Rapid Identification of Thrombocytopenia-Associated Multiple Organ Failure Using Red Blood Cell Parameters and a Volume/Hemoglobin Concentration Cytogram

Thrombocytopenia-associated multiple organ failure (TAMOF) has a high mortality rate when not treated, and early detection of TAMOF is very important diagnostically and therapeutically. We describe herein our experience of early detection of TAMOF, using an automated hematology analyzer. From 498,390 inpatients, we selected 12 patients suspected of having peripheral schistocytosis, based on the results of red blood cell (RBC) parameters and a volume/hemoglobin concentration (V/HC) cytogram. We promptly evaluated whether the individual patients had clinical manifestations and laboratory findings were consistent with TAMOF. Plasma exchanges were then performed for each patient. All 12 patients had TAMOF. The mean values of RBC parameters were significantly higher in all of the patients than with the reference range, however, 3 patients had % RBC fragments within the reference range. The mean value of ADAMTS-13 activity was slightly lower in patients compared with the reference range. Of the 12 patients, remission was obtained in 9 patients (75%) within 4 to 5 weeks using plasma exchanges. Three patients died. An increased percentage of microcytic hyperchromic cells with anisocytosis and anisochromia indicated the presence of schistocytes, making it an excellent screening marker for TAMOF. Identification of TAMOF with RBC parameters and a V/HC cytogram is a facile and rapid method along with an automated hematology analyzer already in use for routine complete blood cell counting test.

Red cell distribution width (RDW) in the diagnosis of iron deficiency with microcytic hypochromic anemia.

OBJECTIVE: To study the utility of red cell distribution width (RDW) in the diagnosis of iron deficiency among children with microcytic hypochromic anemia. METHODS: 151 children (6 months-12 years) with microcytic (MCV<75 fl) anemia were classified into iron deficient (IDA) and non-iron deficient anemia (non-IDA) on the basis of serum ferritin and total iron binding capacity (TIBC). RDW values were obtained on an automated hematology analyzer. Receiver operator curves (ROC) were constructed and the utility of RDW in diagnosis of iron deficiency was studied. RESULTS: The mean RDW value was 18.37+/-2.22% in IDA group (97 children) compared to 16.55+/-1.51 % in the non-IDA group (54 children) (p<0.0001, unpaired t test). In IDA group, the mean RDW value was 16.60+/-1.78%, 17.95+/-1.91% and 20.55+/-1.32% among mild, moderate and severely anemic children (p<0.0001, ANOVA test). The corresponding values in non-IDA group were 16.03+/-1.25%, 16.76+/-1.20% and 16.77+/-2.68% respectively (p=0.269, ANOVA test). At a cut-off value of 17.4%, as obtained from the ROC curve, the sensitivity and specificity of RDW in diagnosis of IDA were 81.0% and 53.4% and a positive and negative predictive value of 63.0% and 72.2% respectively. CONCLUSION: RDW has a limited specificity for diagnosis of IDA among children with microcytic hypochromic anemia.

Imagecytometry: a new tool for diagnosis of glomerular haematuria.

Differentiation between glomerular and nonglomerular haematuria is a major challenge in clinical medicine, which is very important for a definitive diagnosis and management in individual cases. Phase contrast microscopy of red cells in urine is the standard practice for diagnosis of glomerular haematuria. Urine cell flowcytometry is recently being used for such diagnosis. In this context, the role of determination of haemoglobin content of urine red cells is not know. Application of image analysis to study the red cells in urine may be more objective and accurate for the diagnosis. The present study has been undertaken to evaluate the urine red cells with the help of an automated computerized image analysis system for determination of hemoglobin content by integrated optical density (IOD). The morphometric parameters were also analyzed. The glomerular RBCs were significantly smaller in diameter, area and perimeter than nonglomerular RBCs with a greater variation in shape and lower [OD (p<0.0001 to <0.00002). With the help of morphometric parameters the percentage of cases diagnosed correctly varied from 90 to 95. The IOD helped to diagnose 100% cases. Thus application of this new technique may be very useful diagnostic tool in the investigation of haematuria.

Size distribution curves of blood cells in thalassemias and hemoglobin H diseases.

Thalassemias and hemoglobinopathies in Thailand have been examined with a blood cell counter based on electroimpedance principle and obtained size distribution curves of red cells and platelets. Among various disorders, beta-thalassemia/hemoglobin E and homozygous hemoglobin Constant Spring showed severe anemia. Their red cell size distribution curve shifted to the left and overlapped with the platelet size distribution curve. Red cell distribution width expressed by coefficient of variation and the degree of the overlapping were stronger in beta-thalassemia/HbE than HbH. Heterozygous beta-thalassemia showed a narrow red cell distribution curve width with small standard deviation and low England's value. Although the overlapping of size distribution curves cause inaccurate red cell count and platelet count, careful observation of the size distribution curves was proved to have high diagnostic value.

Biophysical changes of red cells with thalassemia-like abnormal hemoglobin.

Hemoglobin (Hb) E and Hb Constant Spring (CS) are known to have thalassemia-like effects. Investigation on the red cell physical changes in these two abnormalities has been done to clarify the diversity of red cell changes between thalassemia and thalassemia-like abnormal hemoglobin (Hb E represents beta-thalassemia and Hb CS represents alpha-thalassemia). Eleven cases with homozygous Hb CS (CS/CS), 7 homozygous Hb E subjects (E/E) and one double heterozygous case with Hb CS and Hb E were included in this study. The red cells were analyzed by the H* 1 hematology analyzer. The E/E red cells had significantly smaller MCV than the CS/CS red cells (p < 0.001). The smaller MCV of E/E red cells was attributed to markedly increased percent microcyte (p < 0.001) and significantly lower percent macrocyte (p < 0.001) as compared to CS/CS red cells. Degree of heterogeneity in cell volume as indicated by red cell distribution width (RDW) was not significantly different between the two abnormal hemoglobin containing red cells. It was also noted that the CS/CS cases had a more significant increase in small RBC than the E/E cases (p < 0.001). Significant lower intraerythrocyte hemoglobin concentration values of the CS/CS red cells as compared to E/E red cells were shown: cellular hemoglobin concentration mean (CHCM) (p < 0.001), percent hyperchromic red cell (p < 0.001) and hemoglobin distribution width (HDW) (p = 0.0367). Higher values for the CS/CS red cells were MCH (p < 0.001) and percent hypochromic red cells (p < 0.001). Red cells from both genotypes had significant decreases in red cell deformability.(ABSTRACT TRUNCATED AT 250 WORDS)

The thalassemic red cell membrane.

The underlying cause of pathology in thalassemia is the premature destruction of red cells, both in the bone marrow and by the reticuloendothelial system. It is generally accepted that the presence of unpaired excess globin chains is the primary circumstance leading to such membrane alterations as oxidation of phospholipids, modification of cytoskeletal proteins and their interactions, reduced membrane-associated ATPase activities, and enhanced permeability of cations. Such perturbations in turn result in the exposure of outer surface neoantigens, enhanced binding of autoantibodies and complement fixation to the outer red cell surface. These factors contribute to the observed distinctive morphologies, increased rigidity and decreased deformability of the thalassemic red cells. In alpha-thalassemic red cells, excess beta-globin chains form homotetramers, Hb H, which are relatively stable and will only damage red cell membrane when precipitated as inclusion bodies, whereas excess alpha-globin chains cannot form such homotetramers and upon synthesis rapidly bind to the cytoplasmic side of the beta-thalassemic red cell membrane, even in young erythroblasts. This difference in properties of the excess globin chains may offer an explanation for the variation in clinical severity observed between these two forms of thalassemia.