FOCUS: IN TERPRETING T HE COMPLETE BLOOD CO UNT

A Methodical Approach to Interpreting the White

Blood Cell Parameters of the Complete Blood
Count
KATHY DOIG, LESLIE A. THOMPSON

L EAR NI NG OB J ECTI VES terminology.

1. List the white blood cell parameters of the 4. If absolute counts are not available from an
complete blood count. instrument, use relative counts (i.e. percentages)

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2. Describe the principle of analysis for each of the to calculate absolute values.
white blood cell parameters of the complete blood 5. Make note of immature cells in any leukocyte
count. cell line reported in the differential that should
3. Recognize instances in which the white blood cell not appear in normal peripheral blood.
count may be spurious and require technical or 6. Make note of any morphological abnormalities
mathematical correction before reporting. of wbcs.
4. Apply appropriate techniques to spurious white 7. Correlate the wbc findings with red blood cell
blood cell counts to achieve valid counts. and platelet findings for a complete clinical
5. Given relative differential counts and total white assessment of the patient’s blood picture.
blood cell count, calculate absolute white blood cell
Explanations for conducting the evaluations are provided
differential counts.
and the above steps are applied to example cases to
6. Use proper terminology to describe elevations and
demonstrate how this approach is used to interpret the
decreased of white blood cell numbers and
wbc parameters of the CBC.
differential cell counts.
7. Given the white blood cell parameters of a complete AB B R EVI ATI ONS: CBC - complete blood count, dL-
blood count, apply a methodical approach to deciliter, fL-femtoliter, g-gram, NRBC-nucleated red
interpretation of the results for diagnostic and blood cell, rbc-red blood cell, RNA-ribonucleic acid,
clinical purposes. wbc-white blood cell, WBC-white blood cell count, µL-
microliter
AB STR ACT
Consistent use of a methodical approach to interpreting I NDEX TER MS: Leukocyte counts, differential
complete blood count (CBC) results can help detect leukocyte count, white blood cell count
spurious results that require remedy before results are
reported. It can also help ensure that no clinically Cl i n L a b S c i 2 0 1 7 ; 3 0 ( 3 ) : 1 8 6
important information is overlooked during diagnostic
interpretation of the results. The steps for interpreting Kathy Doig, PhD, MLS(ASCP)CM SH(ASCP)CM, Professor
the white blood cell portion of the CBC are: Emeritus, Biomedical Laboratory Diagnostics Program,
Michigan State University, E. Lansing, MI
1. Ensure that nucleated red blood cells or other
conditions are not falsely affecting the white Leslie A. Thompson, MS, MLS(ASCP)CM, Graduate
blood cell count (WBC); correct the WBC if Clinical Placement Coordinator, College of Nursing,
needed, before proceeding. Michigan State University, E. Lansing, MI
2. Examine the WBC for variations in the total
number of white blood cells. A d d ress fo r C o rresp o n d en ce: K a th y D o ig , P h D ,
3. Interpret absolute differential counts against MLS(ASCP)CM SH(ASCP)CM, 354 Farm Lane, Rm.
appropriate reference intervals using proper N322, E. Lansing, MI 48824,517-353-1985, doig@msu.
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 FOCUS: INTERPRETING THE COMPLETE BLOOD COUNT

edu or other conditions are not falsely affecting the WBC;

correct the WBC if needed, before proceeding.
I NTRODUCTI ON
Though a complete blood count (CBC) is ordered as a Table 1. Steps for interpreting the white blood cell parameters of
single test, it is a battery of multiple tests and calculations a complete blood count.
Step 1. Ensure that NRBCs or other conditions are not falsely
that collectively assess the cellular elements of the blood:
affecting the WBC; correct the WBC if needed, before
red blood cells (rbcs), white blood cells (wbcs) and proceeding.
platelets. Clinical interpretation of the CBC requires that Step 2. Examine the WBC for variations in the total number of
all results be evaluated thoroughly since some patient wbcs.
conditions will affect all cell lines. However, it is helpful Step 3. Interpret absolute differential counts against appropriate
reference intervals using proper terminology.
to review the multiple results for each of the cellular Step 4. If absolute counts are not available from an instrument,
elements separately, correlating within that group of use relative counts (i.e. percentages) to calculate absolute
tests, before a comprehensive assessment is completed. values.
This article will focus on a method for interpreting the Step 5. Make note of immature cells in any leukocyte cell line

