Another valuable test that we
do in patients with anemia
is we can actually look at the
blood under the microscope.
And the blood under the microscope,
it’s hard to say whether
the blood cells are
small or big or have a
that’s what the machine is for.
But the blood cells can give us
clues as to what’s going on.
Do you see this picture here?
This is a patient who is having
an acute hemolytic anemia
that’s an intravascular problem.
They got helmet cells and cells
are being clearly ripped apart.
Here’s an example of a patient with
a multi-lobular white blood cell,
that’s going to tell me a little bit that
this patient may have B12 deficiency.
Here’s another example of where
the picture might help us.
Look at this slide carefully and you
can see especially on the top right,
next to that one little purple dots,
this is called basophilic stippling.
We sometimes see this in lead poisoning.
So if saw this under the
microscope, I know,
“Uh-oh, better worry about lead poisoning.”
Here’s another example of a picture.
This patient has very
abnormal shaped cells.
So here’s a last one.
This one should be
pretty obvious to you.
If you look at it carefully, you
can see that some of the cells
are long and thin instead of round.
Yeah, this person has sickle cell disease
and you can see it if you step back even
if you look at the farther away view,
you can see lots of
little sickled cells.
Even looking at this mirror might tell
you how bad off they are right now,
how much sickling is going on.
So we’ve got a CBC,
we know their reticulocyte
and we know their MCV
and we have sense
of the RDW as well.
Let’s break it down in terms
of what might be going on.
So I got a CBC in this patient,
they had a high reticulocyte count, they
are making lots of red blood cells,
but they are microcytic.
This is going to
be a thalassemia.
It’s a chronic indolent problem
where the hemoglobin doesn’t quite
work right and it breaks down easily,
but they are trying
to make more.
If they have a high MCV, it’s big cells,
this might be a membrane
disorder or they may have G6PD
or an autoimmune disease or sickle cell
disease or hemolytic uremic syndrome.
Perhaps they have DIC or disseminated
or they could be suffering
from chronic blood loss.
We’ll use our history to start to get
into this or if we are still unsure,
we can do some tests
to make sure.
For example, for sickle cell disease,
we could easily check hemoglobin.
Or for G6PD, we could look for
signs of G6PD on the smear
or we can get a history that will clarify
that or we can test for the enzyme.
Now, here’s a CBC with diff
where we going to have a low
or a normal reticulocyte count.
In other words, this patient
is not cranking out cells.
They have a low MCV, they may
have ongoing iron deficiency.
It’s hard for them to make
reticulocyte counts, so it’s low.
They may have lead poisoning
or thalassemia trait
or perhaps anemia
of chronic disease.
If they have large cells, once again,
they may have aplastic anemia,
transient erythroblastopenia of
childhood, sickle cell disease,
membrane disorders or autoimmune disease.
You can see how these values
are going to start to
tweak our understanding or
guessing of what things are
and if you understand the disease,
you’ll be able to put it together.
So knowing that lead poisoning
causes microcytic anemia
and is a long indolent thing and prevents
the production of reticulocyte counts,
you can predict where
it falls in this table.