C H A P T E R

ABC of CBC

60 Pankhi Dutta

INTRODUCTION White cell count differential (DC)- 3 parts /complete 5 part

The complete blood count (CBC) is the most commonly differential count.
ordered blood test in a healthcare set up. The fully Absolute white cell counts
automated sophisticated cell counters give us very
accurate and precise blood counts rapidly alongwith Platelets
a number of additional newer parameters which give Platelet count (PC)
valuable extra information added to the routine CBC.The Mean platelet volume (MPV)
origin of the modern cell counters date back to 1953, when
Wallace H Coulter, an American engineer by training, Platelet distribution width (PDW)
obtained a patent for a principle for counting and sizing Over and above all these , few new parameters available on
microparticles suspended in a fluid.1 The principle was some analyzers have found clinically utility and are being
named the ‘coulter principle’ and is the basis of the incorporated into the routine CBC. Two new US FDA
technology of most cell counters even today. approved parameters are the Reticulocyte Haemoglobin
A basic CBC comprises of the following parameters Content (CHr) or Reticulocyte Haemoglobin Equivalent
Haemoglobin (Hb) (Ret-He) and Immature Platelet Fraction (IPF). Promising
research parameters include Leucocyte Positional
Haematocrit (Hct) Parameters(LPP).2
Red blood cells(RBCs) and indices The Hb and the Hct
Total Red Cell count (TRBC) The haemoglobin is measured after the RBCs are lysed
Mean corpuscular volume (MCV) and the Hb converted to a stable coloured compound
whch is measured spectrophotometrically. Hence, like
Mean corpuscular haemoglobin (MCH) lipemia and hyperbilirubinemia can interfere with the
Mean corpuscular haemoglobin concentration (MCHC) results.
Red cell distribution width (RDW) The Hct can be used synonymously with the Hb to classify
a sample as anaemic or polycythemic. The Hct is the given
White blood cells (WBCs) volume of packed RBCs as compared to the plasma and
Total white cell count (WBC) can be measured by a microhaematocrit centrifuge (as in
Sysmex analyzers) or calculated (as in Beckman Coulter
instruments) by taking into account the Hb and the MCV.
Due to differences in the methodologies there can be
a pe rtu re in tern al
e xt ern a l considerable variation in the Hct between analyzers while
e lect ro d e
e le ct ro d e the Hb value is more reproducible. Hence, it is better to
use the Hb to make clinical decisions.
TRBC and MCV
The most common technology for counting and sizing
the blood cells is the impedance technology based on the
va cu um coulter principle. The basic counting chamber comprises
of two electrodes with a partition between them. The
U=RxI partition has an aperture through which electrolyte
flows and maintains flow of electrical current between
the electrodes (Figure 1). The cells are suspended in the
electrolyte and when an individual cell passes through
the aperture, there is a break in the flow of current as
I m p u ls e
blood cells are poor conductors of electricity. Each break
3-p ar t D iff te ch no lo gy V 0 70 6 is counted as a pulse. The number of pulses generated
give the cell count. The TRBC and the platelet counts are
Fig. 1: Impedance based cell counter.
https://www.sysmex.com obtained in this manner.
Source-https://www.sysmex.com
 328
Incubation 30 min

RBC-Histogram Results RBC-Histogram Results

RU 2.23x10 /L RBC 4.35x10 /L

12
RBC ± 12

HGB 14.4g/dl HGB 14.5g/dl

HCT RU± 24.9% HCT 43.5%
MCV RU± 111.7fl MCV 100.0fl
MCH RU± 64.6pg MCH 33.3pg
MCHC RU± 57.8g/dl MCHC 33.3g/dl
100 200 (fL) RDW ± 25.4fl 100 200 (fL) RDW 14.7fl