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reported in the differential that should not appear in
results of the wbc-related assays.
normal peripheral blood.
Step 6. Make note of any morphological abnormalities of wbcs.
The method recommended here differs from commonly Step 7. Correlate the wbc findings with rbc and platelet findings
published diagnostic algorithms in that it incorporates for a complete clinical assessment of the patient’s blood
strategies for laboratorians to detect invalid results so they picture.
can be corrected before clinical interpretation.
Furthermore, there is an emphasis on translation of The lysing solution used in WBC counting on some
numerical data into a narrative description that is more instruments removes rbcs leaving only nucleated cells for
easily communicated. This is especially helpful for counting. Under normal circumstances, only WBCs
laboratory science students since it does not make prior remain intact for counting. However, NRBCs also resist
assumptions about the reader’s vocabulary. lysis and thus are counted with the wbcs when present,
falsely elevating the WBC. Modern instruments are able
The sequencing of the steps below is not necessarily fixed. to identify NRBCs and subtract them from the WBC
However, the consistent use of Step 1 as the first step value, thus ensuring that the WBC represents only wbcs,
ensures that the white blood cell count (WBC) is as intended. In instances when an instrument-corrected
accurate and not falsely affected by spurious results. With WBC value is not available, a manual correction must be
an inaccurate WBC, all other conclusions that follow will applied.
be inaccurate. Many modern instruments will recognize
and automatically correct for some interferences so that The method for manual correction of a WBC involves
an accurate WBC can be reported. Once an accurate counting the number of NRBCs encountered while
WBC is assured, evaluating the total WBC (Step 2), is a conducting a microscopic 100-cell wbc differential
sensible starting place for thorough interpretation of the count. That value is reported as NRBCs/100 wbcs. Most
results. The steps that follow are then logical. It is laboratories will not correct the WBC until the number
important that no parameter is overlooked since the of NRBCs encountered creates a meaningful difference
reported parameters provide related, but different, in the WBC. Thus, the protocols typically direct that the
information for quality control assessment and patient WBC be corrected when there are, for example, 10 or
diagnosis. The white blood cell portion of the CBC more NRBCs/100 wbcs, thus allowing for up to a 10%
includes the WBC and the wbc differential count error in the count. More stringent limits can be set and
(relative and absolute values, and morphological are particularly important for lower WBCs.1 Institutional
evaluation, if justified). The steps to interpreting the protocol should be followed in all instances.
WBC are presented in Table 1.
The WBC must be corrected for NRBCs when two
U sin g th e S te p s fo r th e In te rp re ta tio n o f W h ite B lo o d conditions are met: 1) the differential was generated
C e ll P a ra m e te rs manually OR if the instrument cannot correct the count
Step 1. Ensure that nucleated red blood cells (NRBCs) and 2) the number of NRBCs reported is at or above the

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 FOCUS: INTERPRETING THE COMPLETE BLOOD COUNT

threshold of the institutional protocol. The formula for Falsely low WBC values, called pseudoleukopenia, may
correcting the WBC for the presence of NRBCs is occur with cryoglobulins that agglutinate the wbcs3 and
described in Figure 1. The derivation of the formula is may warrant an instrument flag due to their very large
available in Table 2. The corrected WBC value, whether size. Warming the sample before testing may provide an
instrument or manually generated is used to make all accurate count. In other cases, a redraw into sodium
additional wbc assessments. citrate may be necessary and the instrument generated
WBC will need to be multiplied by 1.1 before reporting.
Corrected WBC (cells/μL) = Uncorrected WBC (cells/µL) x Some patients’ wbcs will clump in the presence of EDTA
100/(NRBCs + 100) without cryoglobulins being present and a redraw into
where NRBCs = number of NRBCs/100 wbcs citrate will correct the problem.4 In instances where the
instrument may not be able to flag these false values,
Figure 1. The formula for correcting the WBC for the presence of
NRBCs is shown examination of the blood film (see Step 6) may identify
them and prompt corrective action. The remaining steps
should be completed once an accurate WBC is available.

