Coulter VCS Technology

Bulletin # 3008

Clinical Case Studies

TM

Index

Introduction

1. Sample Stability Studies

with Normal Blood

2. Left Shift

3. Left Shift

4. Hypereosinophilia Syndrome

10

5. Infectious Mononucleosis

12

6. Agranulocytosis

14

7. Acute Myeloid Leukemia FAB M0

16

8. Acute Myeloid Leukemia FAB M4

18

9. Acute Myeloid Leukemia FAB M5a

20

10. C-ALL, FAB L2

22

11. Refractory Anemia (RAEB-t)

24

12. CML in Blast Crisis

26

13. Non-Hodgkins Lymphoma

28

14. Prolymphocytic Leukemia (PLL)

30

15. Pernicious Anemia

32

16. Hereditary Spherocytosis

34

17. Anisocytosis

36

18. Essential Thrombocytemia

38

Introduction

he quantitative and qualitative analysis of

blood cells, one of the oldest medical laboratory procedures, remains one of the most
important basic tests of medical diagnosis. The
term "blood picture" vividly reflects the fact that
pathophysiologically correct and clinically relevant interpretation requires comparative and
contrastive evaluation of the number and
appearance of various blood cells. Changes in
the blood picture, or blood count, may be the
normal reactions of the blood cell system to
demands placed on it by the environment or by
disease, or they may be the expression of a primary or secondary disease of the hematopoietic
system itself. Quantitative and qualitative
changes may be related to disorders of cell formation, cell disintegration or cell distribution.
The methodological basis for interpreting the
blood count is to determine as accurately and
rapidly as possible, with a minimum of interfering factors, the concentrations of various blood
cells, which differ in their origin, function and
morphological properties. Classical chamber
counting methods combined with microscopic
differentiation of fixed, stained blood cells only
partially fulfilled these requirements, and were
extremely time-consuming.
The standardization of hemoglobin determinations by Heilmeyer and Wintrobe's hematocrit
method, as well as use of the impedance
method of performing blood cell counts,
described as the "Coulter principle," made it
possible for the first time to determine with
adequate precision, the concentration of red
blood cells, nucleated cells (white blood cells)
and platelets, in the course of routine medical
diagnosis. From these counts, it was also possible to determine fairly precisely the size and
hemoglobin content of individual red blood
cells, two important parameters in the diagnosis of anemia.
However, there was one essential challenge of
blood cell diagnosis, which these methods were
unable to solve, the biological heterogeneity of
nucleated cells, which result from different terminal differentiation pathways and have different functions. The improved precision obtained
by automating the white cell count was lost
again due to the "error of the small sample size"
which occurred during conventional differentiation of white cells by stained blood smear. The
necessary consequence of improving counting
accuracy was therefore the development of
automated methods of identifying cells within
the nucleated blood cell group. Two completely
different approaches were taken to solve this
problem. One attempt, largely unsuccessful,
was based on conventional microscopy; it
involved using a computer-controlled microscope to find and identify, based on structure
and coloration, nucleated cells which had been

fixed and stained in a blood smear. This method

thus replaced the hand, which moves the
microscope stage with a computerized mechanism and the memory and decision-making
capability of the human brain with a computer.
Within the technological restraints of a practical
diagnostic setting, it was not possible to
increase precision by substantially increasing
speed, nor to overcome the problems of algorithmic structural identification, i.e., the ability
of an experienced morphologist to recognize
and classify a structure was not then achieved,
and has yet to be achieved by any instrument.
A solution that was practical in the context of
medical diagnosis was first achieved with the
use of flow cytometry, which is also based on
particle counting according to the Coulter principle. Today, blood counts are evaluated around
the world using instruments, which suspend
nucleated blood cells in a suitable fluid and
quantify them with a high level of precision.
Different manufacturers detect different biophysical, structural and biochemical parameters. All include cell volume. The solution
selected by Coulter in its VCS system for blood
cell differentiation, also includes conductivity
and light scattering properties.
A unique benefit of VCS Technology is that the
measurements selected, impedance, conductivity and laser light scatter, analyze as closely as
possible, similar cellular characteristics that
enable morphologists to visually classify blood
cells. To achieve this, the system uses electrooptical analysis of individual cells in their nearnative state to provide complete and detailed
analysis in a single channel.
These Case Studies have been compiled in collaboration with hematologists and physicians
specializing in laboratory medicine, who have
their own experience both in laboratory diagnosis and in clinical hematological diagnosis. The
guide is intended to show, using concrete
examples, some of the possibilities of translating conventional morphological and flow
cytometry concepts, and to demonstrate the
diagnostic conclusions which can be drawn
from analytical results obtained with VCS technology. It will help users recognize the benefits
that can result if laboratory results are interpreted correctly and in a manner suited to the technology. The examples cited will enable hematology laboratory personnel, hospital and private-practice physicians to take advantage of
the results of this highly developed technology
and to examine them critically and intelligently
for the benefit of their patients. We hope that
this short case study book, produced collaboratively by Beckman Coulter and the hematology
laboratories of three university hospitals, does
justice to these intentions.

1.

Sample Stability Studies

with Normal Blood
Clinical Data
The sample was collected from a healthy
46-year-old woman. The blood sample was
collected in K3EDTA and stored at room
temperature (approx. 20C).
2hr

12hr

24hr

48hr

Suspect Flags
WBC

Definitive Flags

Blasts
Immature Granulocytes 2
Atypical lymphocytes

RBC
PLT

Scatterplot and Histograms

Blood from a patient with normal values was
tested 2, 12, 24, and 48 hours after drawing
with K3EDTA. The values were stable over
the entire period. The specimen was stored at
room temperature. Of note are the changes
in the Scatterplot. After 2 hours, the
distribution is normal. After 12 hours,
changes are due to changes in the cells, e.g.
vacuolization, nuclear distortions, etc. After
24 hours, suspect flags appear for "Blasts,"

"Atypical lymphocytes," and "Immature

Granulocytes 2." Neutrophilic granulocytes
show distinct dispersion upward into the
large-volume region of the Scatterplot and
moderate dispersion into the region below
the population, the region of aging cells.
After 48 hours, very many cells disperse
into this region, and the suspect flags are
identical to those in the analysis after
24 hours.

Coulter VCSTM Technology

Clinical Case Studies

Upper: Lymphocyte and Segmented Neutrophil at 2 hrs

Lower: Monocyte and Granulocyte at 24hrs.