Fig. 2: CBC printout

HAEMATOLOGY

Fig. 4: Algorithmic approach to Anaemia

quantify anisocytosis and give a numerical value. On the
other hand, on the analyzers, a numerical value of the
Fig. 3: RBC Histogram RDW is obtained as a percentage coefficient of variation
(CV%) or as the standard deviation of the mean size
The height/size of a pulse generated depends on the size (SD). A raised RDW indicates a heterogenous population
of the cell causing it. In the case of RBCs, the average of RBCs from the size point of view.3 In nutritional
height of the pulses gives us the MCV. The MCV is anaemias, this parameter is often the first to be altered
expressed in femtolitres (fl) and red cells with MCVs in and a raised RDW even with a normal MCV warrants a PS
the range of 80-100fl are considered normocytic. Cells examination to look for a small population of microcytic
with MCV less than 80fl are called microcytic. An MCV or macrocytic RBCs. It is important to realise that the
above 100fl would classify the cells as macrocytic. Besides MCV is just an average value and even if a population of
numerical values, the instruments also give RBC volume microcytes /macrocytes are present in a sample, the MCV
distribution histograms. may fall in the normal range if majority of the cells are
normocytic. Moreover, an admixture of microcytes and
MCH AND MCHC macrocytes as may be seen in a case of nutritional anaemia
Having obtained the Hb, Hct , TRBC and MCV, the may average out the MCV, causing it to fall in the normal
instruments give us the calculated parameters of MCH range. However, the RDW would be much raised. Thus,
(Hb x 1/TRBC) and MCHC (Hb x 1/Hct) which give the RDW is an useful parameter to differentiate between
information about the concentration of Hb in the RBCs. nutritional and other causes of anaemias.
Values below the reference range are used to classify the
RBCs as hypochromic. Samples with higher concentrations The following RBC histogram shows marked anisocytosis
of MCH indicate dense RBCs as may be seen in and a raised RDW (Figure 3).
megaloblastic anaemias or in the presence of spherocytes. RETICULOCYTE COUNTS
Very high (non-physiological) values of MCV, MCH and An underutilised but useful parameter in the work up of
MCHC indicate presence of red cell clumping, often due anaemias is the reticulocyte count. As reticulocytes are
to cold agglutinins. The abnormalities are reversed on the youngest forms of RBCs, their presence in the blood
reanalyzing the samples after incubation at 37 deg C. establishes the fact that the bone marrow is producing
The CBC printout with the characteristic RBC indices is RBCs. Increased bone marrow production of RBCs is
diagnostic of red cell agglutination. The following RBC reflected in a raised reticulocyte count. Unlike mature
histogram illustrates the same (Figure 2). RBCs, the reticulocytes contain remnant RNA which
RDW is stained by a supravital dye and which appears as a
From the RBC volume distribution histogram, the ‘blue reticulum’ under the microscope.4 Thousand RBCs
analyzers calculate an index of variation of RBC size have to be counted and reticulocytes enumerated and
(anisocytosis) called the RDW. Anisocytosis is appreciated expressed as a percentage of RBCs which can be difficult
on the peripheral smear (PS) but it is not possible to and unreliable. Today’s cell counters provide automated
 characterised by macrocytic anaemia and thrombocytosis. 329
Increased reticulocytes seen in haemolytic anaemias may
lead to slight macrocytosis. Normocytic indices may be
seen in ACD, haemolytic anaemias and even combined
nutritional anaemias.
In the presence of microcytosis, the TRBC (raised in
thalassemia) and RDW (increased in IDA) can help
differentiate between iron deficiency and beta thalassemia
trait. Indices like the Mentzer’s index7 have been put
forward to make this differentiation more objective. If
the quotient of the MCV (in fl) divided by the TRBC (in
millions/cubic mm) is less than 13, thalassemia is more