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Table 2. Derivation of the formula for correction of the white
blood cell count due to NRBCs.
Original WBC (cells/µL) = includes wbcs + NRBCs Step 2. Examine the WBC for variations in the total
Corrected WBC (cell/µL) = includes wbcs only number of wbcs.
NRBCs = NRBCs counted with 100 wbcs on a microscopic
WBC values vary depending on age, particularly in the
differential
early months of life, through childhood, and into
A proportionality is created:
adolescence.5 While gender differences are not observed,
Original WBC = Corrected WBC the WBC can vary with genetics, typically as a result of
NRBC + 100 wbc 100 wbcs differences in specific cell lines.6 Thus, the use of the
proper reference interval is especially important to the
Cross multiplication to: interpretation of WBC values. An increase above the
Corrected WBC x (NRBC+100 wbc) = Original WBC x 100 wbc reference interval is called leukocytosis while a decrease is
leukopenia.
Solve for Corrected WBC:
Corrected WBC = Original WBC x 100 wbc / NRBC + 100 wbc Step 3. Interpret absolute differential counts against
appropriate reference intervals using proper terminology.
Other causes of false values must also be detected and
corrected.2 Falsely elevated WBC values may be due to Like the total WBC, the quantity of the subtypes of wbcs
aggregated platelet clumps or incomplete rbc lysis. that are normally present depends on age.5 Benign racial
Instruments are typically able to flag these, though they differences are also documented.6 Thus, appropriate
may not be able to correct for them automatically. In the reference intervals are essential. The absolute wbc
case of aggregated platelets, the clumping increases the differential enumerates the number of each subtype of
size of particles to be comparable to wbcs. In this wbc that the instrument is able to distinguish. When
situation, a simultaneous pseudothrombocytopenia is reported as cells/volume, e.g. neutrophils/µL, the
also expected. A redraw into a blue top sodium citrate number is called an absolute value because it is an actual
tube is necessary and then the measured WBC value must concentration of that cell type. The alternative is the
be multiplied by 1.1 to adjust for the anticoagulant relative value expressed as a percentage and subject to
dilution. In the case of incomplete rbc lysis that can occur misinterpretation (discussed below). Modern
in conditions such as thalassemia and sickle cell anemia, instruments actually count absolute values and calculate
rbcs will remain in the WBC dilution fluid and be relative differential values (Figure 2). The absolute
counted as wbcs. Preparing a manual dilution and differential values are the best value to use in making
allowing it to incubate longer before instrument diagnostic conclusions, especially when generated by an
sampling should permit the cells to lyse, thus providing instrument.
an accurate WBC.

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 FOCUS: INTERPRETING THE COMPLETE BLOOD COUNT

% of a given cell type = 100% x Absolute number of given cell type they are normal. It is this risk of misinterpretation of the
(cells/µL) / Total WBC (cells/µL) relative differential that limits its value.
Figure 2. The calculation of relative differential values is shown
Absolute values can be calculated from the relative
differential percentages for more accurate interpretation,
To interpret absolute differential counts, follow these
as long as the total WBC is known (Figure 3). One can
steps.
assume that the absolute counts are normal if the total
WBC is within the reference interval and all the relative
a. As a quality check, add up the absolute counts of the
values are within their reference intervals. In such
subtypes of cells and it should equal the total WBC.
instances, calculation of absolute values is not necessary.
Conversely, absolute counts should be calculated for all
b. For a given cell line, add together all cell counts of
cell types, not just those outside relative reference
any stage, e.g. add together all the stages of
intervals, when 1) the total WBC is outside the reference
neutrophilic cells (promyelocytes + myelocytes +
interval (low or high) OR 2) any relative value is outside

