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BC-5300/5380
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2013
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P/N: ENG-CCS-5300/5380-210145x36-20110804
BC-5300/5380Auto Hematology Analyzer
Full automatic 5-part differentiation of WBC, 27 parameters, 3
histograms and 1 scattergram
Laser scatter, Advanced flow cytometry, Chemical dye
method
Independent Basophil channel
Up to 60 samples per hour
2 Sampling modes: Autoloader and Closed tube
Large storage capacity: 40,000 results with graphs
Preface to Clinical Case Study for Mindray Hematology analyzer BC-5300/5380
Microscope and Romanowsky dyes availability have resulted in
accumulation of a vast pool of knowledge about cytological chang-
es seen in various blood disorders. This is applied prospectively to
not only suspect, but also diagnose or even differentiate haemato-
logical disorders. It is unthinkable today to practice hematology
without support from an expert morphologist. At the base of such
approach lies the process of pattern recognition i.e. first discerning
a set of test results (qualitative + quantitative) as not normal (or
abnormal) and then establishing its association with a known he-
matological condition.
CBC+DIFF or ABC (i.e. Automated Blood Count & differentiation of
white cells into 5 common subtypes) is the most ordered blood test
worldwide. While Clinical laboratories world over test millions of
blood specimens daily on automated hematology analyzers; Lab
managers also have to grapple with a decreasing pool of expert
morphologists. Consequently, the newer entrants to medical pro-
fession look for solutions that bridge the gap between newer (not
necessarily well known) technologies and known maladies. Obvi-
ously, an interested user is looking for repositories of data produced
by automated devices that establishes link between the data and
diseases.
Mindray is a global healthcare manufacturer committed to bring
healthcare within reach of wider section of people. With a wide-
spread product portfolio and an established presence in over 165
countries; Mindray takes the task of supporting current healthcare
demands seriously.
Clinical case study for BC-5300/5380 hematology analyzer is an
example of that effort. It is a compilation of BC-5300/5380 hemato-
logy analyzer results obtained on healthy individual and patients
with commonly seen hematological abnormalities. It is designed to
introduce the BC-5300/5380 user to the benefits of pattern reco-
gnition. We wish to draw user's attention to the 'screening' principle
that is fundamental to judicious & proper use of this Clinical case
study book. Currently available hematology analyzers are unable to
classify all types of morphological abnormalities, primarily due to
the limitations of technology which cannot match the accuracy of
an expert morphologist who observes visual attributes of a well
stained cell and using his past knowledge classifies the cell. How-
ever, the analyzers make up for the lower accuracy by providing far
greater reproducibility/precision because they count large number
of cells and consistency to 'flag' an abnormality.
Hence, when BC-5300/5380 analyzer 'flags' a result, an expert
morphologist is expected to review patient's blood film from before
issuing findings & opinion, of course only after correlating with
patient's medical history and clinical condition.
It is also our hope that with your feedback, suggestions and newer
observations; we will be able to bring out richer editions of Clinical
Case Study in future.
Dr. Vijay Parekh, Scientific Director in Mindray
1 2
For RBC/PLT numeration, the classical electrical impedance
method is used. When cell passing through the aperture by
vacuum, it will introduce the change on resistance. In a
constant current, the voltage change signal will be recorded
and accords with the volume of cell.
For WBC 4 parts(lymphocytes, monocytes, neutrophils and
eosinophils) differentiation, chemical dye, flow cytometry
and laser scatter are applied.
Cells are injected into a flow cell
which is located in the optical path
of a light source, usually a laser;
Surrounded with sheath flow, the
blood cell pass through the center of
flow cell in a single colume at a fast
speed.
Flow cytometry
LEO I lyse breaks down red blood
cells and imposes on effect on white
blood cells.
LEO II lyse densifies the granules of
eosinophils.