CHAPTER 60
likely. If the result is greater than 13, iron deficiency
is more likely. Co-existing iron deficiency and beta
thalassemia trait make these values redundant. Beta
thalassemia carriers have microcytic hypochromic RBC
indices with a normal RDW as the red cells are uniformly
small , i.e., homogenously microcytic. On the other hand,
iron deficiency shows microcytosis along with an altered
Fig. 5: Scattergram from a sysmex x class analyzer. Source- RDW.
https://www.sysmex.com
CHr/ Ret-He
reticulocyte counts on the basis of their larger volumes A close differential diagnosis of iron deficiency anaemia
and presence of RNA. (IDA) is anaemia of chronic disease (ACD), characterised
For ease and familiarity, the reticulocytes continue to be by functional iron deficiency (FID) where iron is not
expressed as a percentage of the RBCs which may lead to incorporated into developing erythroid cells in spite
falsely raised values when the absolute number of RBCs of adequate bone marrow iron stores. It is now well
is low as seen following haemolysis or blood loss. A better established that release of hepcidin from liver cells under
way is to ‘correct’ the reticulocyte count for the patient’s the influence of inflammatory cytokines like interleukin -6
Hb or Hct. A simple formula is- Corrected reticulocyte is responsible for blockage iron iron movement from iron
count= % of reticulocyte x patient’s Hct/45.5 storing macrophages into the developing red cells.8 This
block also occurs at the level of the intestinal cells wherein
Getting used to absolute reticulocyte numbers provided absorbed iron cannot enter the blood stream. Over weeks,
by the automated analyzers may be a better solution but this lead to formation of RBCs with low MCV and low
limited by the limited access to automated reticulocyte MCH. The traditional biochemical tests like serum
counts. iron, transferrin and ferritin levels fail to convincingly
distinguish between IDA and ACD. An improvement over
CBC IN THE WORK UP OF ANAEMIAS (FIGURE 4) these tests is the soluble transferrin receptor level (sTfr)
The following is a simple algorithm for the start up of
which is raised only in IDA and remains low in ACD.9
the work up of a case of anaemia using the Hb, red cell
This parameter is limited by its complexity of testing and
indices and reticulocyte count.5
its relative unavailability.
If the reticulocyte count is raised and blood loss is ruled
Changes in the RBC parameters as described occur over
out, few routine biochemical tests like serum bilirubin
the life span of RBCs (120 days) while changes occurring
and fractions, haptoglobin, lactate dehydrogenase (LDH),
in reticulocytes occur quickly, i.e., within 2-3 days (the life
etc, may establish ongoing haemolysis. Added to these,
span of the reticulocytes). CHr provided by instruments
a peripheral smear examination may help to clinch the
manufactured by Siemens and Ret-He provided by Sysmex
exact diagnosis/cause of haemolysis. For example, finding
analyzers measure reticulocyte haemoglobin content
a spherocyte would suggest an autoimmune haemolytic
or its equivalent directly. Both are helpful parameters
anaemia or hereditary spehrocytosis while a ‘bite cell’
to detect iron insufficient erythropoiesis,10 either due to
or ‘blister cell’ would suggest oxidant damage as seen in
pure and simple iron deficiency or due to FID at a very
G6PD enzyme deficiency.
early phase. Effective treatment of these conditions bring
Alternatively, one may look at the RBC indices. about a rapid change or increase in the CHr or Ret-He as
Macrocytic anaemias may be due to B12 /folate deficiencies these are measurements on the reticulocytes. Moreover,
but may be also seen with use of anti retroviral drugs, this information is obtained at the cost and at turn around
liver disease, hypothyroidism.6 Macrocytic anaemia time of a routine CBC. However, it should be noted that
as a part of generalised pancytopenia may be seen in the Ret-He is a size based assay and will be useless in
megaloblastic anaemia or aplastic anaemia. A unique the presence of an underlying beta thalassemia or in the
type of myelodysplastic syndrome, associated with loss presence of concomitant megaloblastic anaemia.
of the long arm of chromosome 5 (5q- syndrome) is
It has been shown that using a combination of sTfr, serum
 330 are characteristic. Any deviation from these as given by
the mean value and standard deviation of each of these
parameters reflect changes in size and complexity for a
particular cell type which in turn may be reflective of
specific diseases. These positional parameters have been
used to differentiate between chronic lymphoproliferative
disorders (CLPD) like chronic lymphocytic leukaemia
(CLL) vis a vis reactive lymphocytosis as in the former,
the cells are uniformly small.14 Changes in the parameters
of neutrophils have been found to indicate sepsis and
bacterial infections.15 Changes involving lymphocytes
and monocytes have also been used to flag for presence
HAEMATOLOGY

