3 Hematological Tests Bone Marrow Examination wileemdkhu ac
혈액 3 Hematological Tests & Bone Marrow Examination 진단검사의학과 이 우인 wileemd@khu. ac. kr
Hematological Tests & Bone Marrow Examinations Hematological Tests • Anticoagulants • CBC with Differential count • Reticulocyte • ESR • PBS Bone Marrow Examinations
Hematological Tests I. Anticoagulants • Tri-sodium citrate • EDTA • Heparin • • • calcium chelating PT, a. PTT, Platelet aggregation test 항응고제 1 : 혈액 9의 비율로 채혈 Hematocrit에 따른 항응고제 비율 조정 [1: 5 ~ 1: 6~~~~1: 9(45%) ~ 1: 11] • • Calcium chelating Blood cell count, cell morphology • • Anti-thrombin III 와 결합하여 thrombin 억제 Arterial blood gas analysis, osmotic fragility test
• Plasma (혈장) • Serum (혈청) Seum separating tube, SST
Hematological Tests II. Complete Blood Cell Count (CBC) CBC Traditional Unit Internationa l Unit Hemoglobin g/d. L (12~16) Hematocrit d. L/d. L(%) (45%) L/L(%) Red Blood Cells(RBC) White Blood Cells 106/u. L (3. 8 ~ 5. 4) 1012/L 103/u. L (4. 0 ~ 10. 0) 109/L Platelet count 103/u. L (100 ~ 400) 109/L g/d. L
Hematological Tests CBC RBC index Formula MCV (평균용적) Hct(%) x 10 Mean corpuscular volume RBC count(106/u. L) MCH (평균혈색소) Hb(g/d. L) x 10 Mean corpuscular Hb 적혈구 한개당 혈색소량 MCHC (평균 혈색소농도) Mean corpuscular Hb conc. RDW (크기분포의 변이계수) Red Cell distribution Width RBC count(106/u. L) Traditional * International Unit 80~96 fl 27~33 pg Hb x 100 Hct SD x 100 MCV 33~36 g/d. L 11 ~15%
Hematological Tests WBC Differential Count(D/C)-백혈구감별계산 • Automated or manual • Granulocyte – Segmented neutrophil – Eosinophil – Basophil • Lymphocyte • Monocyte
Hematological Tests Platelet (혈소판) • 혈소판수 – 검체의 부적절한 상태에 따라 실제보다 높게 혹은 낮게 측정 – Pseudothrombocytopenia – Ex) EDTA - induced pseudothrombocytopenia • 말초혈액도말검사 • Citrate 항응고제, 헤파린 등 다른 항응고제 이용하여 다시 측정 • Reticulated platelet – 골수의 보상적인 혈소판생성능력 예측 • Mean platelet volume(MPV) • Platelet distribution width(PDW)
Hematological Tests • Corrected Reticulocyte Count = Reticulocyte count x patient Hct 정상 Hct(0. 45) • Reticulocyte Production Index Corrected reticulocyte / maturation time = ** Hct 에 따른 maturation time (days) 45% - 1. 0, 35% - 1. 5, 25% - 2. 0, 15% - 2. 5 RPI 가 2라면 정상에 비해 적혈구 생산이 2배 증가
Hematological Tests Normoblast Reticulocyte Bone Marrow PB Wright stain - polychromasia Supravital stain - reticulocyte RBC
Hematological Tests IV. Erythrocyte Sedimentation Rate (ESR) • 염증, 외상, 암 등에 이용되는 비특이적인 검 사 • 관련인자 – 혈장인자 • 섬유소원, alpha 2, beta, gamma globulin 상승 적혈구 막의 음전하(zeta potential) 저하 Rouleaux formation(연전) ESR 증가 • Albumin, lecithin은 ESR 감소 – 적혈구인자 • 빈혈, 적혈구 크기, 모양 • Interpretation – 0 ~ 9 mm/hr(M) – 0 ~ 20 mm/hr(F)
Hematological Tests V. Peripheral Blood Smears (PBS) • CBC 검사 결과를 추정 – Hb, Hct, RBC index (MCV, MCHC, RDW) – WBC count • 200배 시야 field 당 평균 WBC No. x 1, 000/μL – Platelet count • 1, 000배 시야 field 당 평균 혈소판 수 x 20, 000/ μL – Reticulocyte count : polychromasia • 각 cell의 shape, size, 분포 등을 관찰 – PBS 의 ideal zone 에서 판독
Hematological Tests Ideal zone
Hematological Tests • 적혈구 크기의 이상 (Anisocytosis) – normocytic, microcytic, macrocytic • 적혈구 염색성의 이상(Hemoglobin 양) – normochromic, hyperchromic Normocytic normochromic Microcytic hypochromic Macrocytic hyperchromic Dimorphic normochromic