Counting Principles for Hematology Analyzer BC-5300/5380
Chemical dye
DIFF Channel
EOS
Other WBC
RBC
LEO I LEO II
3 4
+ -electrode vacuum
aperture
Laser scatter
Light scattering occurs when a particle
deflects laser light. The extent to which
this occurs depends on the physical
properties of the particle:
Forward scatter (FS): cell volume
Side scatter (SS): cell granularity
FS
SS
LH Lyse breaks down red blood cell and shrinks other WBC cells except
basophils while keeps the original volume of basophils
BASO
Other WBC
RBC
WBC/BASO Channel
LH
5 6
For basophils and WBC total number count, the cells are first
treated by chemical dye, and then numerated by the classical
electrical impedance method.
LH lyse is also used for HGB quantitative analysis. With the
aid of a color reagent, the concentration of HGB is
determined by the change of absorbance in 525nm using
colorimetric method.
LH lyse breaks down red blood cells, binds to hemoglobin and converts
it to a complex that is measurable at 525nm.
LH
Flags Appendix
Abnormal Suspect
WBC
1Leucocytosis
High monocytes analysis results
Flag Meaning
High WBC analysis results
Low WBC analysis results
High neutrophils analysis results
High lymphocytes analysis results1Lymphocytosis
RBC/HGB
1Microcytosis Small MCV
RBC Abn. Distribution Abnormal RBC scattergram
Sizes of RBCs are dissimilar1Anisocytosis
Diamorphologic RBC dimorphic distribution
PLT
1Thrombocytosis
1Thrombocytopenia
PLT Abn Distribution
PLTs increase
PLTs decrease
PLT histogram distribution abnormal
WBC
Flag Meaning
RBC/HGB
PLT
WBC numbers of BASO and DIFF channels are inconsistent. The sample may be abnormal, or the analyzer may be abnormal
7 8
The criterions which trigger the flag information can be edited from the software version of V01.19.
2 For this flag, if the analyzer determines that it is resulted from fragile WBCs, or 9 9the WBC result in the predilute mode is between 0.5x10 /L and 2.0x10 /L, the
analysis result will be displayed; otherwise, the analysis result shows ”***”.
1
2WBC Abn. ?
WBC Abn. Histogram?
Abnormal WBC scattergram WBC Abn Scattergram?
RBC or HGB Abn.? 1 Results of RBC or HGB may be inaccurate
RBC Lyse Resist? RBC hemolysis may be incomplete
Immature Cell? Immature cells may exist
PLT Clump? PLT clump may exist
Left Shift?
Abnormal WBC histogram
Left shift may exist
Abn./Atypical Lym?
Abnormal lymphocytes or atypical lymphocytes may exist
1Leucopenia
1Neutrophilia
Low neutrophils analysis results1Neutropenia
Low lymphocytes analysis results1Lymphopenia
1Monocytosis
1Eosinophilia High eosinophils analysis results1Basophilia High basophils analysis results
1Macrocytosis Large MCV1Erythrocytosis Increased RBCs
1Anemia Anemia1Hypochromia Hypochromia
Normal scattergram appearance; the WBC sub-populations
are well differentiated from each other and aggregate with-
in expected areas; no flag message for abnormal cells. The
WBC/BASO, RBC and PLT histograms are normal.
Male, 27-year-old healthy volunteer.
Under microscope, the morphology of erythrocytes, platelets and all
sub-populations of leukocytes were normal, and no atypical or imma-
ture cells were observed.
Microscopic Differential
WBC DIFF Neutrophilic band granulocyte
Neutrophilic segmented granulocyteLymphocyte Monocyte Eosinophil Basophil
RBC morph
PLT morph
Screen Interpretation:
Upper part: results, reference ranges and flag information areas
Lower part: histograms and scattergram (
)
lymphocytes monocytes
neutrophils eosinophils
(n=200)
1%
54%37% 4%
3.5%0.5%
Normal Normal
Normal Sample
9 10
Lym
Neu
The dimorphic RBC population in this case indicates aniso-
cytosis and evidenced by presence of two red cell popula-
tions with different cell size distributions. Dimorphic RBC is
commonly seen in patients with sideroblastic anemia. It can
also be seen in patients recovering from iron deficiency
anemia upon receiving iron therapy or patients who have
received massive blood transfusion.