of malaria.16 As of now, these are still research parameters

and yet to be incorporated into routine clinical practice.
The CBC will indicate if there is leucocytosis or leucopenia.
The type of cell involved suggests the possible differential
Fig. 6: Platelet clumps in EDTA diagnoses. For example, increase in neutrophils could
suggest a bacterial infection, an inflammatory state,
ferritin and the Ret-He, it is possible to accurately diagnose steroids use, etc. An extremely high count with left
and provide guidelines for appropriate management shift suggests a chronic myeloid leukaemia (CML) or
of all microcytic hypochromic anaemias (Thomas plot, a leukamoid reaction. A bimodal peak of myelocytes
11). Both Ret–He and CHr have been incorporated into and neutrophils alongwith presence of basophils point
guidelines for management of anaemia in chronic renal towards CML and the molecular test for the diagnostic
disease patients and FID.12 fusion gene, BCR:ABL1 should be asked for.
A high haematocrit which is inexplicable (no history of Similarly, finding sustained absolute lymphocytosis
living at high altitude, no smoking , no chronic obstructive without any chronic infection would warrant a
airway disease, etc) should prompt one to work up for a haematological work up for a CLPD like CLL. Lymphoma
primary haematological disorder like polycythaemia vera spillover into blood may also cause a lymphocytosis.
(PV). A the Jak2 mutation performed on peripheral blood Peripheral smear may reveal characteristic morphology
is warranted.13 but immunophenotyping using flowcytometry is the
main stay of diagnosis.17
WBCS
Popular technologies for enumeration and differentiation Eosinophilia is most often secondary to allergic
of WBCs include the Volume Conductivity and Scatter conditions, parasitic infestations, drugs, vasculitides. If
(VCS) used by the Beckman Coulter instruments (from no such cause is found after reasonable investigations and
Beckman Coulter Inc, USA) and the Fluorescence if eosinophilia is sutained, a primary eosinophilia (clonal
Flowcytometry (FFC) principle used by the Sysmex or hypereosinophilic syndrome) needs to be considered.
analyzers (from Sysmex Corporation, Japan). Molecular studies for FIP1L1-PDGFR mutation are
important to determine response to a tyrosine kinase
The VCS principle differentiates cells based on their inhibitor like Imatinib.18
volume measured by impedance , conductivity of radio
frequencies which give information about the internal Monocytosis may be seen in some chronic infections or
structure of cells and and scatter of light which tells us during recovery of counts following chemotherapy or
about surface structure and granularity. In the FFC drugs. However, sustained absolute monocytosis of at
technology, cells are hit by a laser beam which gets least 1000/ul in absence of chronic infections warrant
scattered in various directions. The forward scattered light investigating for a haematological disorder like chronic
is a measure of the cell volume while the side scattered myelomonocytic leukaemia in an adult and juvenile
light is a measure of cell granularity. When a fluorescent myelomonocytic leukaemia in children.
dye is used, side fluorescence gives information about the In the presence of leucopenia , it is prudent to look
nucleic acids in the cells. Thus, monocytes have the highest at the absolute cell counts to see if any particular cell
forward scatter owing to their large size while eosinophils line is predominantly suppressed. Neutropenia is
have the highest side scatter owing to the presence of the most commonly encountered due to drugs and severe
prominent granules. immature granulocytes have high infections which would be apparent from the patient’s
fluorescence. Thus, various scatter plots are generated clinical condition. When neutropenia occurs alongwith
and the total WBC and the differential counts obtained. anaemia and thrombocytopenia, a serious bone marrow
Leucocyte positional parameters- Numerical data disorder like aplastic anaemia should be thought of.
coordinates generated by VCS technology are available as Inherited conditions of neutropenia are rare but known
research parameters on LH Beckman Coulter analysers. (e.g., Kostman syndrome). Acquired lymphopenia may
Volume, conductivity and light scatter for each WBC type be seen following use of monoclonal anti CD20 antibodies
 331