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metamyelocytes + bands + neutrophils), and evaluate
its reference interval. After calculating absolute values,
the total relative to the reference interval for the
follow the steps for interpreting absolute values described
mature form of that cell, since that interval
in step 3.
represents the number of those cells normally
expected (for neutrophils, the interval can include
Absolute number of given cell type (cells/µL) = Total WBC
the upper end of neutrophils plus bands). (cells/µL) x % of a given cell type / 100%

c. Use the following terms to describe the value: Figure 3. The calculation of absolute values from relative differential
i. Increases above the top of the reference interval percentages is shown.
include: neutrophilia, lymphocytosis, monocy-
tosis, eosinophilia, basophilia. Step 5. Make note of immature cells in any leukocyte cell
ii. Decreases below the bottom of the reference line reported in the differential that should not appear in
interval: neutropenia and lymphopenia. Mono- normal peripheral blood.
cytopenia, eosinopenia, and basopenia are not
typically noted since the lower limits of the Young cells of any leukocyte cell line should have been
normal reference intervals are so low noted when interpreting the differential e.g.
prolymphocytes plus lymphocytes contributing to a
Step 4. If absolute counts are not available from an conclusion of lymphocytosis. However, the presence of
instrument, use relative counts (i.e. percentages) to young cells that are abnormal typically carries serious
calculate absolute values. clinical implications, so even small numbers must be
noted. To continue the example, perhaps the
Absolute differential values will not be available when the prolymphocytes are too few to contribute to overall
differential is generated microscopically; only the lymphocytosis. Nevertheless, they cannot be ignored.
percentage of each cell type is known. In this case,
because the number of cells counted is limited to 100, Two additional items pertinent to young cells merit
the number of cells of each type observed within that 100 mention. 1) Elevation above reference values for bands
cell limit is relative to the frequency of each of the other or any of the younger neutrophilic cells is called a “left
cell types. Misinterpretation occurs when, for example, shift.” This phrase is used exclusively to describe the
the concentration of lymphocytes actually present in the presence of young neutrophilic cells. The origin of the
sample is normal, but the concentration of neutrophils term “left shift” refers to frequency distribution
increases during a bacterial infection. As the relative (i.e. histograms labeling the stages from left to right with the
manual) differential is conducted, neutrophils are youngest on the left. Generating such graphs was a
encountered and counted more frequently, thus reducing standard practice historically. When young cells were
the number of lymphocytes that will be encountered and present, the distribution histogram shifted left.7 2)
counted within 100 cells. The lymphocytes will appear NRBCs may require correction of the white blood count;
to be reduced relative to the neutrophils, though in fact, refer to Step 1 above.
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Step 6. Make note of any morphological abnormalities of differential. During this microscopic review, it was noted
wbcs. that the patient had 14 NRBC/100 wbcs, which is
significant in affecting the validity of the WBC
Typically, when the wbc morphology is normal, there is determined by the instrument. A correction calculation
no notation in the report; only abnormalities are must be made.
reported. Morphological abnormalities of wbcs may
affect the overall cell appearance (i.e. reactive WBC x [100/(100+14)] = corrected WBC
lymphocytes), just the nucleus (i.e. hyper- and hypo- 18.3 x 103 /µL x 100/100+14 = 16.0 x 103 wbc/µL
segmentation, multiple nuclei, nuclear blebbing, Reider
forms), or just the cytoplasm (i.e. toxic granulation, Therefore, all subsequent assessments are conducted on
vacuolization, agranularity, cytoplasmic blebbing). a WBC of 16.0 x 103 wbc/µL

When performing the morphological assessment, it Table 3. White blood cell parameters for Case 1.
should be standard practice to perform an estimate of the

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P a tie n t P e d ia t ric R e fe re n c e In t e rv a l
WBC as a quality check, helping to ensure that the slide WBC
18.3 5.5-15.0
being examined is from the same sample as the numerical (x 103 wbc/µL)
parameters. The estimate is expected to match the P E D IA T R IC P E D IA T R IC
measured value. However, if the estimated value and the D iffe re n tia l (% ) R E L A T IV E A B SO LU T E
(% ) (x 1 0 3 /µ L )
instrument value do not correlate well, it may indicate a
Neutrophils 45 30-50 1.5-7.5
spurious instrument result.
Bands 15 0-5 0.0-0.8

