Complete blood count
What is being tested?
The complete blood count (CBC) is a test that evaluates the cells that circulate in blood. Blood consists of three types of cells
suspended in fluid called plasma: white blood cells (WBCs), red blood cells (RBCs), and platelets (PLTs). They are produced and
mature primarily in the bone marrow and, under normal circumstances, are released into the bloodstream as needed.
A CBC is typically performed using an automated instrument that measures various parameters, including counts of the cells that
are present in a person's sample of blood. The results of a CBC can provide information about not only the number of cell types but
also can give an indication of the physical characteristics of some of the cells. A standard CBC includes the following:
o Evaluation of white blood cells: WBC count; may or may not include a WBC differential
o Evaluation of red blood cells: RBC count, hemoglobin (Hb), hematocrit (Hct) and RBC indices, which includes mean
corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC),
and red cell distribution width (RDW). The RBC evaluation may or may not include reticulocyte count
o Evaluation of platelets: platelet count; may or may not include mean platelet volume (MPV) and/or platelet distribution
width (PDW) Significant
abnormalities in one or more of the blood cell populations can indicate the presence of one or more conditions. Typically
other tests are performed to help determine the cause of abnormal results. Often, this requires visual confirmation by
examining a blood smear under a microscope. A trained laboratorian can evaluate the appearance and physical
characteristics of the blood cells, such as size, shape and color, noting any abnormalities that may be present. Any
additional information is noted and reported to the healthcare provider. This information gives the health practitioner
additional clues as to the cause of abnormal CBC results.
The three types of cells evaluated by the CBC include: White
Blood Cells
There are five different types of WBCs, also called leukocytes, that the body uses to maintain a healthy state and to fight infections
or other causes of injury. They are neutrophils, lymphocytes, basophils, eosinophils, and monocytes. They are present in the blood
at relatively stable numbers. These numbers may temporarily shift higher or lower depending on what is going on in the body. For
instance, an infection can stimulate the body to produce a higher number of neutrophils to fight off bacterial infection. With allergies,
there may be an increased number of eosinophils. An increased number of lymphocytes may be produced with a viral infection. In
certain disease states, such as leukemia, abnormal (immature or mature) white cells rapidly multiply, increasing the WBC count.
Red Blood Cells
Red blood cells, also called erythrocytes, are produced in the bone marrow and released into the bloodstream as they mature. They
contain hemoglobin, a protein that transports oxygen throughout the body. The typical lifespan of an RBC is 120 days; thus the bone
marrow must continually produce new RBCs to replace those that age and disintegrate or are lost through bleeding. A number of
conditions can affect the production of new RBCs and/or their lifespan, in addition to those conditions that may result in significant
bleeding. The CBC determines the number of RBCs
and amount of hemoglobin present, the proportion of blood made up of RBCs (hematocrit), and whether the population of RBCs
appears to be normal. RBCs normally are uniform with minimal variations in size and shape; however, significant variations can
occur with conditions such as vitamin B12 and folate deficiencies, iron deficiency, and with a variety of other conditions. If the
concentration of red blood cells and/or the amount of hemoglobin in the blood drops below normal, a person is said to have anemia
and may have symptoms such as fatigue and weakness. Much less frequently, there may be too many RBCs in the blood
(erythrocytosis or polycythemia). In extreme cases, this can interfere with the flow of blood through the small veins and arteries.
Platelets
Platelets, also called thrombocytes, are special cell fragments that play an important role in normal blood clotting. A person who
does not have enough platelets may be at an increased risk of excessive bleeding and bruising. An excess of platelets can cause
excessive clotting or, if the platelets are not functioning properly, excessive bleeding. The CBC measures the number and size of
platelets present. Details on Red Blood Cell
Irregularities (RBC morphology) Size
o Anisocytosis: this is a variation in size of RBCs; it may be an indication of anemia
o Macrocytosis: large RBCs that may be due to a vitamin B12 or folate deficiency. They are seen in megaloblastic anemia
(e.g., pernicious anemia), chronic alcoholism, liver disease, thyroid disease, and myelodysplastic syndrome.
o Microcytosis: this is the presence of small RBCs that is commonly due to an iron deficiency anemia or to an inherited
disorder such as thalassemia.
