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The Role of Lab Exam

Screening
Diagnosis :
Routine Lab tests
Confirmatory Lab tests
Prognosis
Monitoring
Disease activity
Therapy responses

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Laboratory examination for Infection

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 Routine examination
HEMATOLOGY :
Blood cell count complete blood cont (CBC)
Hemoglobin concentration (Hb)

White Blood Cell Count (WBC)

Platelet count

Differential cell count

Red blood cell count & Hematocrit

Erythrocyte Sedimentation Rate (ESR)

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 Routine examination - hematology

Blood cell count

Hemoglobin concentration
Normal range :
At birth : 15 20 g/dl
At 2 months : 9 14 g/dl
10 years of age : 12 15 g/dl
Female adult : 12 - 16 g/dl
Male adult : 13 18 g/dl

< Normal range : Anemia

Anemia occur in several infection diseases as
follows: - bacterial infection
- virus infection
- parasite infection
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Anemia in bacterial infection

Extracellular microorganism

Clostridial Septicemia Bartonellosis

Invade to RBCs Adhere to the exterior surface

of the RBC

Destruction of RBCs

Lysis ANEMIA

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Hemolytic anemia in parasites infection
Infected cell

Immune complexes ruptures

Lysis ANEMIA

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 Anemia of Chronic Disease
ACD is associated with an underlying disease
(usually inflammation, infection, or malignancy),
but is without apparent cause (not due to a lack
of the nutrients iron, vitamin B 12, or folic acid)

Anemia of chronic disease (ACD) is difficult to

define as its etiology and pathogenesis is not
clear.
ACD is the most common anemia in hospitalized
patients.

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Anemia of Chronic Disease
Pathophysiology:
Erythropoesis suppression
Chronic inflammatory process secretion of TNF
& IL-1
Lack of iron for Hb synthesis
Lactoferrin release from granules of neutrophils
Lactoferrin competes with transferrin for iron
Decreased RBC survival

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 Routine examination - hematology

LEUKOCYTE COUNT (WBC)

Measure number of total leucocytes

Method: manually & automatically
Principle : dilution of blood with acid solution in
order to lyses erythrocytes

Reference range :
adult = 4000 -11.000 cells/L
child = 4500-17.000 cells/L
newborn= 6000-30.000 cells/L

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 Kinetics of Leucocyte
Storage pool

Circulating pool
Input
Output
from
to tissue
marrow

Marginal pool

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 WBC

Pathology
Leukocytosis Leukopenia
WBC > 11.0 (x 109/L) WBC < 4.0 (x 109/L)

Bacterial infection Virus infection

Leukemia Typhoid fever
Uremia Rheumatoid arthritis
Cirrhosis of the liver
Physiologic: SLE
Pregnancy Radiation, drugs
Strenuous exercise
Emotional stress, anxiety

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 Routine examination - hematology

White Blood Cell Differential

To determine the relative number of each

type of WBC present in the blood.

Blood smear :
- relative number
- leukocyte immaturity
- morphologic abnormality

Abnormality: Quantitative
Qualitative

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Classification of Leucocytes
Granulocyte Non-granulocyte
Neutrophil, Monocyte
Eosinofphl, Lymphocyte
Basophil
Polimorfonuclear Mononuclear
Neutrophil, Monocyte
Eosinofphl, Lymphocyte
Basophil
Immunocyte
Phagocyte Lymphocyte
Neutrophil
Monocyte
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 All white blood cells originate from the bone marrow

Growth and differentiation factors (cytokines) produced by and present on bone

marrow stromal cells determine the type of white blood cell that will emerge, as well
as their relative numbers.
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Blood cells derived from bone marrow cells

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Blood cells migrate through blood and lymph nodes or home to tissues

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 Cells in blood circulation

Very few in blood

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Resting lymphocytes are round cells with a large nucleus

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Differential cell count
Refference range:

Polymorphonuclear
neutrophils : 50 70 %
Bands : 05 %

Lymphocytes : 18 42 %
Monocytes : 1 10 %
Eosinophils : 14 %
Basophils : 02 %

Course of ds : shift to the left (acute), shift to the right (chronic)

Cause : bacterial, viral and parasites infection
neutrophilia (bacterial infection), lymphocytosis
(viral infection, tuberculosis) 21
 Quantitative abnormality

NEUTROPHILIA
3 major cause : infection,
inflammation, malignancy

Severity of neutrophilia in
infection depend on:
- virulency of organism,
- age : child >
- patient immunity:
immunocompromised host

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 Quantitative abnormality
Causes of neutrophilia
1. Bacterial Infection
2. Toxic agent
3. Metabolic: uremia, eclampsy, metabolic
acidosis
4. Drugs & chemicals: mercury, digitalis, steroid
5. Physic & emotional stimuli
6. Tissue damage & necrosis: myocardial infarct,
wound, neoplastic diseases
7. Hemorrhage: especially intra serous cavity
(peritoneal, pleural, joint space, subdural)
8. Hematological diseases: leukemia.