Microscopic Differential
Segmented
Lymphocytes
Monocytes
Eosinophils
Basophils

% x109/L
45
3.7
41
3.4
4
0.4
4
0.4
1
0.1

RBC morphology

No abnormalities

DIAGNOSIS

Old blood

Comment

As this example shows excellent analytical results are possible for up to 1-2
days, 3 days at most. To achieve this some samples may well require a period of
correct equilibration and this is especially true for poorly collected or pediatric
tubes. For samples that have been left to stand without mixing, what is called
In-Vitro stasis, there is also a period of equilibration when the sample is first
mixed. With continuous mixing this can be shortened to 10-20 mins in most
cases.
For the results to be optimal, the differential should always be performed within
24hrs of the blood being drawn.
The quantitative results of this normal patient test would still be reproducible
after 48 hours.

2.

Left Shift
Clinical Data
35 year-old woman who had been coughing
for a week. She also complained of pain in the
limbs and fever as high as 39C.

Scatterplot
and Histograms
The status display on the
printout indicates abnormal
WBC. A neutrophil
population shifted slightly
upward can be seen in the
Scatterplot. This is the cause
of the Imm Gran 1 flag. At
79% neutrophils, the value
indicates a slight elevation,
likewise for the marginal
WBC. The smear reveals a left
shift with 10% band cells as
the cause.
The Plt and RBC histograms
are normal. Aside from a mild
normochromic anemia, the
remaining parameters are
normal. The normal MCV is
marked with a flag as defined
by the lab.

Suspect Flags
WBC
RBC
PLT

Immature Granulocytes 1

Definitive Flags

Coulter VCSTM Technology

Clinical Case Studies

Reactive left shift with pneumonia. In addition

to 2 segmented, neutrophil granulocytes, two
band neutrophils and a small lymphocyte are
pictured in the detail.

Microscopic Differential
% x109/L
10
1.8
62
5.5
15
1.5
9
0.9
1
0.1
3
0.3

Bands
Segmented
Lymphocytes
Monocytes
Eosinophils
Plasma cells
RBC morphology
Anisocytosis
+

Additional Tests

None required

DIAGNOSIS

Pneumonia (pathogen not identified)

Comment

Reactive left shift with marginal leukocytosis. The course of the current disease
is too short to explain the mild normochromic anemia. The suspect flag
Immature Gran. 1 indicates an increase in band neutrophils. In such a case,
an additional differential count should be done with a blood smear.

3.

Left Shift
Clinical Data
52-year-old male with testicular tumor,
Status post chemotherapy and administration
of G-CSF.

Scatterplot
and Histograms
The Scatterplot is remarkable
for a population in the
neutrophil region extending
into the larger-volume
channels, indicating the need
to look for immature
precursors on smear. In
addition, the instrument
shows suspect flags "Blasts"
and "Immature Granulocytes
2." The total WBC count is
elevated, as is the proportion
of neutrophilic granulocytes.
RBC and Plt histograms show
normal distribution. Among
the values, the low Hgb and
the borderline
thrombocytopenia are
noteworthy.

Suspect Flags
WBC

RBC
PLT

Blasts
Immature Granulocytes 2

Definitive Flags
Leukocytosis
Neutrophilia %
Neutrophilia #

Coulter VCSTM Technology

Clinical Case Studies

Promyelocyte and segmented neutrophil

granulocyte. In the smear, only very few
thrombocyte agglutinates (lower right hand
side in photo) were present.

Microscopic Differential
(n=200)

% x109/L

Blasts
Promyelocytes
Myelocytes
Metamyelocytes
Bands
Segmented
Lymphocytes
Monocytes
RBC morphology:
Anisocytosis
Poikilocytosis
Polychromasia
Toxic granulation

1
2
6
5
4
71
7
4

0.3
0.4
1.2
1.1
0.8
14.5
1.4
0.8

+
+
+
+

DIAGNOSIS

1. Leukocytosis with left shift as far as blasts on administration of

G-CSF after chemotherapy
2. Testicular tumor

Comment

Growth-stimulating factors (in this case, G-CSF) may lead to significant leukocytosis with marked left shift all the way through blasts, which bears a clear morphologic resemblance to CML in its chronic phase.

4.

Hypereosinophilic Syndrome
Clinical Data
49-year-old female referred because of
fever, weight loss, dyspnea, and
unproductive cough.

Scatterplot
and Histograms

Suspect Flags
WBC

RBC
PLT

10

Immature Granulocytes 2

Definitive Flags
Leukocytosis
Eosinophilia %
Eosinophilia #

At first sight, the Scatterplot

is remarkable for the closely
opposed populations in the
neutrophil and eosinophil
region. The suspect flag
"Immature Granulocytes 2"
is displayed, and confirmed
on smear. Lymphocytes,
monocytes, and basophilic
granulocytes make up only
a small portion of the
nucleated cells.
The total WBC count is
elevated. The differential
parameters show marked
eosinophilia.
The RBC histogram is shifted
into the microcytic region,
i.e. to the left, and the MCV
is low. In addition, the curve
is widened and the RDW
increased, indicating
anisocytosis. Both findings
are confirmed on smear.
The patient is anemic (Hgb).
Plt count and histogram are
unremarkable.

Coulter VCSTM Technology

Clinical Case Studies

A segmented granulocyte (with toxic granulation)

and an eosinophilic granulocyte. The eosinophilic
granulocyte is larger than usual, the nucleus has
four lobes, and the eosinophilic granules do not

completely fill the cytoplasm. (In the photo the

granules are rather pale and do not have the
characteristic reddish color that is typical under
the microscope.)

Microscopic Differential
% x109/L
Promyelocytes
1
Myelocytes
1
Metamyelocytes 3
Bands
9
Segmented
46
Lymphocytes
3
Monocytes
3
Eosinophils
33
Basophils
1
RBC morphology
Anisocytosis
++
Poikilocytosis
+
Polychromasia +++

0.45
0.45
1.4
4.1
21.0
1.4
1.4
15.0
0.45

DIAGNOSIS

Hypereosinophilic syndrome (HES)

Comment

The peripheral blood shows leukocytosis, granulocytosis with left shift as far as
promyelocytes, and pronounced eosinophilia (15 x 109/L). The closely opposed
populations of neutrophils and eosinophils are probably due to the greater light
scattering of the toxic granulation of the neutrophils and the lesser light scatter
of the pale eosinophilic granules seen on the film. The eosinophilia has been
recognized for years, but no cause (such as allergic reactions, parasitic diseases,
specific skin disorders, or autoimmune diseases.) has been found. Infiltrates
were shown in the lungs and heart.