Shape
o Poikilocytosis is a variation in the shape of RBCs and may include several different abnormalities at the same time.
o Acanthocytes (spur or spiculated cells): irregular shaped cells with 5-10 spicules; may be present in the blood of people
who have had their spleen removed (splenectomy) or with liver disease. They are also present in an inherited disorder
called abetalipoproteineimia.
o Echinocytes (burr or crenated): may have 10-30 blunt projections and often are seen in people with renal failure; may be
an artifact – something caused during sample preparation.
o Elliptocytes (ovalocyte): elliptical-shaped RBCs seen in hereditary elliptocytosis and various anemias, myelofibrosis.
o Fragmented cells (schistocytes, helmet cells): fragmented RBCs of various shapes that may be seen in people
with disseminated intravascular coagulation (DIC), hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, or
a vascular artificial device (prosthesis) such as a mechanical heart valve.
o Rouleaux: RBCs that appear as a stack of coins and are seen in people with multiple myeloma or Waldenstrom
macroglobulinemia because of increased serum proteins.
o Sickle cells: crescent-shaped RBCs that are characteristic of sickle cell anemia.
o Target cells: RBCs that resemble a bull's-eye; commonly seen in people with abnormal inherited forms of hemoglobin
(hemoglobinopathies), thalassemia, various anemias and liver disease.
o Teardrop cells (dacrocytes): RBCs that resemble a teardrop; often seen in people with myelofibrosis and thalassemia.
o Spherocytes: sphere-shaped RBCs that are often present in immune hemolytic anemia or hereditary spherocytosis.
Color
o Hypochromia/hypochromasia: this may be seen in a variety of disorders, including thalassemia and iron deficiency. The
RBC is pale in color due to insufficient hemoglobin and contains a large, hollow middle (central pallor) of the cell.
o Hyperchromia/hyperchromasia: the RBC is darker in color than normal due to a greater than normal concentration
of hemoglobinwithin the cell; this may be due to dehydration or presence of spherocytes.
o Polychromasia: blue-staining RBCs reflecting increased RNA content, indicating that they are immature due to early
release from the bone marrow.
Abnormal structures within the red blood cell
o Nucleated RBCs (NRBC, normoblasts): an immature form of RBCs seen when there is increased demand for RBCs to be
released by the bone marrow, or when there is marrow involvement by fibrosis or tumor; may be seen in severe anemia,
myelofibrosis, thalassemia, miliary tuberculosis, cancers that involve the bone marrow, and in chronic low oxygen levels
(hypoxemia). Nucleated RBCs can be normal in infants for the first two or three days after birth.
o Reticulocytes: these are immature RBCs that are usually a blue-staining (polychromatic) color. A few of these young red
blood cells are normal in the circulation, but they may be present in elevated numbers with acute blood loss, hypoxia,
RBC destruction, sickle cell disease, glucose-6-phosphate. dehydrogenase (G6PD) deficiency, and autoimmune
hemolytic anemia.
o Siderocyte, sideroblast, ring sideroblast: When RBCs are stained with Prussian blue dye, iron granules may be seen.
Sideroblasts are immature siderocytes and may actually form a ring pattern indicative of sideroblastic anemia.
o Basophilic stippling (punctate basophilia) is dark blue dots inside the RBC; due to abnormal aggregation of ribosomes and
polyribosomes and may be present in heavy metal intoxication (such as lead), thalassemia and many other anemias.
o Heinz bodies: large inclusion bodies (granules) in the RBCs when stained with a supravital stain like crystal violet; often
seen in the setting of an enzyme (G6PD) deficiency, drug-induced hemolysis, or unstable hemoglobin disease.
o Howell-Jolly bodies (small, round remnants of nuclear DNA inside cell): present in sickle cell anemia, hemolytic or
megaloblastic anemias, and may be seen after a splenectomy.
o Cabot ring: uncommon threadlike inclusions that form a loop or figure-of-eight structure within the RBC; may be seen in a
variety of anemias.
o Malarial parasites: in people with malaria, these parasites live inside RBCs and may be visible on a blood smear. This is
not a routine finding; these parasites are usually found in those who live in or have traveled to areas where the disease
is endemic.
Details on White Blood Cells
Neutrophils
NEUTROPHILS (also called segmented neutrophils, segs, polymorphonuclear cells, polys, or PMNs) are about 12 microns in
diameter and their function is to engulf and destroy invading organisms. They normally make up about 50-70% of the total WBC
count in the blood of older children and adults and may have two to five nuclear lobes connected by a thin strand of nuclear
material. This type of WBC may be seen in greater numbers during infections, malignancies, or extreme stress situations.
The cytoplasm of neutrophils is pale and often contains small pink to purple granules. These granules (specific granules and
azurophilic granules) contain certain enzymes and proteinsthat neutralize or destroy microbes. Bands are immature neutrophils with
a U-shaped nucleus.
Anomalies of neutrophils may include:
Toxic granulation: large dark blue granules in the cytoplasm, associated with severe infection, burns, trauma, and G-CSF
colony stimulating factor therapy; often reflects accelerated neutrophil maturation.