Male, 50-year-old, outpatient.Diagnosis: Rectal cancer
Under microscope, the erythrocytes varied in size; All WBC sub-
populations were within normal limits.
Microscopic Differential
WBC DIFFNeutrophilic band granulocyteNeutrophilic segmented granulocyte LymphocyteMonocyteEosinophilBasophil
RBC morph
PLT morph
Report Analysis:
Inaccurate RDW-CV and RDW-D results displayed as “**.*”; MCV results
might be affected; related parameters including HCT, MCV and MCHC
were flagged with ”?” where microscopic examination was suggested
RBC flag messages: “Dimorphologic” and “Anisocytosis”
Histogram: dimorphic RBC histogram indicated anisocytosis; in the
PLT histogram, the right part was raised from the X axis, indicating an
abnormal PLT distribution which might be interfered by microcytic
red cells
(n=200)
1%
55%35%
4%4.5%0.5%
Vary in size, the pale area in the center of some RBC
expandedNormal
Diamorphic RBC
11 12
Large RBC
Small RBC
Microcytosis is a condition where red blood cells are reveal-
ed to be unusually small when their mean corpuscular
volume is measured. A large number of hypochromic micro-
erythrocytes appear in blood smear, indicating reduction in
hemoglobin synthesis. It is seen in case of iron deficiency
anemia and thalassemia. However the microerythrocyte in
hereditary spherocytosis is well filled with hemoglobin and
the hypochromic area in its physiological center disappears.
Under microscope, the erythrocytes decreased in size, but were in
similar sizes.
Male, 34-year-old, outpatient.
Microscopic Differential
WBC DIFFNeutrophilic bandgranulocyte Neutrophilic segmented granulocyteLymphocyteMonocyte Eosinophil Basophil
RBC morph
PLT morph
(n=200)
1%
51%42.5%
4%1%
0.5%
Decrease in size, microcytic
Normal
Microcytosis
13 14
Neu
Report Analysis:
RBC and PLT counts increased; MCV decreased significantly
RBC flag messages: “Microcytosis” and “Erythrocytosis”
Histogram: the RBC dominant peak moved to left, indicating that
there were microcytes; in the PLT histogram, the right part was raised
from the X axis, indicating an abnormal PLT distribution due to
interference by microcytes
Aplastic anemia (AA) is a hematopoietic depletion syndrome
which may be caused by exposure to chemical toxins, physi-
cal trauma, biological factors or may be idiopathic in origin.
The hematopoietic stem cell dysfunction is prominent,
which leads to the replacement of hematopoietic red pulp by
fat, resulting in decrease of healthy blood cells causing pro-
gressive anemia, hemorrhage or infection. AA is usually seen
in adults.
Under microscope, the erythrocytes and leukocytes appeared fewer
than normal. The leukocyte in the field view on this page, was a
neutrophilic segmented granulocyte.
Female, 30-year-old.Diagnosis: aplastic anemia confirmed half a year ago.
Report Analysis:
WBC, RBC, HGB and PLT counts decreased significantly; lymphocyte
and neutrophil numbers decreased, especially the neutrophil number,
which was consistent with the features of aplastic anemia histogram
WBC flag message: “WBC Abn. scattergram”
RBC flag message: “Anemia”
PLT flag messages: “PLT Abn. Distribution” and “Thrombopenia”
WBC Differential
WBC DIFFPromyelocyteMyelocyteMetamyelocyteNeutrophilic bandgranulocyte Neutrophilic segmented granulocyteLymphocyteMonocyteEosinophil
RBC morphPLT morph
(n=200)1%1%2%
12%
71.5%12%
1%0.5%
Normal
Normal
Aplastic Anemia
15 16
Neu
Monocytes and phagocytes in tissues form a defense mecha-
nism by phagocytizing or killing damaged cells and antigens
. Monocytosis is an increase in the number of circulating
monocytes in blood. Physiological monocytosis is commonly
found among children and infants, while pathological
monocytosis is usually seen in patients with subacute infec-
tious endocarditis, malaria, kala-azar, active tuberculosis. It
may also present during the convalescence of an acute infec-
tion or hematological diseases such as malignant histocyto-
sis, lymphomatosis and agranulocytosis.
