticulocytes 25 (20-80) 18 Re 3 Blood Film Diagnosis Iron deficiency anaemia Cause of iron deficiency - Iron deficiency anaemia Stool sample 1. 2. 3. Endoscopy 4. 5. Commonest cause of anaemia in UK and world wide Always need to define a cause Diet Physiological Blood loss – GI Ix Malabsorption – check coeliac screen Intravascular haemolysis – rare, have elevated LDH menorrhagia diet related In Bradford check stools for Ova Treatment iron deficency? Who to refer? Ferrous Refer sulphate 200mg tds in adults Hb 1g/dl per week Give for a minimum of 3 months (min 6 weeks after normal FBC) GI side effects try: Lower dose Laxatives Liquid preparation Sytron Increase to gastroenterology if baseline investigations normal and history indicates possible GI blood loss / malabsorption Refer to haematology if intolerant of oral iron and require intravenous iron 4 FBC CASE 3 Hb 77 WCC 12.7 345 Neutrophils 5.2 Mother brings her 6 year old son to see you He has had a recent cold but now pale and tired all the time with little appetite Platelets MCV He was born with neonatal jaundice but otherwise has been well 108 (78-99) 18 (11 - 15) MCH 28 (27-31) MCHC 42 (32-36) RBC 3.5 (4.7 - 6.1) reticulocytes 180 (20-80) RDW 25 26 Re Blood Film Further tests DCT negative EMA positive FHx positive Bilirubin 38 27 Diagnosis 28 Treatment Hereditary Spherocytosis Depends on severity Acid Blood transfusions Splenectomy Cholecystectomy Folic watch 29 out for Parvovirus B19 (slapped cheeks) remember to screen relatives (FBC, Film, retics, Bilirubin) 30 5 CASE 4 What tests would you do? 60 FBC year old lady presents with extreme tiredness Two weeks earlier had the Flu jab and then had back pains and passed very dark urine for 3-4 days OE pale with mild jaundice and spleen just palpable 1cm Blood UE film / LFT Should be referred as emergency to haematology FBC Hb Haematinics 64 WCC Bilirubin Platelets 11.1 333 Neutrophils 6.2 ALT 112 (78-99) RDW 20 (11 - 15) MCH 28 (27-31) MCHC 32 (32-36) RBC 3.1 (4.7 - 6.1) reticulocytes 270 (20-80) 78 (unconjugated 60) 25 Alk phos 144 B12/folate/ferritin - normal MCV 33 Re Referred to haematology Retics 12% 270 ++++ IgG Haptoglobins <0.06 LDH 1099 Urinary haemosiderin – detected DCT 6 Diagnosis and Treatment Haemolysis screen AIHA History 2er vaccination FBC, Treatment pred 1mg/kg DCT Hb increase over time 17.5 LFT, in 4 weeks and now stopped pred and well Hb g/dl 14. Resolved and examination Film, retics 10.5 Series1 7. 3.5 0. 1 5 6 9 days 15 22 28 Haptoglobins, LDH dip stick Urinary haemosiderin Specific tests Urine FBC CASE 5 Hb 76 WCC year old man presents to her GP with tiredness and SOBOE Previous very well Examination pale but well 5.3 9.1 Platelets 79 Neutrophils 1.1 MCV 116 (78-99) 20 (11 - 15) MCH 35 (27-31) MCHC 33 (32-36) RBC 2.4 (4.7 - 6.1) reticulocytes 12 (20-80) RDW 40 Re Blood Film and haematinics Diagnosis Ferritin 90 Folate 2.8 B12 <50 B12 deficient anaemia low folate) (also 7 Investigations B12 – assay can have rare false negative (consider checking homocysteine level) Serum IF antibody – very specific, but 60 - 85% sensitive Parietal cell antibody – sensitive 90% but 10% false positive Endoscopy Schillings – gastric atrophy (not an essential test) test – PA v malabsorption – no longer available Treatment. Hydroxycobalamin 