11

5.

Infectious Mononucleosis
Clinical Data
26-year-old male with fever of 39C persisting
for the past 10 days.
The patient also complained of difficulty with
swallowing, night sweats and coughing.

Scatterplot
and Histograms

Suspect Flags
WBC
RBC
PLT

12

Blasts
Atyp. Lymphocytes

Definitive Flags
Lymphocytosis %
Monocytosis %

Immediately obvious on the

printout is a highly abnormal
distribution of the cells in the
Scatterplot. In addition to a
small population in the
lymphocyte field, the
overlapping population of
lymphocytes and monocytes
is also noteworthy. The
microscopic differential
count reveals that the latter is
due to the large virocytes
typical of mononucleosis.
Only a small percentage
(28%) is normal lymphocytes.
Some of the abnormal cells
were classified in the
monocyte region. The suspect
flags Blasts and Atyp.
Lymph give an indication of
this alteration, as do the
lymphocytosis and
monocytosis flags.
This patient also has
leukocytosis and
thrombocytopenia. The Plt
curve is not extrapolated
since the Plt volume is mostly
small. The value is therefore
flagged R. The RBC values
and histogram show no
abnormalities.

Coulter VCSTM Technology

Clinical Case Studies

A Monocyte and Lympho-Monocytoid Virocyte.

Microscopic Differential

Metamyelocytes
Bands
Segmented
Lymphocytes
Virocytes
Monocytes
Eosinophils
Basophils

x109/L

2
6
10
28
40
12
1
1

0.3
0.9
1.5
4.1
5.9
1.8
0.1
0.1

Special Observations:
Virocytes: Lymphomonocytoid cells and large
blast-like cells with nucleoli.

Additional Tests
Mononucleosis quick test:

positive

Other viral serology:

negative

Direct Coombs' test:

positive

Haptoglobin:

marginally diminished

Liver and spleen enlarged:

Transaminases elevated.

Gamma globulins elevated:

23 g/L

DIAGNOSIS

Infectious mononucleosis

Comment

The instrument assigned the morphologically abnormal population of the lympho-monocytoid virocytes partially to the lymphocytes and, to a lesser extent, to
the monocytes. Still, the total population is marked with the flag blasts. The
simultaneously existing massive left shift of the neutrophils was not flagged. The
reason for the predominance of small platelets is not clear. The absence of giant
platelets in this cell distribution is counterindicative of the presence of immune
thrombocytopenia or other increases in peripheral turnover platelets.
Virocytes occur in infectious mononucleosis and seldom in other viral diseases
such as cytomegalovirus infections or viral hepatitis

13

6.

Agranulocytosis (Neutropenia)
Clinical Data
59-year-old woman with hyperthyroidism, treated with Favistan.
After an interval for convalescence, she comes in for routine
examination, where agranulocytosis (presumably from Favistan)
is established. Presently in reverse isolation, receiving G-CSF.

Scatterplot
and Histograms
Significant in the Scatterplot
is the total absence of any
neutrophil population. The
percentage count is less than
1%. The total WBC count is
likewise greatly reduced.
Based on the position and
percentage and/or absolute
values, normal populations of
lymphocytes, monocytes,
eosinophil and basophilic
granulocytes are present.
RBC and Plt histograms are
unremarkable. Among the
values, the borderline anemia
and the very small Plt (MPV)
are noteworthy.

Suspect Flags
WBC

RBC
PLT

14

Definitive Flags
Lymphocytosis %
Neutropenia %
Neutropenia #

Coulter VCSTM Technology

Clinical Case Studies

Lymphocyte at low magnification.

Microscopic Differential
%

x109/L

Lymphocytes
91
Monocytes
6
Eosinophils
1
Basophils
2
RBC morphology
Anisocytosis
+
Anulocytes*
+

1.63
0.11
0.02
0.04

Special Observations:
No segmented granulocytes
found even after prolonged
search.

* extremely hypochromic RBC

with only a little
peripheral circle of Hgb.

DIAGNOSIS

Drug-induced agranulocytosis

Comment

The new development of an almost total absence of neutrophilic granulocytes

among otherwise mostly normal blood values was a significant criterion in the
diagnosis. The patient was taken off Thiamazol and treated with B-CSF. Four
days later the granulocyte count had once again exceeded 1000.

15

7.

Acute Myeloid Leukemia FAB M0

Clinical Data
54-year-old male with increasing fatigue
and fever. No swelling of lymph nodes or
splenomegaly. Referred by private physician
for possible acute leukemia.

Scatterplot
and Histograms

Suspect Flags
WBC

Blasts
Atypical lymphocytes

Definitive Flags
Leukocytosis
Lymphocytosis %

RBC
PLT

16

Thrombocytopenia

The Scatterplot displays a

distinct population located
in the region of lymphocytes
and monocytes. The
neutrophilic granulocytes
comprise only a small, poorly
defined population. The total
WBC count is elevated. The
lymphocyte fraction is
relatively and absolutely
increased. Suspect flags are
shown for "Blasts" and
"Atypical lymphocytes." For
the RBC, there are marked
changes in the histogram
(widening, absence of normal
ascent and descent of the
curve) and in the counts.
Based on the increased RDW,
anisocytosis is to be
expected, and anemia is
present in addition (Hgb).
The Plt curve is not
extrapolated, since
predominantly very small
Plt (MPV) are counted, and
moderate thrombocytopenia
is present.

Coulter VCSTM Technology

Clinical Case Studies

Blast and lymphocytes

Microscopic Differential
(n=200)

% x109/L

Blasts
59
Segmented
5
Lymphocytes
35
Monocytes
1
RBC morphology:
Anisocytosis
+
Poikilocytosis
+

11.9
1.0
7.0
0.2

Special Observations:
Morphologically mediumsized blasts without granules
or Auer Rods.

Additional Tests
Cytochemistry:

Blasts: Peroxidase negative; Esterase negative

Flow Cytometry:

No reaction of blasts with lymphatic markers cyCD22, CD19, CD10, cyCD3,

CD5, CD2, Significant reactions with myelomonocytic markers CD13
and CD33

Cytogenetics:

Not done

DIAGNOSIS

AML-M0 according to FAB classification

Comment

In this case the position of the Blasts in the Scatterplot gives no indication as to
which line the blasts belong. In the typical AML FAB M0 the blasts are usually
medium to large, undifferentiated with few granules. In this case the VCS
technology has placed them where they would be expected based on their
structure. The final diagnosis is based on flow cytometric data. An AML FAB M0
is characterised by an expression of myelo-monocytic markers and negativity for
other cell lineage antigens.