CHAPTER 60
Fig. 7: RBC & Platelet Histogram
like Rituximab.19 Absolute monocytopenia is a feature of
Hairy cell leukaemia while eosinopenia is a feature of Fig. 8: Measurement of IPF using platelet-F technology.
sepsis. Source-https://www.sysmex.com
PLATELETS The following figure shows overlapping RBC and platelet
A small percentage of people develop platelet clumping histograms (Figure 7).
when blood is collected in EDTA (the preferred
anticoagulant for CBC analysis) because they carry As manual platelet counts are difficult and time
antibodies against certain epitopes of platelets unmasked consuming, there have been attempts to innovate
in the presence of EDTA (Figure 6).20 In such cases, a repeat technology to overcome the problems with impedance
count after a repeat collection in citrate is indicated. counts like optical counts based on light scatter, use of
monoclonal anti platelet antibodies (Abbott), fluorescent
It should be noted that in the presence of platelet clumps platelet counts (platelet-F, Sysmex),23 etc.
it is not possible to give an accurate platelet count ,
whatever be the technology used. Platelet –F involves use of a fluorescent dye which is
highly specific for platelet membrane and counts obtained
The most common method of counting platelets is by this method have been found to be very accurate.24
impedance as described earlier in the section on RBCs.
The difference in size between the RBCs and platelets Besides the counts, platelet indices like the MPV and
makes it possible to separate out the the platelets and PDW have also been useful reflecting the average platelet
RBCs. Problems occur when there are very large platelets size and platelet anisocytosis respectively.
which may be falsely picked up as RBCs leading to a A PS confirmation of thombocytopenia is a must to
falsely lowered platelet count. rule out EDTA induced agglutination, presence of large
Pathological conditions associated with large platelets like platelets, fibrin strands, etc.
Bernard Soulier syndrome and familial platelet disorders Infections and sepsis alongwith drugs are the commonest
with myosin heavy chain9 (MYH9) gene mutation are causes of thrombocytopenia encountered in a hospital
well documented but are rare.21 More commonly, in set up wherein the clinical history is indicative of the
the eastern part of our country , a large chunk of the cause. Thrombocytopenia associated with abnormalities
population have mild thrombocytopenia and very large in other cell lines may indicate a bone marrow disorder
platelets (constitutional macrothrombocytopenia) which like an acute leukaemia. Isolated thombocytopenia in the
cause further artefactual lowering of the platelet count absence of any other cytopenia (except perhaps for an
on impedance cell counters.22 There is no risk of bleeding IDA secondary to bleeding) may be due to an immune
but the low platelet count leads to panic and unnecessary thrombocytopenia (ITP) which may be primary or
investigations. secondary to an associated immunological disorder.25
Extremely microcytic or fragmented RBCs may be ITP is a diagnosis of exclusion. It is crucial to rule out
wrongly counted as platelets causing an inaccurate higher a thrombotic thrombocytopenia purpura (TTP) in the
platelet count. This becomes more significant when the appropriate clinical setting by looking for fragmented
platelet counts are low. cells (schistocytes) in the PS and analysing the serum
LDH as TTP has a 90% mortality if plasmapheresis is not
In these situations, the platelet and the RBC histograms started early. Another life threatening situation is Heparin
overlap with each other and the instrument gives a flag induced thrombocytopenia which needs to be considered
which warrants a peripheral smear check. A manual in patients exposed to unfractionated heparin.26
platelet count is useful in such situations.
Thrombocytosis(>450,000/ul) is seen in inflammatory
 332 states, infections and IDA. However, persistent and red blood cell distribution width in the differential
thrombocytosis in the absence of these conditions may diagnosis of microcytic anaemias. Arch Pathol Lab Med 1992;
indicate an underlying chronic myeloproliferative 116:1030-32.
neoplasm like CML, essential thrombocytosis , idiopathic 4. Bain B J, Lewis M S, Bates I 2006. Basic haematological
myelofibrosis, etc. In such situations, bone marrow techniques in Lewis, Bain and Bates (ed) Dacie and Lewis
trephine biopsy and molecular tests for BCR;ABL1, JAK2 Practical Haematology. Elseiver Ltd.
mutation, CALR mutations are warranted.27 5. Glader B. 2004. Anaemia:general consideration in Greer
JP, Foerster J, Rodgers G M, et al (ed) Wintrobe’s clinical
IMMATURE PLATELET FRACTION (IPF) haematology. Lippincott Williams and Wilkins.
Akin to the reticulocyte count in RBCs is the IPF in the 6. Aslinia F, Mazza JJ, Yale SH. Megaloblastic anaemia and
platelets (Figure 8). In the higher end Sysmex analyzers other causes of macrocytosis. Clin Med Res 2006; 4:236-241.
it is possible to reliably quantify the fraction of the most 7. Mentzer WC. Differentiation of iron deficiency from
HAEMATOLOGY

