The Complete Blood Cell Count (CBC)

CBC – Part 2
WBC Differential Count and Morphology

A Clinical Pathology 201 Study Module

by
Carolyn Sue Walters, MHS, MT(ASCP)
Department of Pathology
School of Medicine
Louisiana State University Health Sciences Center
New Orleans, Louisiana
DO NOT REPRODUCE THIS EXERCISE.
©01-07-03 click here to continue
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C. Sue Walters, MHS, MT(ASCP)

Associate Professor
Department of Pathology
LSU Health Sciences Center
New Orleans, LA

click here to continue

 csw
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2001 The CBC
This study exercise is the property of Carolyn Sue
Walters, MHS, MT(ASCP) and the Department of
Pathology, LSU Health Sciences Center in New Orleans,
LA. All rights are reserved. It is intended for use solely
within the LSUHSC campus network. No part of this
exercise may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means (to include but
not be restricted to electronic, mechanical, recording, and
photo-copying) without prior written permission from the
author.

click here to continue

 Special Acknowledgment
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Special thanks is given to Ms. Angela Foley,

MS, MT(ASCP), Department of Clinical
Laboratory Sciences, LSUHSC School of
Allied Health in New Orleans, LA for the use of
some of her images of blood cells and for her
assistance in the art of creating image files.

click here to continue

 The CBC
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This is the second module of a 4-part study exercise

regarding the CBC. The 4 parts are entitled:
CBC – Part 1 The hemogram

CBC – Part 2 WBC differential & blood morphology

CBC – Part 3 RBC morphology & platelet estimate
CBC – Part 4 Post-test

The review of hematopoiesis and blood cell morphology

(i.e., Hematology Atlas located on the LSUHSC server) is
recommended as a prerequisite for the CBC exercise.

click here to continue

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2001 Feedback
Feedback as to the quality and usefulness of
this exercise is solicited and suggestions for
improvement are welcomed. Please forward
your remarks by E-mail [email protected]

or via US MAIL:
C. Sue Walters, MHS, MT(ASCP)
LSUHSC Department of Pathology
1901 Perdido Street
New Orleans, LA 70112

click here to continue

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Directions

The directions for navigating through the exer-

cise are given on the next 3 pages. They are the
same as those used in the other modules of this
5-part exercise. Click on:

to visit the directions before continuing

with the exercise.
or
to go directly to the Main Menu.
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Directions, continued
The following directional icons are provided
throughout the exercise for your convenience.
You can click on:
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in the upper left hand corner of every page to
2001 return to the previous page

menu in the upper right corner of the page to

return to the Main Menu selection.

click here to continue

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Directions, continued

You can click on:

in the lower right corner of the page

to continue.

in the lower right corner of the Main Menu

page to Quit (i.e., end the exercise).
Quit
 Directions, continued
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“Hot points” (symbols, words, phrases) have

been inserted on the pages as navigational
tools and can be identified by their “gold”
color. If it’s “gold”, click on it to move to the
next text/data entry. Also, sounds have been
added in a few places for emphasis.
Caution, failure to follow the structured order
of the “hot points” may result in confusion. If
you use the mouse without placing the cursor
directly on the “hot point” , you may skip over
vital information.
Remember, if it’s gold, click on it. Try it!
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2001 Special Comments
This exercise has numerous images. You may
note that, when a page contains images, there
may be a rather long delay before you regain
control of the cursor. Please be patient. I think
you will find the images are worth the wait.
NOTE:
Some animation and/or interactive affects may
be lost if you attempt to replay a page by re-
turning to the previous page and then advanc-
ing to that page again.

Now, click on the gold to begin.

 CBC - Part 2
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The Complete Blood Cell Count (CBC)

Part 2
WBC Differential Count & Morphology
 MAIN MENU
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Introduction & Review of WBC Morphology

Manual differential WBC count

Total WBC count vs. differential WBC count

Relative % vs. absolute number

Review: mature & immature WBC; non-
neoplastic WBC alterations; neoplastic
WBC alterations

Quit
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Introduction & Review

of WBC Morphology
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2001 WBC distribution & morphology

Evaluation of the distribution and morphology

of white blood cells is one of the most valuable
procedures used in examination of the blood.
The information obtained may furnish the
diagnosis, serve as a guide to therapy and as
an indicator of harmful effects of radiotherapy
and chemotherapy.
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2001 continued