17

8.

Acute Myeloid Leukemia FAB M4

Clinical Data
70-year-old female with bleeding tendency,
otherwise feeling well.
Clinical findings: Gingival hyperplasia,
multiple hematomas.

Scatterplot
and Histograms

Suspect Flags
WBC

Blasts
Immature Granulocytes 2

Definitive Flags
Leukocytosis
Monocytosis %
Monocytosis #

In the Scatterplot, a
population is easily identified
in the monocyte region that is
shifted fairly far to the right in
the direction of the
neutrophils. Eosinophilic
granulocytes are not
identifiable as a population,
and lymphocytes barely so.
The instrument flags Blasts
and Immature Granulocytes
2. WBC count is elevated.
The RBC curve is shifted into
the microcytic region and the
MCV decreased. On the righthand side it is atypically
shaped and widened
(RDW). Hypochromia is
present (MCH). The reason
for the slightly atypical shape
of the left-hand side of the
curve in the histogram is the
presence of microcytic and
fragmented cells. These are
also seen in the > 20-fL
region of the Plt curve.
Nevertheless, the instrument
can separate RBC from Plt, as
shown in the extrapolation.
The Plt count is markedly
decreased.

RBC
PLT

DIAGNOSIS

18

1. Secondary acute myelomonocytic leukemia (AML M4 by FAB

classification).
2. Status post multiple combined immunosuppressive therapy.

Coulter VCSTM Technology

Clinical Case Studies

Lower Left: Bone Marrow Cytology:

A maturing apparent left-shift of the
granulopoiesis with a high percentage of
maturing myelomonocytic blasts interspersed
with islets of maturing erythropoiesis and
dimorphic megakaryocytes.

Upper Right: Monocytoid Blasts, marked

anisocytosis and poikilocytosis of the
erythrocytes.

Microscopic Differential
% x109/L
Blasts
2
Promyelocytes
1
Myelocytes
2
Metamyelocytes
3
Bands
7
Segmented
21
Lymphocytes
12
Monocytes
51
Eosinophils
1
Normoblasts
1
RBC morphology
Anisocytosis
+
Poikilocytosis
+
Polychromasia
+
Elliptocytes
+
Schistocytes
+
Teardrops
+
Basophilic stippling +
Spicule cells
+

0.8
0.4
0.8
1.2
2.8
8.3
4.7
20.2
0.4
0.4

Special Observations:
Atypical monocytes
Toxic granulation
Giant Plt

Additional Tests
Bone marrow cytology:

Cellularity markedly increased

Megakaryocytes decreased
Micromegakaryocytes
Granulopoiesis markedly shifted to left
70% blasts
Eosinophilia

Cytochemistry:

The leukemic blasts are peroxidase positive, nonspecific-esterase positive, PAS

negative.

Flow Cytometry:

The circulating blasts are CD11a positive, CD11c positive, CD13 positive,
CD14 positive, CD33 positive, CD65s positive, HLA-DR positive, TdT negative.

Comment

The atypical monocyte population is appropriately located in the monocyte

window. The left shift of the neutrophils up to the blasts was also properly identified. Although no flag for giant platelets was displayed on the instrument,
careful observation of the thrombocyte histogram reveals a change in the curve
in the region > 20 fL. Interference with the erythrocytes is negligible in this
case. In general, attention should be paid to the histogram as well as to the flag.

19

9.

Acute Myeloid Leukemia FAB M5a

Clinical Data
60-year-old male presenting with severe back pain, testicular
swelling, infiltration of the skin and thrombosis of the axillary
vein following catheter sepsis.
Fever and blood coagulation deficiency upon admission.

Scatterplot
and Histograms

Suspect Flags
WBC
RBC
PLT

DIAGNOSIS

20

Blasts
Immature Granulocyte. 2

Definitive Flags
Leukocytosis
Monocytosis %

In the Scatterplot, there is

a noticeable upward shift
in the monocyte population.
The neutrophil population
also shows strong dispersion
into the upper region of the
display. The instrument
indicates Blasts and
Immature Gran. 2, which
are confirmed by smear. A
few small cells are found in
the debris region below the
leukocyte threshold.
Pronounced leukocytosis,
neutrophil generation, and
monocytosis are identified
with their respective flags.
The patient has a slight
microcytic anemia. The RBC
readings indicate
microcytosis (MCV) and
anisocytosis (RDW). In the
small volume threshold
region (<50 fL), the curve
does not reach the x-axis.
The abnormal parameters of
the RBC are not flagged since
the lab failed to enter the
respective limits.
The Plt count is greatly
diminished. The result was
marked with an R due to
the atypical distribution in
the region of 20 fL.
Microcytic RBCs and
cytoplasm fragments can
be assumed to be the cause
of the atypical curve in this
region. Since the patient's
long-term history is known
and the reading did not
deviate greatly from the
previous one, it was not
confirmed.

Early relapse of acute monoblastic leukemia (AML, M5a according

to FAB classification) with Trisomy 8.

Coulter VCSTM Technology

Clinical Case Studies

Lower left: Bone marrow cytology: in the

bone marrow there is proliferation of the
Monoblastic population. The blasts in the
bone marrow are less mature than those
in the blood.

Upper right: Monoblastic leukemia: The

crenations at the fringes of the cytoplasm are
the sites of the formation of cytoplasmic
fragments.

Microscopic Differential
% x109/L
Blasts
34
Promyelocytes
1
Myelocytes
3
Metamyelocytes
4
Bands
13
Segmented
29
Lymphocytes
12
Eosinophils
3
Basophils
1
RBC morphology:
Anisocytosis
++
Poikilocytosis
+
Microcytosis
+
Schistocytes
+

26.8
0.8
2.4
3.2
10.3
22.9
9.5
2.3
0.8

Special Observations:
Monocytoid blasts,
upon examination, some
normoblasts, cytoplasm
fragments

Additional Tests
Bone marrow cytology:

90% blasts with greatly elevated cell density, less mature than in peripheral
blood, few maturing granulocytes, isolated maturing RBCs, megakaryocytes
diminished.