Estimation of the WBC is done by observing 10 fields Lymphocytes 33 40-55 2.0-8.3

with 40X or 50X objective and averaging the number of Monocytes 7 0-5 0.0-2.0
white blood cells in those fields.7 Multiply the average Eosinophils 0 0-2 0.0-0.7
obtained with a 40X objective by 2 x 103/µL or multiply Basophils 0 0-1 0.0-0.3
the average using 50X objective by 3 x 103/µL. The result Patient Morphology
14 NRBC/100 wbcs, toxic granulation,
should approximate the instrument value, assuming the vacuolization of neutrophils
patient has a normal rbc count and the optimum area of
the slide is used in this assessment. Step 2. Examine the WBC for variations in the total
number of wbcs.
Step 7. Correlate the wbc findings with rbc and platelet
findings for a complete clinical assessment of the 16.0 x 103 WBC/µL is above the pediatric reference
patient’s blood picture. interval upper limit, thus, there is a leukocytosis.

A p p lic a tio n o f th e S te p s to th e I n te r p r e ta tio n o f R e su lts Step 3. Interpret absolute differential counts against
fo r S a m p le C a s e s appropriate reference intervals using proper terminology.
Case 1: The WBC and differential results presented in
Table 3 are for a 6-year-old African-American girl. The Since absolute values are not generated by this
testing was conducted in the physician office using an instrument, proceed to Step 4.
instrument that provides a 5-cell relative differential.
From the information given, one can use the 7 steps to Step 4. If absolute counts are not available from an
assess this patient’s white blood cell picture. instrument, use relative counts (i.e. percentages) to
calculate absolute values. See Table 4 for the calculated
Step 1. Ensure that NRBCs or other conditions are not absolute counts using the formula in Figure 3.
falsely affecting the WBC; correct the WBC if needed,
before proceeding. The patient has an absolute neutrophilia while the
lymphocytes are within the normal reference interval, as
Looking at the white blood cell picture, the sample likely are the monocytes.
flagged the instrument and thus reflexed a manual

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 FOCUS: INTERPRETING THE COMPLETE BLOOD COUNT

To verify the calculations of the absolute values, total patient’s blood picture.
them; (9.6 + 5.3 + 1.1) x 103/µL = 16.0 x 103/µL which
was the total WBC. Therefore, the calculations are In summary, this patient’s wbc picture is described as
correct. leukocytosis with an absolute neutrophilia, a left shift,
and toxic changes to the neutrophils. This picture is one
Table 4. Calculations of absolute white blood cell values for of infection or inflammation. The presence of NRBCs
Case 1. suggests a significant anemia, which was seen with a low
C e ll T y p e C a lc u la t io n T o ta l n u m b ers
hemoglobin (rbcs values not shown). The rbc
Neutrophilic cells
(Neutrophils + bands =
16.0 x 103/µL x 9.6 x 103 morphology included anisocytosis, poikilocytosis, sickle
60%/100% cells/µL cells, target cells, and polychromasia. Her platelet values
60% neutrophilic cells)
Lymphocytes
16.0 x 10 /µL x
3
5.3 x 103 were all within normal limits. This girl had gone to the
33%/100% cells/µL physician experiencing severe abdominal pain under her
16.0 x 103/µL x 1.1 x 103
Monocytes
7%/100% cells/µL
ribs on the left side, likely related to the spleen, as well as
fever. Sickle cell patients are prone to infection due to