A study of white blood cell morphology and

distribution of blood cells is an essential
part of the clinical description of practically
every disease. A normal number and
distribution of cells in the blood are so
important as physiologic constants that
some authorities say the absence of
disease cannot be determined until this
information is available.
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lsuhsc What WBC are present in normal
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peripheral blood?
In normal peripheral blood, there are three basic
types of leukocytes (illustrated below).
1. granulocytes 2. lymphocytes
neutrophils normal atypical (few)
mature
band

eosinophils basophils 3. monocytes

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2001
associated with disease?
An abnormal number and/or distribution of leuko-
cytes (WBC) may be seen in disease. Immature
WBC and/or WBC with abnormal alterations may
also be seen. The immature and abnormal cells
are distinguishable from normal cells by their
morphologic characteristics.

Recognition and identification of these abnormal-

ities play a major role in the diagnosis and treat-
ment of true blood diseases and numerous other
pathologic processes.
continue
Review immature and abnormal WBC or w/o review
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2001 Examples of immature WBC:
granulocytes
(various stages)

myeloblasts

lymphoblasts

monoblasts
 csw Examples of granulocytes in menu
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2001 various stages of maturation:
late myeloblast or 6 5
1
early promyelocyte 4 6 7
2 late promyelocyte 5 3 2
or early myelocyte
3 myelocyte
4 metamyelocyte 4 4
5
5 band neutrophil

6 mature segmented
4 1
neutrophil (PMN)
8 5
7 eosinophil 5
3 4
8 Whoa! That’s not a WBC. It’s a nucleated RBC but
will also be included in the total WBC count.
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Now, Can you Identify the stages of
2001 granulocytes just illustrated?
6 5
1 late myeloblast or
early promyelocyte 4 6
7
2 late promyelocyte 5 3
2
or early myelocyte
3 myelocyte 4
4 metamyelocyte 4
5
5 band neutrophil

6 mature segmented
4 1
neutrophil (PMN) 5
8
5
7 eosinophil
3 4

8 NRBC
 csw Overview of the stages of granulocytes menu
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2001 just illustrated:
6 5
1 late myeloblast or
early promyelocyte 4 6
7
2 late promyelocyte 5 3
2
or early myelocyte
3 myelocyte 4
4 metamyelocyte 4
5
5 band neutrophil

6 mature segmented
4 1
neutrophil (PMN) 5
8
5
7 eosinophil
3 4

8 NRBC
review granulocytes again or continue
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Another look at the granulocytes just
2001 illustrated:
6 5
1 late myeloblast or
early promyelocyte 4 6
7
2 late promyelocyte 5 3
2
or early myelocyte
3 myelocyte 4
4 metamyelocyte 4
5
5 band neutrophil

6 mature segmented
4 1
neutrophil (PMN) 5
8
5
7 eosinophil
3 4

8 NRBC
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non-neoplastic alterations:
neutrophils lymphocytes
in bacterial in megaloblastic in viral
infections anemias infections

with reactive
with with nuclear
(atypical) changes
Dohle bodies hypersegmen-
and/or tation (ie, > 5
toxic granulation lobes)
inherited disorders
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non-neoplastic alterations:
Pelger-Huet Anomaly May-Hegglin Anomaly

hyposegmented nuclei cytoplasmic blue bodies

Alder-Reilly Anomaly Chediak-Higashi Syndrome

cytoplasmic black granules cytoplasmic large

black granules
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menu
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alterations:
hairy cell leukemia

&
hairy cell lymphocytes

acute myelocytic leukemias

myeloblasts w/ Auer rod(s)

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lsuhsc What can be learned from a
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differential WBC count?
Because the total WBC count does not differen-
tiate WBCs as to cell lines, a differential WBC
count (“diff”) is performed to provide informa-
tion regarding the frequency distribution of
WBCs and to identify increases or decreases
when they occur in one or more of the cell lines.
A morphologic study of the various blood cells
(i.e., WBC, RBC, & platelets) is made during the
differentiation process to detect and identify
atypical and/or abnormal cells.
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lsuhsc What methods can be used for the
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differential WBC count ?