Under microscope, the monocyte proportion increased, in the micro-
scopic field shown here, two monocytes could be observed.
Male, 20-year-old, outpatient. Diagnosis: ankylosing spondylitis.
Microscopic Differential
WBC DIFF Neutrophilic segmented granulocyte Lymphocyte Monocyte Eosinophil
RBC morph PLT morph
(n=200)
49%32.5%
16%2.5%
NormalNormal
17 18
Report Analysis:
WBC count increased and monocyte number increased significantly
RBC and HGB results were within normal range; PLT count increased
WBC flag message: Monocytosis
Scattergram: in the DIFF scattergram, the monocyte area was brighter
than normal, indicating an intense aggregation of spots and increase
of monocyte proportion
" "
Mo
no
cytosis
MonMon
Eosinophil is capable of inhibiting allergic responses,
phagocytizing and is involved in immunological reactions to
parasites. Eosinophilia, elevated eosinophil count, is
commonly seen in patients with parasitic diseases, allergic
reactions and dermatological diseases. Increased eosino-
phil count is not unusual in chronic granulocytic leukemia,
polycythemia vera, multiple myeloma. Eosinophilia may
also be seen in patients with malignant tumors, infectious
diseases, rheumatic diseases, pituitary gland anterior lobe
deterioration, adrenal cortex deterioration and allergic
interstitial nephritis.
Under microscope, the eosinophils population appeared increased. In
the microscopic field shown here, two eosinophil granulocytes could be
observed.
Report Analysis:
Eosinophil number increased significantly; MCV decreased
WBC flag message Eosinophilia
Scattergram: in the DIFF scattergram, there were a significant
increase of eosinophil spots and increase of eosinophil proportion
: " "
Microscopic Differential
WBC DIFFNeutrophilic segmented granulocyte Lymphocyte Monocyte EosinophilBasophil
RBC morph PLT morph
Female, 25-year-old, outpatient. Diagnosis: edema of unknown cause.
(n=200)
42.5%28%
4.5%24.5%
0.5%
NormalNormal
19 20
Eosin
op
hilia
Eos
Eos
Large Immature Cell (LIC) refers to the increase of stab cells
and/or the presence of metamyelocytes, myelocytes and
promyelocytes in the peripheral blood. It can be divided into
reproductive left shift and degenerative left shift. The form-
er is a kind of left shift accompanied by elevated WBC count.
Left shift has its significance in evaluating the seriousness of
illness and the patients’ ability to respond.
Male, 34-year-old, outpatient. Diagnosis: Adult Still’s disease.
Report Analysis:
WBC count increased, RBC and HGB decreased
There was no clear distinction to differentiate neutrophil spots and
monocyte spots. The abnormal cells might affect the Baso histogram;
Neu#/%, Mon and Bas were flagged with “?”, indicating these
results might have been affected by presence of abnormal cells and a
microscopic examination was indicated
WBC flag message: ”Immature cell”?
Scattergram: in the DIFF scattergram, there was an cluster of spots in
the LIC area
#/% #/%
Microscopic Differential
WBC DIFF MyelocyteMetamyelocyteNeutrophilic band granulocyte Neutrophilic segmented granulocyte Lymphocyte MonocyteEosinophilBasophil
RBC morph PLT morph
Under microscope, a trend of left shift, for neutrophils & promyelocytes,
was observed. The cell in the left of the microscope field shot shown on
this page were a myelocyte and a .metamyelocyte
(n=200)1%
2.5%
2%
66.5%22.5%
3.5%1%1%
NormalNormal
21 22
Large Im
matu
re Cell
Myelocyte
Metamyelocyte
Atypical lymphocytes (ALY), also known as reactive lympho-
cytes, are enlarged and elongated white cells with an ellip-
tical nucleus. They are usually associated with viral illnesses
when normal lymphocytes are stimulated by the viral anti-
gens. These are commonly seen in infectious mononucleosis,
infectious hepatitis, measles, viral pneumonia, pertussis-
like syndrome, influenza, epidemic hemorrhagic fever and
even common cold.
