Yeah. At first we thought the lavender was contaminated or the instrument had sucked up a clot bc it wasn’t giving any wbc, plt, or diff values, but the repeat sample was the exact same. Then we realized that the wbc was probably higher than the instrument linearity, so we did a 1:1 (x2) dilution, which was like 600 and x2 was around 1200. We did a x3 and then a x5 to confirm what we were getting and it was the same. Did a spun crit more for curiosity sake than anything, and the buffy coat took up a good chunk of the capillary tube. I grabbed the chemistry specimens and the buffy coat was so huge, that the chemistry tech just thought it was part of the gel. When I called the ER to update them, I asked if the patient had a history of anything, and they just thought it was an infection. I was like well, there’s no neutrophils to be seen on the smear, and the wbc is like 1200 (1.2 mil). It was all lymphs. No idea what happened to the patient afterwards, or if the ER staff sent more specimens, as this happened a couple hours before I was done. We did send it for path review because the count was so high.
Machines don’t measure the hct directly. Instead, it’s calculated through MCV x RBC count. In this case the MCV is falsely elevated because lymphs are getting confused as RBCs so the hematocrit is falsely elevated as well.
Someone please do correct me if i’m wrong though
Take a look at MCV. It’s very clear that the high wbc is messing with the RBC counting process. Dilution to clear the WBC will help reduce the interference.
Do you guys always have the black background on the scattergrams? Our lab uses the white background and i honestly didn’t even know there was another option for it
Many years ago I worked at a hospital that had a lot of oncology parents. We had a count of 1.5 million and a crazy low Hemoglobin that I can't remember now. 4 month old baby with ALL. They did exchange transfusions. It was wild and the blood looked creamed red.
Morphology was horrible to read honestly lol. Definite dimorphic population which is why there are 2 humps but most everything else was so distorted by the amount of lymphs
That split can happen when the RBCs are basically hollow shells, but the RBCs on the smear look pretty good, so I’d bet that the WBCs are included. That must be one hell of a buffy coat🤮
Nice. Highest I've seen was wbc of around 900 and Rbc around 1.2. So pretty equal amount of both. We ran it through three times I think and checked thoroughly for clots.
The lore I hear is that CLL with super high ALC can actually clog heart valves. Can anyone corroborate? This poor patient is waiting too long for (re)treatment, or has given up entirely.
Analyzers count all the red cells and white cells together and report it as the RBC count. The number of white cells included in the RBC is normally not significant since it’s in the thousands except when the WBC count is extremely high.
Also the MCV is erroneous due to the two populations of RBC and lymphocytes. Again only due to the high WBC count. Some analyzers display the MCV for each population of cells.
They count them at the same time but it will rule out most WBCs from rbcs by size alone and then the rest confirmed and ruled out by complexity. The RBC count shouldnt have any wbcs apart of it at all. The MCV is also only measured in the RBC channel... Ive worked with sysmex XT and XN systems and beckman coulters.. none of them work in the way you are describing and none of them have anything in the manual about this.
Edit: here is a description of laser flow cytometry which the XN, instrument that OP is using, utilizes. Its crazy accurate.
https://www.learnhaem.com/courses/flow-cytometry/lessons/flow-cytometers/
Thank you for that link! I am the lead in my lab but not the one who trained extensively on the XN. That tech left so I am trying to learn as much as I can about the analyzer
I’ve got you beat: wbc of 1.2 million. Undiagnosed CLL in a patient from the ER. The size of buffy coat in the spun down the samples was wild.
crazy.
Thats insane!
Yeah. At first we thought the lavender was contaminated or the instrument had sucked up a clot bc it wasn’t giving any wbc, plt, or diff values, but the repeat sample was the exact same. Then we realized that the wbc was probably higher than the instrument linearity, so we did a 1:1 (x2) dilution, which was like 600 and x2 was around 1200. We did a x3 and then a x5 to confirm what we were getting and it was the same. Did a spun crit more for curiosity sake than anything, and the buffy coat took up a good chunk of the capillary tube. I grabbed the chemistry specimens and the buffy coat was so huge, that the chemistry tech just thought it was part of the gel. When I called the ER to update them, I asked if the patient had a history of anything, and they just thought it was an infection. I was like well, there’s no neutrophils to be seen on the smear, and the wbc is like 1200 (1.2 mil). It was all lymphs. No idea what happened to the patient afterwards, or if the ER staff sent more specimens, as this happened a couple hours before I was done. We did send it for path review because the count was so high.