The differential WBC count and blood cell study

may be performed by one of several methods, e.g.:
• A manual microscopic examination of a Wright’s
(or Wright’s Giemsa) stained peripheral blood
smear.
OR
• An automated multi-channel instrument (in
this exercise, it is a Coulter STK-S 5-part
differential), which is discussed in the auto-
mated CBC section.
 End of Introduction
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This concludes the Introduction to the Differential

WBC Count. Select one of the following:

Go to Manual Differential WBC Count, the next

section, to continue with the exercise as
designed.
OR

Return to the Main Menu and make an alternate

selection.
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Manual Differential WBC Count

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2001 What kind of blood smear is used ?

A peripheral blood film (made from a drop of

blood from an EDTA anticoagulated tube or
skin puncture) is stained with Wright (or
Wright-Giemsa) stain and microscopically
examined using scanning (10x), high-dry
(40x), and oil (100x) objectives.

Refer to the Clinical Pathology 202 Course

Manual for the complete procedure.
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lsuhsc What studies will be performed on the
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stained blood smear?
A complete differential WBC count (“diff”) which
includes identification of mature and (if any)
immature WBC and description of WBC morph-
ologic alterations.
A complete description of RBC morphology
which includes (if any) a description of RBC
morphologic alterations and, if present, the
number of NRBC per 100 WBC.
Platelet estimate of adequacy which includes
(if any) abnormal morphologic alterations,
distribution, and clumps.
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2001 continued:

This section is limited to the differential count

and morphology of white blood cells.

RBC morphology and platelet estimate discus-

sions are addressed later in other sections.
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lsuhsc How are the WBC identified and
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classified?
Typical nuclear and cytoplasmic morphologic
features provide a means by which WBC can be
identified and classified as to:

• cell line (i.e., granulocytes [neutrophils, eosino-

phils, or basophils], lymphocytes, or mono-
cytes)
• maturity (i.e., mature cell or specific immature
stage of development).
• abnormal morphology (i.e., nuclear or cyto-
plasmic alterations)
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How are the WBC differentiated and
enumerated?
At least 100 WBC are counted and a tabulation is
made as to the number of each leukocytic cell
type included in the count.

The 100 cell count provides the RELATIVE

number (or percent) of each white blood cell
type present in the peripheral blood.
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2001 How can you determine whether there is
an increase or decrease of one or more
of the cell lines?

Increases or decreases in a white blood cell line

(or type) can then be determined by comparing
the number obtained on the differential count
with established reference ranges.
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Reference Range (Relative %)
Reference ranges (values considered to be normal)
for differential WBC counts may vary among
laboratories, but are usually about:

segmented band eosinophils lymphocytes monocytes

neutrophils neutrophils 1-5% 20-40% 1-6%
50-70% 0- 5%
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2001 What terminology is used to indicate an
increased or decreased number of a
specific white blood cell line?

Cell Line Increased: Decreased:

Neutrophils Neutrophilia Neutropenia
Lymphocytes Lymphocytosis Lymphocytopenia

Monocytes Monocytosis Monocytopenia

Eosinophils Eosinophilia Eosinopenia

Basophils Basophilia Basopenia

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Review Morphology?

Review WBC morphology

or

continue without review

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PMN band eosinophil basophil

(neutrophils)

monocyte lymphocyte ATL (few)

(atypical lymphocyte)
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menu
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Examples of immature WBC:
granulocytes
(various stages)

myeloblasts

lymphoblasts

monoblasts
 csw Examples of granulocytes in menu
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2001 various stages of maturation:
late myeloblast or 6 5
1
early promyelocyte 4 6 7
2 late promyelocyte 5 3 2
or early myelocyte
3 myelocyte
4 metamyelocyte 4 4
5
5 band neutrophil

6 mature segmented
4 1
neutrophil (PMN)
8 5
7 eosinophil 5
3 4
It’s a nucleated RBC but will also be included
8
in the WBC count.
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non-neoplastic alterations:
neutrophils lymphocytes
in bacterial in megaloblastic in viral
infections anemias infections

with reactive
with with nuclear
(atypical) changes
Dohle bodies hypersegmen-
and/or tation (ie, > 5
toxic granulation lobes)
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2001
non-neoplastic alterations:
Pelger-Huet Anomaly May-Hegglin Anomaly

hyposegmented nuclei cytoplasmic blue bodies

Alder-Reilly Anomaly Chediak-Higashi Syndrome

cytoplasmic black cytoplasmic large

granules black granules
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menu
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alterations:
hairy cell leukemia

hairy cell lymphocytes

acute myelocytic leukemias

myeloblasts w/ Auer rod(s)

