1

The Role of Lab Exam ScreeningDiagnosis :

Routine Lab testsConfirmatory Lab tests

PrognosisMonitoring

Disease activityTherapy responses

2

Laboratory examination for Infection

3

4

Routine examinationRoutine examination

Blood cell count complete blood cont (CBC) Hemoglobin concentration (Hb)Hemoglobin concentration (Hb) White Blood Cell Count (WBC)White Blood Cell Count (WBC) Platelet countPlatelet count Differential cell countDifferential cell count Red blood cell count & HematocritRed blood cell count & Hematocrit

Erythrocyte Sedimentation Rate Erythrocyte Sedimentation Rate (ESR)(ESR)

HEMATOLOGY :

Routine examination - hematology

Blood cell count

5

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

Anemia in bacterial infection

6

Extracellular microorganism

Clostridial Septicemia Bartonellosis

Invade to RBCs Adhere to the exterior surface of the RBC

Destruction of RBCs

Lysis ANEMIA

Hemolytic anemia in parasites infection

7

Infected cell

rupturesImmune complexes

ANEMIA Lysis

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.

8

Anemia of Chronic Disease

Pathophysiology:Erythropoesis suppression

Chronic inflammatory process secretion of TNF & IL-1

Lack of iron for Hb synthesisLactoferrin release from granules of neutrophilsLactoferrin competes with transferrin for iron

Decreased RBC survival

9

Routine examination - hematology

LEUKOCYTE COUNT (WBC)

Measure number of total leucocytes Method: manually & automaticallyPrinciple : dilution of blood with acid solution

in order to lyses erythrocytes

Reference range : adult = 4000 -11.000 cells/μL

child = 4500-17.000 cells/μLnewborn= 6000-30.000 cells/μL

10

Kinetics of Leucocyte

11

Input from

marrow

Circulating pool

Marginal pool

Output to tissue

Storage pool

Pathology

LeukocytosisWBC > 11.0 (x 109/L)

LeukopeniaWBC < 4.0 (x 109/L)

12

Virus infectionTyphoid feverRheumatoid arthritisCirrhosis of the liverSLERadiation, drugs

Bacterial infectionLeukemiaUremia

Physiologic: Pregnancy Strenuous exercise Emotional stress, anxiety

WBC

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

13

Classification of LeucocytesGranulocyte

Neutrophil, Eosinofphl,

BasophilPolimorfonuclear

Neutrophil, Eosinofphl,

Basophil

PhagocyteNeutrophil Monocyte

Non-granulocyteMonocyte Lymphocyte

Mononuclear Monocyte

Lymphocyte

ImmunocyteLymphocyte

14

15

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.

All white blood cells originate from the bone marrow

16

Blood cells derived from bone marrow cells

17

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

18

19

Cells in blood circulation

Very few in blood

20

Resting lymphocytes are round cells with a large nucleus

Differential cell count

Refference range:

21

Polymorphonuclear neutrophils : 50 – 70 % Bands : 0 – 5 %

Lymphocytes : 18 – 42 % Monocytes : 1 – 10 % Eosinophils : 1 – 4 % Basophils : 0 – 2 %

• Course of d’s : shift to the left (acute), shift to the right (chronic)• Cause : bacterial, viral and parasites infection neutrophilia (bacterial infection), lymphocytosis (viral infection, tuberculosis)

NEUTROPHILIA3 major cause : infection,

inflammation, malignancy

Severity of neutrophilia in infection depend on:

- virulency of organism, - age : child > - patient immunity:

immunocompromised host

22

Quantitative abnormality

Causes of neutrophilia1. Bacterial Infection2. Toxic agent3. Metabolic: uremia, eclampsy, metabolic

acidosis4. Drugs & chemicals: mercury, digitalis, steroid 5. Physic & emotional stimuli 6. Tissue damage & necrosis: myocardial infarct,

wound, neoplastic diseases7. Hemorrhage: especially intra serous cavity

(peritoneal, pleural, joint space, subdural)8. Hematological diseases: leukemia.

23

Quantitative abnormality

Qualitative Abnormality

Shift to the left or right:

24

Shift to the left :• increase immatur cells• most frequent: stab, • metamielosit, mielosit, promielosit• acute infection (bacterial)

Shift to the right:• increase of segment• hypersegmentation • chronic infection

batang segmenmetamielositmielositpromielositmieloblas

Leukemoid reaction mielocytic/netrophyilic

25Bain, 2002. Blood Cells, A Practical Guide,3rd ed, Blackwell Publ, UK

Quanti+Qualitative abnormality

White blood cell (blood smear)

26

Leucocytosis : netrophilia absolute with toxic granulation & vacuolisation

Toxic granulation

vacuolisation

Qualitative abnormality

vacuolisation

Bacterial infection

27

vakuolisation

Toxic Granulation

Vacuolisation & toxic granulation

Bacterial infection

Toxic GranulationStimulated by organism or antigenColor of granule: dark blue-blackish Profound toxic granulation worse prognosis

Vacuolisation of cytoplasm phagocytosis process

28

Qualitative abnormality

NeutropeniaNetropenia lekopeniaAgranulositosis: severe netropenia

Causes of netropenia:Viral infectionCertain Bacteria: Tifoid/ paratifoidSevere infectionImmune reaction: autoimmune/ drug induced

29

EOSINOPHILIA :1. Parasite investation - correlate with killed parasites - eosinophyl attracted to parasite will be

killed by degranulation process

2. Allergy/ hypersensitivity

30

31

EOSINOPHILIA :EOSINOPHILIA :

Lymphocytosis

32Absolute lymphocytosis Viral infection

33

Variant / atypical/ virocyte/ reactive Variant / atypical/ virocyte/ reactive lymphocytelymphocyte response to infection response to infection

Qualitative abnormality

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, toxoplasmosisLymphocytosis without var lymph: asimptomatic viral inf., diarrhea, resp. inf

Lymphopenia; HIV, SLE, intensive chemotherapy

34

Virus Infection

MONONUKLEOSISINFEKSIOSA (MI)cause: virus

Epstein-Barr (EBV)Lekositosis with

limphocytosis, dan atypical lymphocyte

“Kissing-cell”

35

36

Dengue virus infection

Reactive LymphocyteBlue cytoplasm-Lymphocyte

37

Monocyte

MONOCYTOSIS

Some bacterial inf.,:- Active Tuberculosis :

- Sub acute bacterial endocarditis - SyphilisMyeloproliferatifRecovery

38

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

39

Routine examination - Routine examination - hematologyhematology

Normal sedimentation

i Polisitemia : AEi Dekompensasi

jantungi Sickle sel anemia,

sferositosisi Neonatus

Increase Sedimentation i infectioni myocardial infarcti Rheumatic feveri Malignancy with

necrosisi Active tuberculosis ,

tissue destructioni Surgery Trauma, shocki Hiperglobulinemiai Pregnancy

40

C-REACTIVE PROTEIN (CRP)

an acute phase reactantIn general parallel ESR but not influenced by

erythrocyteMore sensitive than ESRIncrease & decrease faster : - early indicator of acute infection - monitor course of disease

41

CRP increase in :Infection:

Lower in viral compared to bacterial infectionUseful to monitor disease activity

Inflammatory disorders:Earlier,more intense increase than ESRDissaperance of CRP precedes the return to

normal of ESRTissue injury or necrosis

AMI : appears within 24-48 hrsMalignant disease, Following surgery, burns

42