Hematological Tests • 적혈구 구조의 이상 Howell Jolly Body Basophilic Stippling Megaloblastic anemia Splenectomy Iron deficiency anemia 적혈구 생성 증가 Normoblast Malaria infection & Stippling(Schuffner’s granules)
Hematological Tests • 적혈구 모양(형태)의 이상 (Poikilocytosis) Elliptocyte Iron deficiency anemia 정상 성인 10% Spherocyte Cong. Spherocytosis Autoimmune hemolytic anemia Target cell Schistocytes (fragmented cell) Hemolysis (MAHA) Burn Megaloblastic anemia DIC Acanthocytes Abetalipoproteinemia Liver Disease Crenated cell Artifact DDx. Burr cell(kidney dis) 폐쇄성 황달 비장 절제술 후 Tear drop cell Sickle cell Myelofibrosis Sickle cell anemia
Hematological Tests • 기타 Rouleaux formation Platelet clumping Agglutination Giant Platelet
Bone Marrow Study Bone Marrow Examination • Indication • Bone Marrow Aspiration & Biopsy • Stain – Wright, Giemsa, Prussian blue(iron) – Reticulin(fibrosis), etc
Bone Marrow Study Bone Marrow Examination
Hematopoietic organ – BM, spleen, liver, lymph node, thymus, etc – Red vs. yellow marrow – Extramedullary hematopoiesis
Structures of BM • Hemopoietic area – stem cell & hemopoietic cell • Microenvironment – stroma • Vessels of BM – Nutritient a, arterole. capillary-sinus fistula, venule • Fat • Trabecula bone • Paratrabecula area
Characteristics of BM • Hematopoiesis – Production of a day • RBC 20억/kg • Platelet 70억/kg • Granulocyte 8. 5억/kg – Time • RBC 5일 • Platelet 7일 • Granulocyte 5 ~ 6. 6일
Hematopoietic Stem Cell Myeloid Stem Cell CFU-GM Monoblast Myeloblast Lymphoid Stem Cell BFU-E CFU-Meg Pronormoblast Megakaryoblast Promyelocyte B, T Lymphoblast Megakaryocyte Myelocyte Monocyte Metamyelocyte Normoblast Band neutrophil Reticulocyte Segmented Neutrophil Erythrocyte Platelet Lymphocyte B, T
Erythropoiesis Normoblast BM Reticulocyte RBC PB
Granulopoiesis Shift to left maturation in PB Myeloblast BM PB
Megakaryopoiesis Megakaryoblast Megakaryocytes Platelets
Peripheral blood smear
Bone marrow study • Most important diagnostic test – Dx for hematologic abnormalities • Indication – Anemia – Malignancy • Leukemia, Myelodysplastic syndrome, Lymphoma • Cancer metastasis, etc – Myeloproliferative disorders – FUO – Tuberculosis
BM Myeloblast (Monoblast) Shift to left maturation PB Myelocyte (N, E, B) Metamyelocyte (N, E, B) Hematologic Malignancies Promyelocyt (Promonocyte) e Promormoblast Megakarycyte Leukoerythoblastic Reaction Lymphoblast
Blast High N/C ratio, prominent nucleolus Promyelocyte Primary granule(azurophilic) vs. Myelocyte Benign Metamyelocyte Secondary granule Pink Nucleus indentation 시작
Bone Marrow Sites Iliac bone Tibia(newborn)
Jamshidi BM Aspiration/Biopsy Needle
• BM aspiration – Cell morphology, differential count, abnormal cell, etc – Normal cells – M(myeloid): E(erythroid) ratio =정상 2 ~ 4 : 1 – 기타
BM cells (%) Myeloblast 0. 1 - 3. 5 Promyelocyte 0. 5 - 5. 0 Myelocyte 5. 0 -20. 0 Metamyelocyte 10. 0 -30. 0 Band N 5. 0 -20. 0 Segmented N 7. 0 -25. 0 Lymphocyte Monocyte Eosinophils Basophils Megakaryocyte 0. 1 -0. 5 Reticulum cell 0. 1 -2. 0 0. 3 - 6. 0 0 – 1. 0 5. 0 -20 0 -0. 2 Proerythroblast 0. 5 -5. 0 Erythroblast 4. 0 -30 Plasma cell 0. 1 -3. 5
• BM biopsy - Cellularity (세포충실도) - Distribution of cells, Abnormal cell - Tumor invasion, Granuloma, - Lymphoma stage Work-up - Etc
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