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 Qualitative Abnormality
Shift to the left or right:

mieloblas promielosit mielosit metamielosit batang segmen

Shift to the left : Shift to the right:

increase immatur cells increase of segment
most frequent: stab, hypersegmentation
metamielosit, mielosit, promielosit chronic infection
acute infection (bacterial)
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 Quanti+Qualitative abnormality
Leukemoid reaction
mielocytic/netrophyilic

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Bain, 2002. Blood Cells, A Practical Guide,3rd ed, Blackwell Publ, UK
 Qualitative abnormality

White blood cell (blood smear)

vacuolisation

vacuolisation

Toxic granulation

Leucocytosis : netrophilia absolute with toxic granulation & vacuolisation

Bacterial infection
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Vacuolisation & toxic granulation

Toxic Granulation

vakuolisation

Bacterial infection
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 Qualitative abnormality

Toxic Granulation
Stimulated by organism or antigen
Color of granule: dark blue-blackish
Profound toxic granulation worse prognosis

Vacuolisation of cytoplasm
phagocytosis process

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Neutropenia
Netropenia lekopenia
Agranulositosis: severe netropenia

Causes of netropenia:
Viral infection
Certain Bacteria: Tifoid/ paratifoid
Severe infection
Immune reaction: autoimmune/ drug induced

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EOSINOPHILIA :

1. Parasite investation
- correlate with killed parasites
- eosinophyl attracted to parasite will be killed
by degranulation process

2. Allergy/ hypersensitivity

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EOSINOPHILIA :

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Lymphocytosis

Absolute lymphocytosis Viral infection

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 Qualitative abnormality

Variant / atypical/ virocyte/ reactive

lymphocyte response to infection

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 Lymphocytosis with variant lymph:
- Mononukleosis infecsiosa (var lymph 40%),
acute hepatitis, citomegalovirus (CMV)
- measles, pneumonia viral, rubela relatif
- Non viral : Tuberculosis, syphilis, malaria,
typhus, diphteria, toxoplasmosis
Lymphocytosis without var lymph:
asimptomatic viral inf., diarrhea, resp. inf

Lymphopenia; HIV, SLE, intensive chemotherapy

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 Virus Infection
MONONUKLEOSIS
INFEKSIOSA (MI)
cause: virus Epstein-
Barr (EBV)
Lekositosis with
limphocytosis, dan
atypical lymphocyte
Kissing-cell

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Dengue virus infection

Reactive Lymphocyte
Blue cytoplasm-
Lymphocyte

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Monocyte

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MONOCYTOSIS

Some bacterial inf.,:

- Active Tuberculosis :
- Sub acute bacterial endocarditis
- Syphilis
Myeloproliferatif
Recovery

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 Routine examination - hematology

Erythrocyte Sedimentation rate

(ESR)
ESR is the rate in millimeters at
which the RBCs fall in 1 hour

Monitoring the course of an existing

inflammatory disease

Normal range: 0-20 mm/hrs F

0-15 mm/hrs M

Elevated : bacterial infection

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Normal sedimentation Increase Sedimentation
infection
Polisitemia : AE
Dekompensasi myocardial infarct
jantung Rheumatic fever
Sickle sel anemia, Malignancy with necrosis
sferositosis
Neonatus Active tuberculosis ,
tissue destruction
Surgery Trauma, shock
Hiperglobulinemia
Pregnancy

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 C-REACTIVE PROTEIN (CRP)

an acute phase reactant

In general parallel ESR but not influenced by
erythrocyte
More sensitive than ESR
Increase & decrease faster :
- early indicator of acute infection
- monitor course of disease

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CRP increase in :
Infection:
Lower in viral compared to bacterial infection
Useful to monitor disease activity
Inflammatory disorders:
Earlier,more intense increase than ESR
Dissaperance of CRP precedes the return to normal
of ESR
Tissue injury or necrosis
AMI : appears within 24-48 hrs
Malignant disease, Following surgery, burns

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