Cytochemistry:

Not repeated, in initial diagnosis blasts positive for nonspecific esterase, 5%

peroxidase-positive, PAS-negative.

Flow Cytometry:

In initial diagnosis blasts positive for CD11b, CD13, CD14 (30%), CD33,
CD65s, CD10, HLA-DR.

Fluorescent in situ
hybridization (FISH):

Comment

Trisomy 8 (85%) and a new clone with tetrasomy 8.

The circulating monocytoid blasts, recognized by VCS as atypical monocytes,
were more mature than the blast population in the bone marrow. The pathological left shift was an individual characteristic of this leukemia. In the border
region of the thrombocyte and erythrocyte histogram, the curve distributions
were elevated through a significant, small-volume cell population, which is
shown in the Scatterplot in the debris region. This cell population probably consists mainly of cytoplasm fragments which also were partially entered in the
thrombocyte count. The thrombocyte count therefore required correction
(chamber count). It is evident that such changes can only be recognized by
close examination of a good blood smear. The blood coagulation deficiency
would be promoted by a plasmatic coagulation disorder which can occur in
monocytic leukemias.

21

10.

C-ALL, FAB L2
Clinical Data
67-year-old female with a 2-month history of
decreased vitality, fatigue, penicillin-resistant
fever, night sweats and repeated nosebleeds.
A mild splenomegaly was apparent in the
clinical examination.

Scatterplot
and Histograms

Suspect Flags
WBC

Blasts
Immature Granulocyte. 2

RBC

Nucleated RBC

PLT

22

Definitive Flags
Leukocytosis
Monocytosis %

Noteworthy in the Scatterplot

is the neutrophil population
shifted downward, i.e., into
the smaller-volume region,
with dispersion into the
larger-volume region, as well
as the suspect flags Blasts
and Immature Gran. 2. In
the smear, small to mediumsized blasts are differentiated
which are probably classified
in this region due to their
volume and light scattering
properties, producing the
blast alert. A clear distinction
between the lymphocytes
and the neutrophil
population cannot be made
from the DF 1 display alone;
this is possible only from the
DF 2 display. The third
dimension, conductivity, is
capable in this case of
distinguishing the population
in the region of the
lymphocytes and neutrophils.
In addition to these
alterations, there is
pronounced leukocytosis.
The RBC histogram is atypical
in the right-hand region of
the curve. There is also a
noteworthy elevated RDW,
indicating anisocytosis,
which is confirmed by smear.
The patient is anemic (Hgb
9.1 g/dl).
The greatly depressed Plt
level is marked R. Upon
examination of the curve, a
left shift toward the smallervolume region is noticeable;
the MPV is only 6.6 fL.

Coulter VCSTM Technology

Clinical Case Studies

Small to mid-sized undifferentiated blasts with

irregular nucleii, prominent neucleolus and a
small cytoplasmic fringe.

Microscopic Differential
% x109/L
Blasts
80
Segmented
2
Lymphocytes
10
Atyp. Lymphocytes 7
Eosinophils
1
RBC morphology:
Anisocytosis
+
Poikilocytosis
+

31.6
0.8
4.0
2.8
0.4

Special Observations:
Small to medium-sized
blasts, scant
cytoplasm, medium-fine
chromatin with nucleoli in
some cases.

Additional Tests
Bone marrow cytology:

Cell density greatly increased, monomorphic cellular pattern with the blasts
described in the blood; abundant megakaryocytes, reduced erythropoiesis,
granulocytes reach metamyelocyte stage of maturation.

Cytochemistry:

Blasts: peroxidase-negative, nonspec. Esterase-negative, PAS-negative.

Flow Cytometry:

The blasts are HLA-DR-positive, CD34-positive, CD10-positive, CD19-positive,

CD13-positive.

DIAGNOSIS

Acute lymphoblastic leukemia (c-ALL) - L2 blasts according to FAB

classification

Comment

Anemia and low RBC count are the results of the shifted cell formation in the
blood marrow that favors the lymphatic blasts. The thrombopenia is pronounced, although megakaryocytes are abundant in the bone marrow. The reason for this could be an increase in peripheral turnover and/or ineffective
thrombopoiesis.
Anemia, neutropenia and thrombocytopenia are the results of bone marrow
infiltration by the acute leukemia and probably ineffective hematopoiesis. An
increase in peripheral turnover (thrombocytopenia) and blood loss (anemia)
could also play a role.

23

11.

Refractory Anemia (RAEB-t)

Clinical Data
This 64-year-old man has myelodysplastic
syndrome of 4 years known duration.
(Original diagnosis: Refractory anemia (RA).)
The patient presents for follow-up.

Scatterplot
and Histograms

Suspect Flags
WBC

Blasts
Immature Granulocyte. 2

Definitive Flags
Leukocytosis

RBC
PLT

24

Thrombocytopenia

In the Scatterplot, a distinct

population is identified in the
debris region, extending into
the lymphocyte and
neutrophil populations. The
instrument indicates "Blasts"
and "Immature Granulocytes
2," which are confirmed on
smear. In addition, 40
normoblasts are differentiated
per 100 WBC, which appear,
in typical fashion, at bottom
left in the debris region of the
Scatterplot. The total WBC
count is elevated.
The erythrocyte histogram
shows some widening (RDW
elevated) and the MCHC
discretely elevated. At the
same time, significant
normochromic anemia is
present. The thrombocyte
count is extremely reduced
and flagged with an R alert.
The size distribution of the
platelets is irregular and not
extrapolated; there are almost
exclusively small platelets
present.

Coulter VCSTM Technology

Clinical Case Studies

Dysplastic granulopoiesis with Pseudo-Pelger

and Myelocyte.

Microscopic Differential
(n=200)

% x109/L

Blasts
6
Promyelocytes
1
Myelocytes
2
Metamyelocytes
8
Bands
5
Segmented
41
Lymphocytes
37
Normoblasts 40/100
WBC
RBC morphology:
Anisocytosis
++
Poikilocytosis
+
Polychromasia
++
Teardrops
+
Basophilic
stippling
+

0.8
0.1
0.3
1.1
0.7
5.4
4.8

Special Observations:
Binucleate normoblasts;
Dysplastic granulopoiesis
(Pseudo-Pelger cells;
abnormal granulation);
Plt anisocytosis.