Vacuolization: vacuoles appear as holes in the cytoplasm and are frequently found in association with toxic granulation
but can also be a degenerative feature seen when the blood is stored for a prolonged period of time before preparing the
blood smear.
Döhle bodies: irregular grayish or bluish inclusions in the peripheral cytoplasm of neutrophils; they are denatured
aggregates of free ribosomes or rough endoplasmic reticulum that are often seen in association with toxic granules and
vacuoles. They may be present in association with infections, burns, trauma, or with exposure to cytotoxic agents
(i.e., chemotherapy). They may also be seen after cytokine stimulation (e.g., G-CSF) or during a normal pregnancy.
Auer rods: unique, pink or red rod-shaped inclusions that are seen in very immature myeloid cells ("blasts") or rarely more
mature neutrophils in people with acute myeloid leukemia or high-grade myelodysplastic syndrome.
Bands - increased numbers: slightly immature neutrophils are normal in the circulation in small numbers, but if there is a
percentage increase of them, there is said to be a "left shift." This may happen when an acute infection stimulates
increased neutrophil production, causing the bone marrow to prematurely release some WBCs before they have matured
to the neutrophil stage. Other immature forms that may sometimes be seen on a blood smear include myelocyte and
metamyelocyte or even promyelocyte and myeloblast.
Hypersegmentation: neutrophils with six or more nuclear segments; this is mainly associated with vitamin B12 and folate
deficiency and myelodysplasia but can also be seen with alcoholism and rarely as a hereditary condition.
Pelger-Huët anomaly: hereditary anomaly where neutrophils appear with fewer than two lobes; the nucleus is often in the
shape of a peanut or dumbbell, or may consist of two lobes connected with an obvious filament. They may also appear
with certain immunosuppressant drugs or in certain disease states such as myelodysplasia and is referred to a "pseudo-
Pelger-Huët anomaly".
Alder-Reilly granules: large, dark leukocyte granules that stain purple; they suggest mucopolysaccharidosis (an inherited
enzyme deficiency disorder, examples being Hurler's and Hunter's syndromes).
Chédiak-Higashi granules: an inherited anomaly characterized by the presence of big red, blue, or greenish granules that
may be found in granulocytes, lymphocytes, and monocytes. People with this syndrome may have oculocutaneous
albinism as well as a compromised immune system and photophobia.
Lymphocytes
are relatively small (7-10 µm) and round in shape. The nucleus is generally large in relation to the amount of cytoplasm. The
cytoplasm is pale blue and normally only a small proportion of lymphocytes has any granules. The nucleus of most lymphocytes is
smooth in appearance and is dark blue. There are two major
types of lymphocytes, B cell and T cell, but they cannot be distinguished when viewed under the microscope using standard staining
techniques. B cells can be differentiated from T cells using specific fluorescent-labeled antibody stains in conjunction with a special
instrument called a flow cytometer. B cells create specific antibodies while T cells can activate B cells as well as recognize and
destroy invading organisms. Lymphocytes normally make up about 20% to 40% of the total WBC count in adults and a higher
proportion in infants and young children.
o Reactive lymphocyte (atypical lymphocyte, activated lymphocyte): these cells are large lymphocytes that contain a greater
amount of cytoplasm and can vary in size and shape. Often a characteristic bluish tinge of cytoplasm is seen where the
cell abuts with surrounding RBCs. Increased numbers of atypical lymphocytes are found in viral illnesses such
as infectious mononucleosis.
o Hairy cells: these lymphocytes have tiny projections that make them appear hairy under the microscope; they are found in
hairy cell leukemia.
o Eosinophils
o Eosinophils have two or three lobes to their nucleus and contain characteristic reddish/orange granules in their cytoplasm.
They are most often involved in allergic responses and parasitic infections. Normally only about 1-4% of WBCs in the
blood are eosinophils.
o Monocytes
o Monocytes are the largest in size of the WBCs and comprise less than 6% in normal blood. They are characterized by
their abundant blue-grey cytoplasm that is irregular in shape and have a folded nucleus. The main function of monocytes
is to ingest microbes and respond to infection and inflammation by releasing certain proteins (monokines) that can
inactivate bacteria. When stimulated by cytokines, monocytes can move out of the blood and become tissue
macrophages.
o Basophils
o Basophils have a multi-lobed nucleus and have many dark blue granules (which contain histamines) in their cytoplasm.
Only about 1% of WBCs are basophils. A sight elevation in number may be seen during an allergic response, ulcerative
colitis, chronic sinusitis, chickenpox, or after immunizations. A significant increase is common in chronic myeloid
leukemia.