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2001
various stages of maturation.
proerythroblast basophilic erythroblast
(ill-defined or absent nucleoli)
(earliest form w/ nucleoli)

orthochromatophilic
erythroblast polychromatophilic
(last stage before extrusion erythroblast
of nucleus) (cytoplasmic evidence of HGB)
 End of Manual Differential
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WBC Count & Morphology

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This concludes the Manual WBC Differential

Count and Morphology section. Select one of the
following:

Go to Total WBC Count vs. Differential WBC

Count, the next section, to continue with the
exercise as designed.
OR
Return to the Main Menu and make an alternate
selection.
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Total WBC Count

vs.
Differential WBC Count
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2001 How does the differential WBC count
differ from the total WBC count?

The total WBC count reflects the total number of

all leukocytes in circulation but does not differ-
entiate leukocytes as to their various cell lines
(e.g., neutrophils, lymphocytes), stage of matur-
ity, (e.g., band, metamyelocyte), or abnormalities
when present (e.g., toxic granulation, hyperseg-
mented nuclei).

A differential WBC count must be performed to

provide that information.
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lsuhsc Total WBC count = total number of
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leukocytes without differentiation:
 csw menu
lsuhsc “Diff” - differentiates and enumerates
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WBC according to cell type, e.g.:

neutrophils, mature
lymphocytes
monocytes
eosinophils
basophils
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“Diff” - provides frequency distribution menu
2001 (relative % and absolute number/mL, e.g.
total WBC = 10,000/mL):
lymphocytes
neutrophils, mature eosinophils
28% 2800/mL
65% 6500/mL 3% 300/mL

basophils
1% 100/mL

monocytes
3% 300/mL
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lsuhsc Total WBC count - mature and (if present)
2001
immature WBC w/o differentiation, e..g.:

blast myelocyte
promyelocyte
metamyelocyte
band
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“Diff” - differentiates and enumerates mature
and (if present) immature WBC, e.g.:
mature

neutrophil eosinophil basophil lymphocyte monocyte

immature

blast promyelocyte myelocyte metamyelocyte

neutrophilic
band
 csw menu
lsuhsc “Diff” - provides frequency distribution (relative %
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and absolute number e.g., total WBC=50,000/mL):

neutrophil, mature blast

50% 25000/mL 1% 500/mL

neutrophil, bands eosinophil

15% 7500/mL 5% 2500/mL

metamyelocyte basophil
12% 6000/mL 3% 1500/mL

myelocyte lymphocyte
7% 3500/mL 5% 2500/mL

promyelocyte, monocyte
2% 1000/mL 0% 0/mL
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lsuhsc Total WBC count - normal and abnormal menu
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WBC without differentiation, e.g.:
acquired WBC alterations
 csw
lsuhsc “Diff” - differentiates abnormal WBC menu
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with acquired alterations, e.g.:
toxic hypersegmented neutrophils
granulation
Dohle bodies

reactive/atypical lymphocytes
 csw
lsuhsc Total WBC count - normal and abnormal menu
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WBC without differentiation, e.g.:
inherited WBC alterations
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with inherited alterations, e.g.:
Pelger-Huet
May-Hegglin
Alder-Reilly
Anomaly
AnomalyAnomaly

Chediak-Higashi Syndrome
 csw
lsuhsc Total WBC count - normal and (if pre- menu
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sent) neoplastic WBC w/o differentiation:
e.g., leukemic alterations
 csw
lsuhsc “Diff” - differentiates WBC with menu
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neoplastic alterations, e.g.:
hairy cell lymphocyte or myeloblast w/ Auer rod
 End of Total vs. Differential
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WBC Counts
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This concludes the Introduction to the Differential

WBC Count. Select one of the following:

Go to Relative % vs. Absolute Number, the next

section, to continue with the exercise as
designed.
OR

Return to the Main Menu and make an alternate

selection.
 csw menu
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Relative % vs. Absolute Number

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lsuhsc What is meant by the relative % and
2001
absolute number of WBC ?