Report Analysis:
There was no clear demarcation to differentiate clusters of lympho-
cyte and monocyte. The abnormal cells might affect the Baso
histogram; Lym#/%, Mon Eos and Bas are flagged with
“?” , indicating that these results might be affected by presence of
abnormal cells and a microscopic examination was indicated
WBC flag messages: ”Abn./Atypical Lym ? “, ” Lymphocytosis” and
“Neutropenia”
Scattergram: there was a cluster of spots in the ALY area
#/%, #/% #/%
Microscopic Differential
WBC DIFFNeutrophilic band granulocyte Neutrophilic segmented granulocyte LymphocyteAtypical lymphocyte Monocyte EosinophilBasophil
RBC morph PLT morph
Female, 2-year-old, inpatient; Virus test results: adenovirus: weak positive; respiratory syncytial virus: positive; Coxsackie virus: positive.Diagnosis: bronchopneumonia; virus infection confirmed.
Under microscope, the ALY proportion appeared increased. The micro-
scope field shot here showed two mononuclear atypical lymphocytes.
(n=200)
1%
14%75.5%
5%3%
0.5%1%
NormalNormal
23 24
Atyp
ical Lymp
ho
cyte
ALY
ALY
Acute promyelocytic leukemia (FAB M3) is a type of acute
myeloblastic leukemia. In FAB M3, there is an abnormal
accumulation of promyelocytes. The disease presents a chro-
mosomal translocation involving the retinoic acid receptor
alpha (RARα or RARA) gene and is unique from other forms of
AML in its responsiveness to all-trans retinoic acid (ATRA)
therapy.
Report Analysis:
WBC count increased, RBC and PLT counts decreased
WBC flag message: ”WBC Abn scattergram”
RBC flag message: “Anemia”
PLT flag message: “Thrombopenia”
Scattergram: there was a cluster of spots in the immature cell area;
the monocyte spots mixed with the granulocyte spots, while the
lymphocyte spots were clearly differentiated, indicating an abnormal
granulocyte morphology. Therefore, microscopic examination was
recommended
Microscopic Differential
WBC DIFFBlast PromyelocyteMyelocyte Metamyelocyte Lymphocyte
RBC morph PLT morph
Most of the cells observed under microscope were promyelocytes with
increased number of abnormal grains, and there were a few myeloblasts
and other granulocytes.
Female, 33-year-old. Chief complaints: increased menstrual blood loss and ecchymosis. Physical examination results: anemic look; petechiae all over her body; no superficial lymphadenodes could be detected during physical exam.
(n=200)6%
81%2%1%
10%
NormalNormal
25 26
AP
ML
PromyelocytePromyelocyte
Acute myelo-monocytic leukemia (FAB M4) is a form of acute
myeloid leukemia that involves a unwanted proliferation of
CFU-GM myeloblasts and monoblasts. It is a common type of
pediatric AML. The symptoms may be non-specific: weakness
, pallor, fever, dizziness and respiratory symptoms. More
specific symptoms include bruises and/or bleeding, DIC,
neurological disorders and gingival hyperplasia.
Report Analysis:
WBC count increased and RBC and PLT counts decreased
WBC flag message: “WBC Abn scattergram”
RBC flag message: “Anemia”
PLT flag messages: ”PLT Abn. Distribution” and “Thrombopenia”
Histogram: PLT number was very low and indices not reported
Scattergram: there was an cluster of spots in the immature cell area;
the monocyte spots mixed with the granulocyte spots while the
lymphocyte spots were clearly differentiated, which indicated that
the granulocyte and monocyte morphs were abnormal, so
microscopic examination was suggested
Microscopic Differential
WBC DIFF BlastPromyelocyteMyelocyteMetamyelocytePromonocyteNeutrophilic bandgranulocyte Neutrophilic segmented granulocyte Lymphocyte MonocyteNRBC
RBC morph PLT morph
Under microscope, a large number of promyelocytes and premonocytes
were observed, as well as active phagocytes. In the microscope field
shot, there were three leukocytes: promonocyte, promyelocyte and
blast.
