Assistance with CBC

ranmyaku · Apr 15, 2008

I was wondering if anyone could lend me some help with interpretation of some lab results. I had a discussion with my residents, and mentioned this during rounds with the attending but no one seemed to be bothered by it. However, based on my readings, I thought that this was abnormal.

Brief history. Pt is a 5wk old AAM with a Hx of diarrhea since birth (associated with feedings). Pt was initially worked up for a milk protein allergy. Turns out that the pt has a sucrase deficiency. This was the presenting complaint, however, a CBC done on admission showed anemia. Looking at the CBC it showed the following:
Hgb 7.6
WBC 21
PMN 9
band 14
meta 1
blast 2
lymph 51
MCV was 94
dacryocyte, target cell, ovalocyte were present
also was hypochromic

Those are the values I can remember off the top of my head right now since I don't have the chart in front of me.

I was under the impression that anytime you have blasts that it is abnormal. Is this not true? What are your impressions of the CBC findings. I did quite a bit of reading in hematology texts yesterday, but could not find anything satisfactory for an explanation about the presence of blasts.

A repeat CBC a couple days later did not show blasts, but did show an increased number of myelocyte and metamyelocytes (no more CBC's have been done since this last one, 2 total). The discussion on rounds was based around the fact that the underlying absorption issues were the reason for the anemia, and that once this was corrected, the anemia would also correct. This just did not sit well with me, so I am seeking some further explanations from any pathologists.

Path or bust · Apr 16, 2008

Interesting case. Are you sure you're not messing with us?

Well I'll throw up my mumbo jumbo thoughts on this and let others add/take away/destroy. I do have to admit I'm quite rusty.

So my first impression here is Acute Leukemia (Lymphoblastic or Myeloblastic) due to the lymphocytosis, neutropenia, anemia and blasts. What were his thrombocyte values? His diarrhea could be due to an infection which these kiddos are quite prone to getting. I would want to get a bone marrow aspirate and check this out more closely.

Edit: I lean toward AML b/c of the myelocytes and metamyelocytes. For the PMNs what do you mean 9% or 90%? The composite values should add up close to 100% no?

Brian Pavlovitz · Apr 16, 2008

Although it is extremely rare to have blasts in the periphery, you can occasionally see them if the patient is left-shifted to a high degree (same for myelos and metas). Furthermore, newborn smears can look exceedingly strange; I wonder if the original blasts counted were actually reactive lymphocytes (they've certainly fooled me in this age group before).

Without 20% blasts in the periphery, this would not qualify for acute leukemia (unless there are at least 20% in the marrow). My guess is a leukemoid reaction. I'd look for other sources of infection before I marrowed this little guy. Just my $.02.

Gut Shot · Apr 16, 2008

Agreed, peripheral smears can be mighty weird in infants. Always compare the values against normal ranges for the patient's age. What would be bizarre and worrisome in an adult may be normal in a 5 week old. Offhand I don't think a WBC of 21 is even close to leukocytosis in this age group.

The anemia could certainly be dietary, and alpha-thalassemia is not uncommon in African Americans. As for the blasts and immature forms, babies do not yet have tight control over immature cells slipping out of the marrow (or, more likely here, EMH sites that are unusually active secondary to his anemia). It's not uncommon to see a few in kids who are sick enough to be inpatients, whatever the cause. While it's always good to be mindful, I wouldn't be heading down the leukemia path based on the above information.

ranmyaku · Apr 16, 2008

Thanks for the responses. It makes sense that they might not have tight control over the immature forms at such an early age.

Path or bust · Apr 16, 2008

Cool, I love all these nuances and twists....can't wait to get smart like you guys.

Gut Shot said:
Agreed, peripheral smears can be mighty weird in infants. Always compare the values against normal ranges for the patient's age. What would be bizarre and worrisome in an adult may be normal in a 5 week old. Offhand I don't think a WBC of 21 is even close to leukocytosis in this age group.

The anemia could certainly be dietary, and alpha-thalassemia is not uncommon in African Americans. As for the blasts and immature forms, babies do not yet have tight control over immature cells slipping out of the marrow (or, more likely here, EMH sites that are unusually active secondary to his anemia). It's not uncommon to see a few in kids who are sick enough to be inpatients, whatever the cause. While it's always good to be mindful, I wouldn't be heading down the leukemia path based on the above information.

Assistance with CBC

ranmyaku

Full Member

Path or bust

I like meat

Brian Pavlovitz

give me that marrow!

Gut Shot

Full Member

ranmyaku

Full Member

Path or bust

I like meat

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