Relative % is based on the differential count of

100 white blood cells and reflects the per cent
of each cell type present in circulation.

If the total number of white cells in circulating

blood is known and the relative per cent of each
white cell type is known, then the absolute
number of each cell type per mL of blood can be
calculated.
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2001 continued:

For example: given a patient with a total WBC

count of 8,000/mL and the differential WBC count
shown below (i.e., the number observed for each
cell type in the 100 white cell count):

Segmented neutrophils 60%

Band neutrophils 5%
Lymphocytes 30%
Monocytes 2%
Eosinophils 2%
Basophils 1%
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2001 continued:

Then the absolute number of each cell type/mL

can be calculated by multiplying the per cent of
each cell type by the total number of WBC/mL.

Segmented neutrophils 60% x 8,000 = 4,800

Band neutrophils 5% x 8,000 = 400
Lymphocytes 30% x 8,000 = 2,400
Monocytes 2% x 8,000 = 160
Eosinophils 2% x 8,000 = 160
Basophils 1% x 8,000 = 80
Total = 100% = 8,000
 csw menu
lsuhsc What are the relative reference ranges
2001
for leukocytes?
Cell Type Reference Ranges (Relative %)

Neutrophils 40-72 0-5

(PMN) (bands)

Eosinophils 0-6

Basophils 0-0.2

Lymphocytes 24- 45

Monocytes 0.4 - 10
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lsuhsc Do the relative values always indicate
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which cell line is or ?

If the total WBC count is “normal” (i.e., within

the established reference range), the relative
values are a good reflection of the number of
each cell type present, including increases or
decreases.

However, if the total WBC count is abnormal

(i.e., increased or decreased), the relative
percentage must be converted to an absolute
number of each cell type present in order to
determine which cell line is involved.
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lsuhsc How is the relative % converted to an
2001
absolute number ?

For each white blood cell line, multiply the

percentage of cells counted (i.e., during the 100
cell count) by the total white blood cell count to
obtain the absolute number for the cell line.

Total WBC/mL x relative % = absolute no./mL

For example:
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lsuhsc
2001 Given a patient whose total WBC is 8,000/mL,

and the relative distribution of leukocytes on

the peripheral blood smear is as shown below:

segmented band eosinophils lymphocytes monocytes

neutrophils neutrophils 2% 25% 3%
65% 5%

How are the absolute numbers determined?

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2001 How are the absolute numbers calculated
(total WBC = 8,000/mL)?
Cell Type Relative % Absolute No.
65 (8,000 x 0.65) 5,200/mL

Neutrophil (mature segmented)

5 (8,000 x 0.05) 400/mL

Neutrophil (band)
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lsuhsc continued:
2001
Cell Type Relative % Absolute No.

2 (8,000 x 0.02) 160/mL

Eosinophil

25 (8,000 x 0.25) 2,000/mL

Lymphocyte

3 (8,000 x 0.03) 240/mL

Monocyte
 csw menu
lsuhsc Total WBC 8,000/mL x Relative %:
2001
Cell Type Relative % Absolute No.
Neutrophil 65 5,200/mL
(mature segmented)
Neutrophil (band) 5 400/mL

Eosinophil 2 160/mL

Lymphocyte 25 2,000/mL
Monocyte 3 240/mL

Total 100 8,000/mL

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lsuhsc What are the absolute reference ranges
2001
for leukocytes?
The total WBC count reference range for adults is 4,500-
11,000/mL at Charity & University Hospitals, but may vary
slightly among laboratories:
Reference Ranges
CELL TYPE RELATIVE % ABSOLUTE NO./mL
Segmented neutrophils 42 - 72 1800 - 8000
Neutrophilic bands 0-5 0 - 550
Eosinophils 1-6 45 - 550
Basophils 0 – 0.2 0 - 200
Lymphocytes 24 - 45 1100 - 5000
Monocytes 0.4 - 10 200 - 1100
 csw menu
lsuhsc In this case, did the relative per cents
2001
reflect the absolute numbers ?
The total WBC count was within the reference
range.
The relative per cent for each cell type was
within reference range.