Additional Tests
Correction of WBC for
normoblasts
WBC (corrected)
Plt (chamber count)

13.2 x 109/L
15 x 109/L
Normoblasts are included in the enumeration of WBC. The "WBC count,"
therefore, depends on the concentration of nucleated cells.
(18.5 x 109/L) x 100/140= 13.2 x 109/L

DIAGNOSIS

Myelodysplastic syndrome; according to bone marrow findings,

transition into RAEB-t

Comment

This case illustrates that the automated differential cannot be interpreted solely
on the basis of suspect flags, but that the Scatterplot has to be taken into
account also. When the various alerts are combined with interpretation of the
Scatterplot, a false-negative result can be virtually excluded. In this case,
besides the suspect flags, there is extreme thrombocytopenia, which also calls
for confirmation by smear or, as was done here, by chamber count. It must be
added that the limits for definitive RBC alerts were not in effect in this laboratory. They would have been able to alert to the presence of anemia (Hgb) and
anisocytosis (RDW).

25

12.

CML in Blast Crisis

Clinical Data
67-year-old man with CML of 4 years known
duration. Presently general deterioration and
splenomegaly.

Scatterplot
and Histograms

Suspect Flags
WBC

Blasts
Atypical lymphocytes

Definitive Flags
Leukocytosis
Neutrophil %
Neutrophil #

RBC
PLT

26

Thrombocytopenia

The Scatterplot shows a

population of lymphocytes
lying near that of the
neutrophils. Most of the cells
in the neutrophil region are
of lesser volume than normal
neutrophils. Because of this,
the entire population is
grouped somewhat lower and
extends very little into the
large-volume region. The
differential shows a large
proportion of neutrophilic
granulocytes. Suspect flags
for "Blasts" and "Atypical
lymphocytes" are displayed.
Smear differential shows 90%
blasts, which can be
classified on the basis of
immunocytologic typing as
lymphoblasts. They are of
small volume and, if one
interprets the automated
differential, almost all
assigned to the neutrophil
region because of their
volume and their scattering
behavior. The total WBC
count is elevated. The RBC
histogram is unremarkable,
although the values indicate
anemia (Hgb). The Plt curve
does not begin on the x-axis
in the 2-fL region. The count
shows marked
thrombocytopenia. The
reason that the curve does
not begin on the x-axis is,
probably, that the patient
only achieved a count of
47 x 109/L after receiving Plt
concentrate. On admission
his count was 16 x 109/L, i.e.,
for practical purposes he had
next to no Plt of his own.
Largely the transfused Plt thus
determined the strange shape
of the histogram.

Coulter VCSTM Technology

Clinical Case Studies

Small blasts with narrow rim of cytoplasm

Microscopic Differential
(n=100)

% x109/L

Blasts
90
Promyelocytes
1
Bands
1
Segmented
1
Lymphocytes
7
RBC morphology:
Anisocytosis
++
Toxic granulation +

13.3
0.2
0.2
0.2
1.0

Additional Tests
Cytochemistry:

Blasts: Peroxidase negative

Flow Cytometry:

Blasts: CD19 positive, CD10 positive, CyCD22 positive,

CD34 mostly positive.

DIAGNOSIS

Lymphatic blast crisis in CML

Comment

Findings resemble those of acute lymphatic leukemia (c-ALL). Recognizing the

present episode as part of the course of CML with predominance of lymphatic
blasts is possible only with knowledge of the past history.
Blast crises in CML are myeloid 60% of the time, lymphatic (almost always Bcell) 30%, and erythroid and megakaryocytic about 5% each.

27

13.

Non-Hodgkins Lymphoma
Clinical Data
60-year-old male patient with exertional dyspnea, remittent
fever, progressive generalized lymphomas and recent bilateral
development of pleural effusion, as well as splenomegaly.

Scatterplot
and Histograms
The lymphocyte window of
the Scatterplot shows a large
accumulation of cells that
appear to consist of two subpopulations. The instrument
indicates Atypical
Lymphocytes. In addition,
there are well-separated
populations of neutrophils,
eosinophils, and monocytes.
The leukocyte count is
normal. The parameters of
the RBC and the platelets
are also unremarkable.

Suspect Flags
WBC
RBC
PLT

28

Atyp. Lymph

Definitive Flags

Coulter VCSTM Technology

Clinical Case Studies

Small atypical lymphocyte with cleaved nucleus

and narrow cytoplasm. Inconspicuous erythrocytes.

Microscopic Differential
% x109/L
Myelocytes
Bands
Segmented
Lymphocytes
Atyp.
Lymphocytes
Monocytes

1
4
39
17

0.1
0.3
3.4
1.5

33
6

2.8
0.5

Special Observations:
Atypical lymphocytes: large,
some with notched or lobulated nuclei, some with
nucleoli

Additional Tests
Bone marrow cytology and
histology:
Cytology of pleural effusion:
Flow Cytometry:
(from lymph nodes):

Small foci of disseminated bone marrow involvement by the centrocytic

lymphoma; well-preserved hematopoiesis.
Leukocytic effusion with centrocytic portion, pronounced mesothelial reaction.
CD19-positive, CD20-positive, CD5-positive (53%), CD10-negative,
CD23-negative, HLA-DR-positive, surface Ig: kappa light chains.

DIAGNOSIS

Leukemic low-grade non-Hodgkin's lymphoma of the centrocytic

type (mantle cell lymphoma according to the REAL classification)

Comment

The microscopic differentiation confirms the presence of an atypical lymphocyte population, which could not always be clearly distinguished from typical
lymphocytes. If, as in this case, the lymphocyte count and the percentage of
lymphocytes are not elevated, a suspect flag can determine further diagnostics.
The light chain restriction clearly identifies the malignancy of these cells.

29

14.

Prolymphocytic Leukemia (PLL)

Clinical Data
Two years ago this 56-year-old male lost 15 kg
and suffered from fatigue and weakness. In
February 1994, a diagnosis of CLL (Rai II) was
made. One year later, splenomegaly and rising
WBC were noted in addition.

Scatterplot
and Histograms
The leukocyte count is
elevated above 100 x 103/L
and is therefore simply
displayed as +++++. A
dilution of the blood sample
is necessary for determination
of the value. All other
parameters are therefore
flagged with R alerts. In the
lymphocyte field, the
Scatterplot shows a
population which is shifted to
the right and then disperses at
the top through the monocyte
population into the blast
region (Warning: Blast
Immature Granulocyte 2
and Atypical Lymphocyte).
The elevated proportion of
these cells in the monocyte
field causes the definitive
warning Monocytosis.