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This patient’s relative values demonstrate why using diminished spleen function.
absolute values is important to the proper interpretation
of differentials. Adding the bands and neutrophils to a Case 2: The WBC and differential presented in Table 5
total of 60% leads to the conclusion that this patient has were ordered by a physician in the emergency
a relative neutrophilia. This matches the conclusion department on this 53-year-old man. From the
drawn from the absolute neutrophil assessment. The information given, one can use the 7 steps to assess this
relative lymphocyte value is below the lower limit of the patient’s white blood cell picture.
reference interval. While a relative lymphopenia exists, Table 5. White blood cell parameters for Case 2.
note that the absolute value for lymphocytes was within P a tie n t A d u lt R e fe r e n c e I n te r v a l
the reference interval; therefore, no lymphopenia is WBC
present. Furthermore, a relative monocytosis is noted but 19.3 5.5-15.0
(x 103 wbc/µL)
the absolute value is within the reference interval. Thus, (x 1 0 3
AD U LT AD U LT
using the relative values alone for this patient would lead D iffe re n tia l (% ) R E L A T IV E A B SO LU T E
/µ L )
(% ) (x 1 0 3 /µ L )
to faulty conclusions about the numbers for lymphocytes
Neutrophils 58 11.2 40-75 1.8-7.9
and monocytes.
Bands 2 0.4 0-5 0.0-0.5
Step 5. Make note of immature cells in any leukocyte cell Lymphocytes 23 4.4 20-40 0.9-4.2
line reported in the differential that should not appear in Monocytes 9 1.7 0-9 0.0-0.9
normal peripheral blood. Eosinophils 5 1.0 1-6 0.05-0.6
Basophils 3 0.6 0-2 0.0-0.2
This patient has 15% bands (2.4 x 103/µL) noted in her Patient
differential, and this would be described as a left shift. Morphology
No other immature cells are noted.
Step 1. Ensure that NRBCs or other conditions are not
Step 6. Make note of any morphological abnormalities of falsely affecting the WBC; correct the WBC if needed,
wbcs. before proceeding.

This patient’s neutrophils are showing vacuolization and There are no NRBCs reported or other flags generated,
toxic granulation. During a microscopic differential so the WBC is reliable as reported.
using 50X objective, an average of 5-6 white blood cells
/ field should be encountered to correlate to a WBC of Step 2. Examine the WBC for variations in the total
16.0 x 103/µL. number of wbcs.

Step 7. Correlate the wbc findings with rbc and platelet 19.3 x 103 WBC/µL is above the adult reference interval
findings for a complete clinical assessment of the upper limit, so there is a leukocytosis.

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Step 3. Interpret absolute differential counts against revealing a more significant anemia.
appropriate reference intervals using proper terminology.
Case 3: A CBC with differential were ordered by a
Comparing the absolute values provided to their physician in the emergency department on a 68-year-old
reference intervals, the patient has an absolute male. See results in Table 6. From the information given,
neutrophilia when the neutrophils and bands are one can use the 7 steps to assess this patient’s white blood
combined, a slight absolute lymphocytosis, an absolute cell picture.
monocytosis, an absolute eosinophilia and an absolute
basophilia. Table 6. White blood cell parameters for Case 6.

P a tie n t A d u lt R e fe re n c e In t e r v a l
Step 4. If absolute counts are not available from an
instrument, use relative counts (i.e. percentages) to WBC
45 4.5 – 10. 5
(x 103 wbc/µL)
calculate absolute values.
AD U LT AD U LT

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D iffe re n tia l (% ) R E L A T IV E A B SO LU T E
Absolute values were provided by the instrument and (% ) (x 1 0 3 /µ L )
interpreted in Step 3; proceed to Neutrophils 16 40-75 1.8-7.9
Bands 0 0-5 0.0-0.5
Step 5. Make note of immature cells in any leukocyte cell Metamyelocytes 0 0
Myelocytes 19 0
line reported in the differential that should not appear in Promyelocytes 16 0
normal peripheral blood. Blasts 42 0
Lymphocytes 6 20-40 0.9-4.2
No immature cells were noted nor was a left shift present. Monocytes 1 0-9 0.0-0.9
Eosinophils 0 1-6 0.05-0.6
Basophils 0 0-2 0.0-0.2
Step 6. Make note of any morphological abnormalities of Patient Morphology Auer rods noted
wbcs.
Step 1. Ensure that NRBCs or other conditions are not
Nothing abnormal is noted. During a microscopic falsely affecting the WBC; correct the WBC if needed,
differential using a 50X objective, an average of 6-7 wbcs before proceeding.
should be seen in each field to correlate to the WBC of
19.3 x 103/µL. There were no NRBCs reported or other apparent
interferences, so the WBC is reliable as reported.
Step 7. Correlate the wbc findings with rbc and platelet
findings for a complete clinical assessment of the Step 2. Examine the WBC for variations in the total
patient’s blood picture. number of wbcs.