Male, 30-year-old. Chief complaints: hypodynamia and pyrexia for 1 month; pain in left hip for 1 day.
(n=200)20%15%
4%4%
14%
3%
14%14%12%
5/100
NormalNormal
27 28
AM
Mo
L
Monoblast
Promonocyte
Promyelocyte
Acute Megakaryocytic Leukemia (AMKL) is a rare kind of
leukemia. Its clinical symptoms are similar to other types of
acute leukemias. Micromegakaryocytes that look like lym-
phocytes can be observed in blood smear; in marrow smear,
the abnormal proliferation of megakaryocytes can be found
with the count of megakaryocytes over 1000, among which
megakaryoblasts and promegakaryocytes are prominant.
A large number of immature cells which resembled lymphocytes (could
be megakaryoblasts or promegkaryocytes) were observed under
microscope. In the microscope field shot on this page, there were two
megakaryocytes.Report Analysis:
WBC count increased and RBC and PLT count decreased
WBC flag message: ” WBC Abn scattergram”
RBC flag messages: ”RBC Distribution Abn.” and “Anemia”
PLT flag messages: “PLT Abn. Distribution” and “ Thrombopenia”
Histogram: PLT number was low and indices reported with low
reliability
Scattergram: there was an cluster of spots in the immature cell area,
and the abnormal spots were on the top right; the monocyte spots
mixed with the granulocyte spots while the lymphocyte spots were
clearly differentiated
Female, 71-year-old. Chief complaints: hypodynamia and dazziness for half a year. Physical examination results: anemic appearance; with scattered petechiae on skin; bleeding observed on the left of oral mucosa, no superficial lymphnodes discovered by physical exam.
Microscopic Differential
29 30
WBC DIFF BlastMyelocyteMetamyelocyteImmature cell Neutrophilic bandgranulocyte Neutrophilic segmented granulocyte Lymphocyte MonocyteBasophil
RBC morph PLT morph
(n=200)10%
1%2%
30%
4%
25%24%
3%1%
NormalNormal
AM
KL
Megakayocyte
Chronic myelocytic leukemia (CML) is a clonal proliferative
disease which originates from the hematopoietic stem cells
with primary changes in myelocyte proliferation. The disea-
se is typically diagnosed in individuals aged between 20 and
50. One of the most distinctive features is enlarged or swoll-
en spleen. From the cytogenetic perspective, a positive CML
diagnosis is confirmed when the test for Philadelphia chro-
mosome is positive and the BCR/ABL fusion gene is detected.
Promyelocytes were seen under microscope. Basophil number increa-
sed significantly. In the microscope field shot on this page, there were
one neutrophilic segmented granulocyte and one
.
neutrophilic band
granulocyte
Report Analysis:
The number of basophil increased, and immature cells were observed,
which indicated a possibility of chronic myelocytic leukemia
WBC flag messages: ” Immature Cell?”, “Abnormal/Atypical Lym?” and “
Basophilia”
RBC flag messages: ”Anisocytosis” and “Macrocytosis”
Scattergram: there were a few spots scattered in the immature cell
area and the abnormal/atypical lymphocyte area which indicated an
abnormal WBC morph, so microscopic examination was suggested
Microscopic Differential
Male, 32-year-old. Chief complaint: leucocytosis for 2 years. Physical examination result: Normal. Bone marrow examina-tion result showed a possibility of chronic myelocytic leuke-mia.
31 32
WBC DIFF MyelocyteMetamyelocyteNeutrophilic bandgranulocyte Neutrophilic segmentedgranulocyte Lymphocyte Atypical lymphocyteMonocyte Basophil
RBC morph PLT morph
(n=200)1%1%
2%
46%37%
1%8%4%
Macrocytes presentNormal
CM
L
Neu
Band