Therefore, because both the total and relative

frequencies are within reference ranges, the
relative % is a reflection of the absolute
numbers in terms of normal or abnormal.
 csw menu
lsuhsc
2001
However, given a patient whose total
WBC is 15,000/mL,
with a relative distribution of leukocytes
on the peripheral blood smear the same
as the previous patient:

segmented band eosinophils lymphocytes monocytes

neutrophils neutrophils 2% 25% 3%
65% 5%

Is the interpretation the same for both patients?

 csw menu
lsuhsc What are the calculated absolute
2001
numbers in this case (i.e., total
WBC = 15,000/mL)?
15000 x 0.65 = 9750 segmented neutrophils
15000 x 0.05 = 750 band neutrophils
15000 x 0.02 = 300 eosinophils
15000 x 0.25 = 3750 lymphocytes
15000 x 0.03 = 450 monocytes
The relative per cents are normal, but how do
these absolute numbers compare with the
established reference ranges?
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lsuhsc Are the absolute numbers still within
2001 the reference ranges?
Absolute No./mL
Cell Type Patient Reference Ranges
Neutrophils (mature) 9750 H 1800 - 8000
Neutrophils (bands) 750 H 0 - 550
Eosinophils 300 0 - 600
Lymphocytes 3750 1100 - 5000

Monocytes 450 200 - 1100

 csw menu
lsuhsc Comparison of relative %
2001 and absolute numbers:
Cell Type Relative % Absolute No.
Neutrophil 65 N H 9,750/mL
(mature segmented)
Neutrophil (band) 5 N H 750/mL

Eosinophil 2 300/mL

Lymphocyte 25 3,750/mL
Monocyte 3 450/mL

Total 100 15,000/mL

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lsuhsc Do the relative and absolute values have
2001 the same interpretation in this case?

The relative percentages for all cell types for this patient
were within the reference range (i.e., normal).

However, in this case, there is neutrophila when

converted to absolute numbers based on a total WBC
count of 15,000/mL because:

 segmented (mature) neutrophils = 9,750/mL

which exceeds the reference range (1800 - 8000/mL)

 band neutrophils = 750/mL which also exceeds the

reference range (0 - 550/mL).
 csw menu
lsuhsc Given another patient whose total
2001
WBC is 15,000/mL,
and a relative distribution of
leukocytes on the peripheral blood
smear as shown below:

segmented band eosinophils lymphocytes monocytes

neutrophils neutrophils 2% 15% 3%
75% 5%

How are these data interpreted?

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lsuhsc How are the absolute numbers
2001
calculated (total WBC = 15,000/mL)?
Cell Type Relative % Absolute No.
75 (15,000 x 0.75) 11,250/mL

Neutrophil (mature segmented)

5 (15,000 x 0.05) 750/mL

Neutrophil (band)
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2001

Cell Type Relative % Absolute No.

2 (15,000 x 0.02) 300/mL

Eosinophil

15 (15,000 x 0.15) 2,250/mL

Lymphocyte

3 (15,000 x 0.03) 450/mL

Monocyte
 csw menu
lsuhsc Total WBC 15,000/mL x Relative %:
2001
Cell Type Relative % Absolute No.
Neutrophil 75 H H 11,250/mL
(mature segmented)
Neutrophil (band) 5 N H 750/mL

Eosinophil 2 N N 300/mL

Lymphocyte 15 L N 2,250/mL

Monocyte 3 N N 450/mL

Total 100 15,000/mL

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lsuhsc Do the relative and absolute values
2001
have the same interpretation?

According to the relative percentages, this

patient had increased neutrophils (neutrophilia)
and decreased lymphocytes (lymphocytopenia).

When converted to absolute numbers based on

a total WBC count of 15,000/mL,
• there is indeed neutrophilia (11,250/mL) which
exceeds the reference range (11 - 5000/mL)
• but the number of lymphocytes (i.e., 2,250/mL)
is within the reference range (1000-5000/mL).
 csw menu
lsuhsc What if the patient’s total WBC is
2001
decreased? For example…

If a patient’s total WBC count is 2,500/mL and the

following relative distribution is found on the
differential WBC count, what interpretation can
be made regarding increased or decreased cell
lines?

50% 50%

neutrophils lymphocytes
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2001
How are these data interpreted?
According to the relative reference ranges (i.e.,
neutrophils 40-72% and lymphocytes 24-45%),
the relative values for:
• Neutrophils (50%) were within “normal” range.
• Lymphocytes (50%) were increased.