Suspect Flags
WBC

RBC
PLT

30

Blasts
Immature granulocytes 2
Atypical lymphocytes

Definitive Flags
Monocytosis %

The RBC/Hgb parameters

must be corrected before
evaluation. (White Blood Cell
> 100 x103/L raises R)
The thrombocyte count is at
the lower threshold of the
reference region. The
distribution curve indicates
the presence of rather small
platelets. The thrombocyte
value is flagged with an R
alert as a consequence of
leukocytosis.

Coulter VCSTM Technology

Clinical Case Studies

Prolymphocytes

Microscopic Differential
(n=200)

% x109/L

Segmented
Neutrophils
2
Lymphocytes
98
RBC morphology:
Anisocytosis
+
Poikilocytosis
+

5.0
251

Special Observations:
The majority of lymphocytes
are prolymphocytes

Additional Tests
Corrections of values for
extremely high WBC count
WBC (diluted)
RBC (WBC subtracted)
Hct (centrifuged)
Hgb*
MCV (recalculated)
MCH (recalculated)
MCHC (recalculated)

256 x 109/L
3.83x1012/L
0.34
11.4 g/dL
88.8 fL
29.8 pg./cell
33.5 g/dL
*Determination by reference method (after centrifugation of specimen)

DIAGNOSIS

Prolymphocytic transformation of CLL

Comment

Leukocytosis >100 x 103/L disturbs the hemoglobin measurement (turbidity).

The clouding depends on the leukocyte count and on the cell type. With a
value of 13.2 g/dL, a true HGB value > 10 g/dL can be assumed, although the
exact value can only be determined through photometric measurement after
centrifugation of the Hgb preparation. As an alternative, the hematocrit can be
determined with the reference method (centrifuge) and the severity of the anemia thereby evaluated. Prolymphocytes are easiest to recognize in the thin part
of the smear. The thrombocyte count was flagged with an R alert; if the thrombocyte distribution is unremarkable, the value can be accepted and used.

31

15.

Pernicious Anemia
Clinical Data
This 55-year-old woman consulted her physician because of
increasing fatigue. He diagnosed pancytopenia and referred
the patient to the hospital. Admission data: WBC 2.1 x 109/L;
Hgb 6.7 g/dL; MCV 129 fL; Plt 38 x 109/L.

Scatterplot
and Histograms

Suspect Flags
WBC

Immature Granulocytes 2

RBC

Dimorphic RBC population

PLT

32

Definitive Flags
Neutropenia %
Neutropenia #
Thrombocytopenia

The Scatterplot shows distinct

populations in the lymphocyte, monocyte, and neutrophil regions. Only rare
cells are distinguished in the
eosinophil region.
At 2.0 x 103/L, the leukocyte
count is low, caused by a
significant decrease in the
number of neutrophil granulocytes. The neutrophils disperse in the large-volume
region (suspect flag:
Immature Granulocyte 2).
The lymphocyte count is at
the lower threshold of the reference range.
Compared with the microscopic differential, all values
correlate very well. The total
WBC count is decreased.
Remarkable in this case are
the bimodal RBC curve and
the extremely high RDW
(normal up to about 15%).
The instrument signals
"Dimorphic RBC population."
All other RBC values are likewise abnormal: Hgb markedly decreased, Hct decreased,
MCV extremely high, i.e.
macrocytic or megaloblastic
RBC, and MCH extremely
high, i.e. hyperchromia of
RBC. Only the MCHC value
is normal. The Plt value and
histogram are abnormal.
The curve does not approach
the x-axis in the > 20-fL
region and the value is
flagged "R." most likely as a
result of the microcytic red
cell. Chamber count confirms
the low Plt count.

Coulter VCSTM Technology

Clinical Case Studies

Macrocytes

Microscopic Differential
(n=200)

% x109/L

Bands
3
Segmented
37
Lymphocytes
49
Monocytes
5
Eosinophils
4
Basophils
2
RBC morphology:
Anisocytosis
++
Poikilocytosis
+
Macro and
megalocytes
++

0.06
0.72
1.0
0.1
0.08
0.04

Additional Tests
Plt (chamber count):

35 x 109/L

Bone marrow cytology:

Hypercellular marrow; erythropoiesis markedly increased; megaloblastic

changes; abundant hyperlobular megakaryocytes; dysplastic hemopoiesis.

Vitamin B12:

Decreased

Folic acid:

Normal

DIAGNOSIS

Megaloblastic anemia. Additional diagnostic tests demonstrate

pernicious anemia.

Comment

Upon admission to the hospital, the blood count showed only an erythrocyte
population with a medium volume of approximately 130 fL (measurement on
Coulter STKR in emergency lab; not pictured here). The patient received two
erythrocyte concentrates, the normal erythrocytes of which now can be identified in the region of approximately 85 fL in the erythrocyte distribution curve.
The two erythrocyte populations are also recognizable in the smear: clear anisocytosis with macrocytes and/or megalocytes.
The low thrombocyte value was confirmed in the chamber count.

33

16.

Hereditary Spherocytosis
Clinical Data
26-year-old male for follow-up of known
spherocytosis. Recently performed
splenectomy; outpatient follow-up.

Scatterplot
and Histograms

Suspect Flags
WBC
RBC
PLT

34

Definitive Flags

In the Scatterplot, the

lymphocyte, monocyte, and
neutrophilic granulocyte
populations are situated close
together. This phenomenon
may occur when a specimen
is left standing and unmixed
for several hours and
analyzed without prior reequilibration as in this case.
There are no suspect flags.
There is good agreement with
the microscopic differential.
Hemoglobin concentration
and the number of
erythrocytes, as well as the
size distribution of
erythrocytes, are
unremarkable. The MCV is
within the reference range.
The mean corpuscular
hemoglobin (MCH), however,
is elevated in relation to the
mean corpuscular volume
(MCV), which, compared
with normal persons, results
in an elevation of the mean
corpuscular hemoglobin
concentration (MCHC).
The Plt curve is normal, the
count elevated.

Coulter VCSTM Technology

Clinical Case Studies

Spherocytes

Microscopic Differential
(n=200)

% x109/L

Segmented
45
Lymphocytes
39
Monocytes
11
Eosinophils
3
Basophils
2
RBC morphology:
Spherocytes
++
Howell-Jolly
bodies
+

3.9
3.3
0.9
0.3
0.2

Additional Tests
Hct (centrifuged)
MCV
MCH
MCHC
Reticulocytes

58%

DIAGNOSIS

Spherocytic anemia (shortly after splenectomy)

Comment

Smears from normal persons show "spherocytes" round the periphery. When
spherocytosis is suspected, the thick part of the smear must be examined.