immature platelets containing RNA (reticulated platelets) thalassemia trait. Lancet 1973; 1:449-52.
which is expressed as the IPF % (reference range-1.1 to 8. Weiss G, Goodnough L T. Anaemia of chronic disease.
6.1%).28 NEJM 2005; 352:1011-1023.
In a case of thrombocytopenia, a high IPF indicates 9. Punnonen K, Irjala K, Rajamaki A. Serum transferrin
adequate bone marrow production with peripheral loss/ receptor and its ratio to serum ferritin in the diagnosis of
destruction of platelets. It is seen that with recovering iron deficiency. Blood 1997; 3:1052-1057.
platelet counts, the IPF value falls. Thus, it is a very useful 10. Brugnara C, Schiller B, Moran J. Reticulocyte haemoglobin
parameter in the diagnosis of various thrombocytopenias equivalent (Ret He) and assessment of iron deficient states.
associated with increased peripheral destruction, eg., ITP/ Clin Lab Haem 2006; 28:303-308.
TTP.28 11. Thomas C and Thomas L. Biochemical markers and
haematologic indices in the diagnosis of functional iron
IPF has been found useful in the management of Dengue. deficiency. Clin Chem 2002; 48:1066-1076.
In a small study of 32 patients, 93.75% of the patients 12. Thomas Wayne D, Hinchliffe Rod F, Briggs C et al.
showed platelet recovery within 24–48 h if the IPF was Guideline for the diagnosis of functional iron deficiency.
more than 10% and 100% patients showed a recovery British Journal of Haematology 2013; 161:639-648.
within 24 h of the fall of the IPF compared with the 13. Tefferi A, Gilliland DG. The JAK 2V617F tyrosine kinase
previous days.29 mutation in myeloproliferative disorders:status report
and immediate implications for disease classification and
SUMMARY diagnosis. Mayo Clin Proc 2005; 80:947-958.
The CBC is often the starting point in the investigation
14. Silva M, Fourcade C, Fartoukh C et al. Lymphocyte volume
of a sick patient and important clinical decisions are
and conductivity indices of the haematology analyzers
made based on the findings. Today, the CBC is obtained Coulter GEN.STM in lymphoproliferative disorders and
from automated analyzers which give fast, accurate viral diseases. Clin Lab Hem 2006; 28:1-28.
and reproducible results. Parameters like the RDW are
15. Chaves F, Tierno B and Xu D. Quantitative determination
obtained only from the automated counters. Newer of neutrophil VCS parameters by the Coulter automated
parameters like Ret-He have been incorporated into hematology analyzer:new and reliable indicators for acute
international guidelines for investigation of FID. A basic bacterial infection,. Am J Clin Path 2005; 124:440-444.
understanding of the technologies makes one aware of 16. Briggs C, Da Costa A, freeman L, et al. Development of
the pitfalls and possible problems. While interpreting an automated malaria discriminant factor using VCS
an abnormal CBC, it is important to take the patient’s technology. Am J Clin Path 2006; 126:691-698.