50%
50%

neutrophils lymphocytes

Does this patient have lymphocytosis?

 csw menu
lsuhsc What was your evaluation?
2001
When evaluated with the total WBC count of
2500/mL, the absolute numbers are:
1250/mL 1250/mL

neutrophils lymphocytes
If you responded yes (i.e., lymphocytosis), you were
wrong. The patient has neutropenia. Although the relative
% of PMN is “normal”, the absolute number (1250/mL) is
less than the lower limit of “normal” 1800/mL).

Also, even though the relative % for lymphocytes is

increased, the absolute number (1250/mL) is within
“normal” range (1100 - 5000/mL).
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2001

Summary of relative % vs. absolute number:

An increase or decrease in a cell line is determined by

the absolute number of that type of cell in circulating
peripheral blood. To determine the absolute number,
the total WBC count and frequency distribution must
be determined.

Relative % is reliable as an indicator of normal only

if both the percent and the total number of WBC are
within normal.
 End of Relative %
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vs. Absolute Number

2001

This concludes the Introduction to the Differential

WBC Count. Select one of the following:

Go to Review of White Blood Cell Morphology,

the next section, to continue with the exercise
as designed.
OR

Return to the Main Menu and make an alternate

selection.
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lsuhsc
2001

Review of WBC Morphology

 csw menu
lsuhsc What other study of WBC is
included in a “diff”?
2001

In addition to the differential WBC count, the

leukocytes are examined as to maturity and
morphology.

Are immature cells present? Do the cells show

abnormal acquired or inherited morphologic
alterations?
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2001
E.g., are the WBC mature or immature?

mature cells or immature neutrophils

 csw For example, if the mature and immature menu
lsuhsc
2001 cells shown in the example “diff” were
present in the percentage shown below:
2%
2%

70%
3%
3%

20%
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2001
What leukocytic cells can be identified?
mature immature
2% 2%
eosinophil myelocyte
PMN
3%
70%
metamyelocyte

3%
20%
lymphocyte band neutrophil
 csw menu
lsuhsc Are the immature cells shown in the
2001 example ever seen in normal blood?

band neutrophil (normally

3%
may be present in blood up
to about 5%)

neutrophilic metamyelocyte
3% (are not normally present in
blood)

2% neutrophilic myelocyte (are

not normally present in
blood)
 csw menu
lsuhsc Examples of acquired non-neoplastic
2001
alterations that can be differentiated on a
“diff”, e.g.?

neutrophil with Dohle bodies

and toxic granulation

5
4 6
3 7
2 1 hypersegmented neutrophil

atypical/reactive lymphocyte
 csw menu
lsuhsc Examples of inherited abnormal non-
2001 neoplastic alterations of neutrophils that
can be differentiated on a “diff”.

hyposegmented neutrophil cytoplasmic blue bodies in

in Pelger-Huet anomaly May-Hegglin anomaly

cytoplasmic large black granules cytoplasmic black granules in

in Chediak-Higashi syndrome Alder-Reilly anomaly
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menu
2001
Examples of neoplastic WBC alterations
that can be differentiated on a “diff”:

hairy cell lymphocytes seen in

hairy cell leukemia

Auer rods seen in some variants

of acute myelocytic leukemias
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Are cell types other than WBC differ- menu
2001 entiated and enumerated as part of the
“diff”?
Although NRBC are not included in the 100 white blood
cell count, identification and enumeration of the number of
NRBC/100 WBC is a part of the information provided by a
“diff”. For example, the number of

proerythroblast
basophilic
erythroblast

orthochromatophilic polychromatophilic
erythroblast erythroblast
 End of CBC - 2
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2001

This concludes the CBC – Part 2 segment

of the study module, “The Complete Blood
Cell Count (CBC)”.

Click on Main Menu to review a section.

OR

Click on to quit the exercise.

 THE END
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2001

Additional modules of the CBC are presented in:

CBC – Part 1 The hemogram

CBC - Part 3 RBC morphology & platelet estimate

CBC – Part 4 Post-test

Review of “Hematology Atlas”, a module on normal and

abnormal blood cell morphology and maturation is
recommended as a prerequisite for the CBC modules.

quit