A reference lab revolution - Episode 5
Examining the benefits of a CBC through a case study
What happens when an analysts flags abnormalities in a CBC report
Content sponsored by Zoetis
Adam Christman, DVM, MBA: So I understand we have a case that you're gonna go walk us through. Talk to me about that.
Laura Brandt, DVM, MS, DACVP (Clinical Pathology): Yeah. So this case is also going to kind of explain this process of basic CBC versus comprehensive CBC. And I think it's just a fantastic example, that just shows us how this process works. So we have a four year old female spayed boxer dog, in the clinic clinician submitted a basic CBC. And at this time, we had no clinical history on the dog. That's all. That's all that we got at the laboratory. And so you might be seeing now some information, some laboratory results. And this, this is the information from the basic CBC. So you'll see that there's a moderate leukocytosis. We also have a very severe anemia. Yeah, so we're quite, quite anemic. And this was just on a general submission. Well, we didn't know the history. And so always give us the history we love. We love. We love having history. Yeah. And so you can, you might notice some other red cell indicee changes here. So we have the CHCM is a little bit low, the MCV is a little bit high, the RDW is also increased. So all these things could be hinting that we have red cells that are a little bit too large, maybe not enough hemoglobin in them, maybe we have a ridiculous cytosis. And if we go to the next slide, you can absolutely see that we have a really massive regenerative response here with a retake count of almost 300,000. So this is fantastic. The dog's bone marrow is working, it's responding to the severe anemia, but something's going on. It's not allowing it to really recover from that anemia just yet. And so we need to take a closer look at that. And this, this actual numerical data from the hematology analyzer didn't necessarily flag anything that the analyzer wasn't capturing. But we have these these scatter plots, which are ancillary data, again, not not visible on your reports, they're a little bit complex to interpret, and we don't want to overwhelm you guys. So we kind of look at these behind the scenes, we train our technicians how to use them. And you'll see here on the left a normal dog. And on the right, we have our patient result, in this case, our boxer dog. And so if you just take a moment to look at those two slides, you might realize that there's some differences between the normal dog and the little dog. So you can see an upper right, that's our platelet scatterplot. And the platelets are kind of doing this weird thing, each little black dot here is an event. In this case, in this scatterplot, that event is considered to be a platelet by the analyzer. And you can see that all the little black dots are kind of aggregating at the top. So this is an abnormal distribution. And this is something that the technician is going to look at this and be like, is the analyzer really counting platelets is that automated count that you got on your report of 300, some odd platelets real or is there an interference in there...fragments of cells, something that the analyzer thinks are platelets. And so we're even though this is a basic CBC, we're going to take a quick look at that. And just make sure that the platelets really are platelets, and that that number kind of correlates, we also have some abnormalities down there, and the red cell scatterplot, where you can see the little black dots, instead of being in the nice center like the on the left for the normal dog, they're starting to drift up into the left. And this is showing that we have red cells that are bigger than normal, they have less hemoglobin. And so this is our reticular site population that we have kind of our emerging there. So we have an explanation for that. We're not going to worry about that, that all jives with what the analyzer said. And again, I have a close up here on the next one that's really showing you the platelets scatter plot and abnormalities there. So just so you can follow along with it. Yeah. You're like, this is fascinating.
Adam Christman, DVM, MBA: Yeah, it really is.
Laura Brandt, DVM, MS, DACVP (Clinical Pathology): And now we have...
Adam Christman, DVM, MBA: I think I know our diagnosis, but I don't want to say anything.
Laura Brandt, DVM, MS, DACVP (Clinical Pathology): You think you got it?
Adam Christman, DVM, MBA: I think it's IMHA but I'm not sure.
Laura Brandt, DVM, MS, DACVP (Clinical Pathology): You nailed it. Good job. Fantastic. And so when the technician went to look at the blood smear, and to assess those platelet numbers, they also noticed some some morphological changes in the red cells that concern them. So this report went out as a basic CBC, the technician made a note of please, please, we're seeing some pathology here. We really think that this is one that needs to go for a comprehensive evaluation, the clinician call back and with ours. Within hours, we had the comprehensive CBC reported out and as you can see in some of our images, we did have some sphere sites identified. Yeah, and we also saw some potential for agglutination on that slide, which caused us to do a saline agglutination test. That's a reflexive thing that we'll do and that saline agglutination tests was also positive and these are actual pictures from from this patient. We also saw some reactive lymphocytes. We saw some bands so a little bit of turning towards a left shift and some toxic change in those neutrophils. So we got a lot more information and a final diagnosis of IMHA in this patient, again, within hours, turn that out that dog can get started on its treatment, and hopefully had had towards the road to recovery.
Adam Christman, DVM, MBA: Continuing with that, no matter who it was, you know, it just certainly it's such a great flag and call to action to immediately take action to take care of that dogs. That's really impressive.
Laura Brandt, DVM, MS, DACVP (Clinical Pathology): I know I'm sure I can't I'm sure that this animal presented with some sort of clinical illness with a hematocrit of 11%. And so this is a great example to where that you're choosing the right patient for the right test. So this patient should have segwayed into a comprehensive CBC from the start. Sometimes that doesn't happen. For whatever reason, the wrong box gets ticked, whatever. And this is kind of the failsafe process we have in place to alert people and help them help them get the right diagnostics for their pet.
Adam Christman, DVM, MBA: Wow, that's fantastic.
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