clinical status into account and to review previous reports 17. Hallel M, Cheson BD, Catovsky D, et al. Guidelines for the
if any. For eg., neutrophilia in a hospitalized patient diagnosis and treatment of chronic lymphocytic leukaemia.
occurring over 2-3 days is likely to be due to an acute Blood 2008; 111:5446-5456.
stress/infection while neutrophilia sustained over months 18. Pardanani A, Brockman SR, Paternoster SF et al. FIP1L1-
in the absence of any apparent illness may be due to a PDGFRA fusion:prevalece and clinicopathologic correlates
myeloproliferative neoplasm like chronic neutrophilic in 89 consecutive patients with moderate to severe
leukaemia. Platelets are the most difficult cells to count eosinophilia. Blood 2004; 104:3038-3045.
due to the inherent problems associated with impedance 19. Plosker GL, Figgit DP. Rituximab:a review of its use in non
technology. Methods like platelet-F give highly accurate Hodgkin’s lymphoma and chronic lymphocytic leukaemia.
counts. Newer parameters like IPF have been found to Drugs 2003; 63:803-843.
be in management of dengue and are being incorporated 20. Bizzaro, N., et al. EDTA-Dependent
into the routine CBC. Pseudothrombocytopenia: A Clinical and Epidemiological
Study of 112 Cases, With 10-Year Follow-Up. American
REFERENCES Journal of Hematology 1995; 50:103-109.
1. 2016 Wallace H. Coulter Foundation. http.//www.whcf.org
21. Drachman J G. Inherited thrombocytopenia:when a low
2. Briggs C. Quality counts:new parameters in blood cell platelet count does not mean ITP. Blood 2004; 103:390-398.
counting. Int J Lab Hem 2009; 31:277-297.
22. Harris V. K. N and Harris S. Harris Platelet Syndrome—
3. Lin CK, Lin JS, Chen SY et al. Comparision of haemoglobin
 Underdiagnosed and unrecognized. Archives of Pathol Lab molecular weight heparin prophylaxis:a meta analysis. 333
Med 2008; 10:1546. Blood 2005; 106:2710-2715.
23. Briggs C, Harrison P, Machin SJ. Continuing developments 27. Arber DA, Orazi A, Hasserjian R, Thiele T, et al. The
with the automated platelet count. Int J Lab Hem 2007; 2016 World health Organisation classification of myeloid
29:77-91. neoplasms and acute leukaemias. Blood 2016; 127:2391-
24. Schoori M, schoori M, Oomes J, van Pelt J. New fluorescent 2405.
method (PLT-F) on Sysmex XN2000 hematology analyzer 28. Briggs C, Kunka S, Hart D, Ogumi S, et al. assessment of
achieved higher accuracy in low platelet counting. Am J immature platelet fraction in peripheral thrombocytopenia.
Clin Pathol 2013; 140:495-9. British Journal of Haematology 2004; 126:93-99.
25. Stasi R. How to approach thrombocytopenia. Hematology 29. Dadu T, Sehgal K, Joshi M, Khodaiji S. Evaluation of the
Am Soc Hematol 2012; 2012:191-197. immature platelet fraction as an indicator of platelet
26. Martel N, Lee J, Wells PS. Risk for heparin induced recovery in dengue patients. Int J Lab Hematol 2014; 36:499-
thrombocytopenia with unfractionated heparin and low 504.

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