In summary, this patient’s wbc picture was one of 45.0 x 103 WBC/µL is above the adult reference interval
leukocytosis with elevations in all cells lines but no upper limit, so there is a leukocytosis.
abnormal morphology or immature cells noted. The
elevations of all cell types may point to dehydration, Step 3. Interpret absolute differential counts against
particularly since no morphological abnormalities or appropriate reference intervals using proper terminology.
immature cells were noted. This patient was known to
have alcoholic liver disease. He came to the emergency This sample generated a flag for immature granulocytes
department due to generalized itching which can result and blasts. Thus, a manual differential was performed
from deposition of bile salts in the skin. His rbc and absolute values were not available from the
parameters (not shown) demonstrated a mild macrocytic instrument.
anemia with target cells and polychromasia, consistent
with alcoholic liver disease. His platelet parameters (also Step 4. If absolute counts are not available from an
not shown) were all normal. Rehydration might be instrument, use relative counts (i.e. percentages) to
expected to bring the WBC vales back to normal while calculate absolute values.

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 FOCUS: INTERPRETING THE COMPLETE BLOOD COUNT

Calculations for this patient are shown in Table 7. The neutrophilic, and if included in the relative totals, the
patient has an absolute neutrophilia, even without neutrophilia is even greater. The patient’s lymphocytes
counting the blasts. However, it should be noted that are within the reference interval as are the monocytes.
since Auer rods were noted in the blasts, they are likely

Table 7. Calculations of the absolute differential counts for Case 3.

C e ll T y p e C a lc u la t io n T o ta l n u m b ers
Neutrophilic cells (without blasts) 45.0 x 103 wbcs/µL x 51%/100% 23.0 x 103 cells/µL
Neutrophilic cells (including blasts) 45.0 x 103 wbcs/µL x 93%/100% 41.9 x 103 cells/µL
Lymphocytes 45.0 x 103 wbcs/µL x 6 %/100% 2.7 x 103 cells/µL
Monocytes 16.0 x 103/µL x 7%/100% 1.1 x 103 cells/µL

Although the eosinophils are technically below the gastrointestinal bleeding likely related to the
reference interval, thus eosinopenia, this is not typically thrombocytopenia and/or low level of disseminated

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considered significant. The basophils are within the intravascular coagulation. Ultimately, he was diagnosed
reference interval and since none were observed, no with acute promyelocytic leukemia.
calculation is required.
SU M M A R Y
Checking the calculations by adding up the absolute The systematic application of the steps detailed here will
counts results in (41.9 +2.7+0.45) x 103 cells/µL = 45.05 help ensure that reported results are accurate.
x 103 cells/µL; thus, the individual cell values are correct. Additionally, it will help ensure than no results are
overlooked in the diagnostic evaluation of white blood
Step 5. Make note of immature cells in any leukocyte cell cell parameters.
line reported in the differential that should not appear in
normal peripheral blood. R EFER ENCES
1. Clark KS, Hippel TG. Manual, semiautomated, and point of
care testing in hematology. In: Keohane EM, Smith LJ, Walenga
The patient has a drastic left shift, containing myelocytes, JM, editors. Rodak’s Hematology: Clinical Principles and
promyelocytes, and blasts. Applications, Ed. 5. St. Louis: Elsevier; 2012.
2. Longanbach S, Miers MK. Automated blood cell analysis. In:
Step 6. Make note of any morphological abnormalities of Keohane EM, Smith LJ, Walenga JM, editors. Rodak’s
Hematology: Clinical Principles and Applications, Ed. 5. St.
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Step 7. Correlate the wbc findings with rbc and platelet Hematology: Clinical Principles and Applications, Ed. 5. St.
findings for a complete clinical assessment of the Louis: Elsevier; 2012.
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In summary, this patient’s wbc results include a Lippincott, Williams & Wilkins; 2014.
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anemia with a few shistocytes and thrombocytopenia. He 2012.
had visited the emergency department due to

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