1mg IM 3 x week for 2 weeks, monthly 3 months then 3 monthly Or if IF and GPCAb negative Hydroxycobalamin 1mg PO daily – would need to check levels improve consider Folic acid 5mg AFTER B12 commenced for 4 weeks Check UE day1 and day 5 after starting (risk severe hypokalaemia) Borderline results in asymptomatic – treat as above (no evidence of benefit though) B12 deficient anaemia B12 needed for DNA synthesis Causes of deficiency: 1. Diet - vegans, breast milk 2. MalabsorptionPernicious anaemia Ileal resection or gastric bypass surgery Crohns / Coeliacs Intestinal stagnant loop Tropical sprue Fish tapeworm When to refer? Not always straight forward - could always discuss with haematology first Refer If: Not coping with anaemia e.g.angina, heart failure, falling etc.. Severe pancytopenia Platelets <50 or Neutrophils <0.5 Diagnosis uncertain eg Borderline B12 level 46 FBC CASE 6 Hb 49 WCC year old presents with easy bruising well Previously OE 101 3.1 Platelets 15 Neutrophils 1.0 Bruising and some petechiae 108 (78-99) 17 (11 - 15) MCH 31 (27-31) MCHC 32 (32-36) RBC 3.2 (4.7 - 6.1) reticulocytes 10 (20-80) LUC flag 1.2 MCV RDW B12 normal Folate Normal Ferritin Normal 48 Re 8 / folate / ferritin – normal 1% 10 LFT normal B12 Need to refer? we Retics should be ringing you!!!!!!! 49 Bone marrow aspirate Cytogenetics G-banded Diagnosis MDS – RAEB Prognosis 1. Treatment Azacitidine and BMT complex karyotype: 44,XY,del(5)(q15), -7, -13, -18, +mar. 2. 3. 4. 5. Depends on: Cytogenetics Number of cytopenia’s Blast cell count Transfusion requirement Age R-IPSS score median survival between 4 months – 120 months 9 FBC CASE 7 Hb 89 WCC 13.3 504 Neutrophils 7.1 77 year old lady is feeling increasingly tired and more SOBOE. Platelets She has a background of CCF, hypertension, chronic leg ulcers, DVT and Diabetes MCV 93 (78-99) 14 (11 - 15) MCH 28 (27-31) MCHC 33 (32-36) RBC 3.2 (4.7 - 6.1) reticulocytes 35 (20-80) RDW 55 56 Re Blood Film further investigations Ferritin 130 Fe - reduced TIBC - reduced transferrin saturations - 10% reduced B12 normal Folate nomal electrophoresis - normal eGFR 45 Serum 57 Hepcidin “the insulin of iron metabolism” Diagnosis Anaemia 58 of Chronic Disease 59 60 10 Anaemia of chronic disease Treatment of ACD Hepcidin acute phase protein - increases Free circulating iron reduces Body iron stores not deplete just not accessible Is the anaemia symptomatic? underlying conditions treat Consider IV iron: Ferritin <150 Iron Saturations <20% 61 Causes microcytic anaemia MCV <78 1. 2. 3. 4. Iron deficiency Haemoglobinopathy Anaemia of chronic disease Other – congenital sideroblastic anaemia, MDS, heavy metal poisoning, hyperthyroidism Causes of macrocytic anaemia MCV >100 1. 2. 3. 4. 5. 6. 7. 8. Megaloblastic anaemia Liver disease Haemolysis Hypothyroidism Myelodysplasia Myeloma Drugs (antifolate) Alcohol 62 Causes of normocytic anaemia MCV 79 -99 Anaemia of chronic disease Blood loss – acute Acute illness Renal failure MDS 1. 2. 3. 4. 5. Anaemia summary Why Any did you test the FBC? other clues? - MCH MCHC reticulocytes blood film Are there concerning findings – Normal haematinics More than 1 cytopenia other symptoms / signs e.g. lymphadenopathy, B symptoms 11 67 12
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