0.42 (repeatedly)
79.6 fL
31.9 pg/cell
40.0 g/dL
306 x 109/L

Note: When spherocytosis is suspected, attention should be paid to the MCHC

value on the instrument, which is borderline elevated!
Because of their spherical shape, impedance measurement characteristically
yields MCV values too high for these cells therefore the MCHC determination is
falsely elevated. If spherocytosis is suspected, the hematocrit should always be
measured in parallel with a reference method (centrifugation). Whereas in normal persons the manual Hct is always 1-2% higher than the automated value
("trapped plasma"), in spherocytosis it is lower.

35

17.

Anisocytosis
Clinical Data
58-year-old female in a state of incipient
delirium tremens following alcohol
withdrawal after many years of alcohol abuse.

Scatterplot
and Histograms

Suspect Flags
WBC

36

Definitive Flags
Monocytosis %

RBC

Nucleated RBC

PLT

Platelet aggregates

Noteworthy in the Scatterplot

is the population in the lower
left of the lymphocyte field
and the population of
neutrophilic granulocytes.
The instrument indicates
nucleated RBC and Plt
aggregates. Both flags are
confirmed by the differential
count.
The *R alert for WBC, i.e.,
the measurement of particles
in the region of the 35 fL
threshold can be attributed to
the presence of lysis-resistant
target cells and the platelet
aggregates.
In the chamber count, the
WBC read was 5.1 x 109/L.
The slight upward shift in the
neutrophil population
indicates the presence
of immature granulocytes,
in this case only 5% bands
and 1% myelocytes.
The RBC distribution curve
shows an atypical widening
with an increased RDW
of 21.4%. This corresponds
to the anisocytosis in the
manual differential blood
count.
The Plt curve is normal,
the Plt count diminished.

Coulter VCSTM Technology

Clinical Case Studies

Anisocytosis of the erythrocytes with macrocytes,

target cells, basophilic stippling and pappenheimer
bodies.

Microscopic Differential
% x109/L
Myelocytes
1
Bands
5
Segmented
61
Lymphocytes
8
Monocytes
21
Plasma cells
3
Normoblasts
1
RBC morphology:
Anisocytosis
+
Poikilocytosis
+
Schistocytes
+
Target cells
+
Howell-Jolly
bodies
+
Basophilic
stippling
+
Pappenheimer
bodies
+
Siderocytes
+

0.1
0.4
4.5
0.6
1.6
0.2
0.1

Special Observations:
Giant platelets and platelet
aggregates

Additional Tests
WBC (chamber count):

5.1 x 109/L

Epigastric sonogram:

Recent portal vein thrombosis, cirrhosis of the liver, ascites, normal-sized spleen.

Bilirubin:

Elevated: total 90 mol/L, direct 63 mol/L

Staining of blood smear for iron:

Siderocytes.

DIAGNOSIS

Decompensated alcoholic cirrhosis of the liver

Delirium tremens
Portal vein thrombosis

Comment

The noteworthy small-volume cell population in the Scatterplot is composed of

normoblasts, giant platelets, and thrombocyte aggregates as well as possible lyseresistant macrocytes and target cells. Because of their volume and light scattering
properties, these cells were counted as lymphocytes and raised the leukocyte
count by 2.3 G/L. The R alert and the suspect flags should be understood as a
request for controlling the leukocyte count and differentiation.
The Howell-Jolly bodies were the result of a loss of spleen function with fresh
portal vein thrombosis. Pappenheimer bodies (iron deposits) in the erythrocytes,
for example, are an indication of sideroachrestic disorders in cirrhosis of the liver.

37

18.

Essential Thrombocytemia
Clinical Data
68-year-old female, suffering for several years
from headache and dizziness.
Clinical examination reveals slight
splenomegaly.

Scatterplot
and Histograms

Suspect Flags
WBC

Definitive Flags
Leukocytosis

The Scatterplot shows the

lymphocyte and neutrophilic
granulocyte populations
practically merging into one
another. There are no suspect
flags for the WBC.
Microscopic values correlate
well with the automated
differential. The Plt count is
given as ++++, meaning that
the linearity limit of 1000 x
109/L has been exceeded. The
high Plt count may have
caused interference. For this
reason, the WBC count,
MCH, MCHC, and Hgb have
been flagged R. After
dilution of the blood, a count
of 1988 x 109/L is obtained.
The RBC curve is widened,
with an elevated RDW.
Particles are identified in the
< 50-fL region. This may
indicate aggregated or giant
Plt. (With Plt counts of 2000 x
109/L, there are always small
aggregates.) Anisocytosis is
confirmed by smear. MCV is
borderline low.

RBC
PLT

DIAGNOSIS

38

Chronic myeloproliferative syndrome (MPS with essential thrombocythemia)

Coulter VCSTM Technology

Clinical Case Studies

Very distinct thrombocytosis and aniscocytosis of

the thrombocytes together with macrothrombocytes.
Very little anisocytosis of the erythrocytes.

Microscopic Differential
% x109/L
Bands
5
Segmented
84
Lymphocytes
4
Monocytes
3
Eosinophils
1
Basophils
3
RBC morphology:
Anisocytosis
++
Poikilocytosis
+
Polychromasia
+
Target cells
+

1.1
18.1
0.9
0.7
0.2
0.7

Special Observations:
Giant Plt

Additional Tests
Plt count (after dilution):

1988 x 109/L

Bone marrow cytology:

Bone trabeculae normal. Cellularity increased by 80%. Megakaryocytes significantly increased, some large forms, some nests. Erythropoietic and granulocytic
maturation, E:G = 0.2:1. Increased eosinophils.

Neutrophil alkaline
phosphatase index:

Normal (61)

Serum erythropoietin:

Significantly decreased

Serum ferritin:

Normal (58 g/ml)

Comment

A massive increase in thrombocytes was detected after the blood sample was
diluted. Micro thrombocytes and small thrombocyte aggregation was visible on
the blood smear. These aggregates are responsible for deforming the erythrocyte
histogram in the region below 50fl. The anisocytosis confirmed these findings.
These changes are not visible on the platelet distribution curve. The leukocyte
count and hemoglobin concentrations were increased possibly as a result of the
thrombocytosis and aggregation. No comparison with reference methods were
performed in the absence of any suggested enumeration differences.

39

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