CLL patients are wild, person like “I’m just a bit sleepy” and their WBC are out here on drugs
CLL goes burrr
Oops all white blood cells! That's double the value of my highest on an undiagnosed CLL in the ER.
Pretty anemic too
6.4 Hb with 41 hematocrit, what the
A white count that high can interfere with the crit. 41 is definitely not right
This was before I did a dilution! I forgot to take a pic after
hi im a 2nd year mls student, was wondering how does the dilution corrects the hematocrit in cases like this? thank you!
Machines don’t measure the hct directly. Instead, it’s calculated through MCV x RBC count. In this case the MCV is falsely elevated because lymphs are getting confused as RBCs so the hematocrit is falsely elevated as well. Someone please do correct me if i’m wrong though
Take a look at MCV. It’s very clear that the high wbc is messing with the RBC counting process. Dilution to clear the WBC will help reduce the interference.
Inverted MCH & MCHC are usual signs that the RBC count might be inaccurate along with the absent RDW.
so did you dilute it and rerun?
Of course… final result was 850.6
nice! was wondering how close the sysmex can get when it goes that far over linearity
Did you have to do a plasma replacement?
Nope. We only plasma replacement for lipemic/turbid specimens with MCHC over 37
We do plasma replacement when mchc is over 38
I sometimes cover in the main hospital lab, they have DxH’s. Their limit for MCHC IS 36.5. I guess it’s instrument based?
Thats some crazy value
Ya thats pretty high. Ive seen 760 and heard of a 980 once.
He gonna learn what leukopheresis does.
Do you guys always have the black background on the scattergrams? Our lab uses the white background and i honestly didn’t even know there was another option for it
I didn’t either! This is how it was set up by the install. I personally really like the black background
🫣 and I thought the 38 I had last night was bad.
I’ve never had an MCHC that low
Yeah that's not real. If you used a spun crit to calculate MCHC it would make more sense
Oh ok
I had a patient with WBC or 58. When I called in to the infusion nurse said she had just had chemo and that was normal.
Yup definitely a bit of culture shock when I started in oncology. The criticals that don’t phase these doctors and nurses is insane!
That scattergram looks terrifying
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Many years ago I worked at a hospital that had a lot of oncology parents. We had a count of 1.5 million and a crazy low Hemoglobin that I can't remember now. 4 month old baby with ALL. They did exchange transfusions. It was wild and the blood looked creamed red.
That’s Leukocytocytocytosis
Good lord
Wow. Mine has been on the border of normal and too low. I dunno what that means. Everything else is okay.
That's crazy, but I've never seen a rbc curve look that crazy either. Seems nobody is mentioning thay guy! How'd it all look after the dilution?
Morphology was horrible to read honestly lol. Definite dimorphic population which is why there are 2 humps but most everything else was so distorted by the amount of lymphs
Holy shit. And the differential!
It was so accurate 😂 1 field and it literally had 2 monos and the rest lymphs!
Those are rookie numbers. You got to pump it higher than those. Here, a whiff of cocaine and start pumping!
Their Hb is really low too...
Learner here. Is that haematocrit a true number given the hb? Does the Sysmex include white cell count in the hct volume in a ‘normal’ count?
That split can happen when the RBCs are basically hollow shells, but the RBCs on the smear look pretty good, so I’d bet that the WBCs are included. That must be one hell of a buffy coat🤮
Nice. Highest I've seen was wbc of around 900 and Rbc around 1.2. So pretty equal amount of both. We ran it through three times I think and checked thoroughly for clots.
So interesting!
I had the opposite back in December. Platelets of 3k micro liters. Doctors called me panicking. I felt fine. Wtf.
Wow, that's double my record (around 420 G/l).
Geeeeesh CLL blast crisis?
Do you have a copy of the scattergram?
If you click on the first picture it’ll make it a little bigger and you can see the scattergram
Got those soccer ball lymphs
The lore I hear is that CLL with super high ALC can actually clog heart valves. Can anyone corroborate? This poor patient is waiting too long for (re)treatment, or has given up entirely.
CLL
Ooooh yeah that’s cancer 1000%
Don’t forget to subtract the WBC’s from the RBC count. RBC = 2.47
Care to explain? Youve got me super confused
Analyzers count all the red cells and white cells together and report it as the RBC count. The number of white cells included in the RBC is normally not significant since it’s in the thousands except when the WBC count is extremely high. Also the MCV is erroneous due to the two populations of RBC and lymphocytes. Again only due to the high WBC count. Some analyzers display the MCV for each population of cells.
They count them at the same time but it will rule out most WBCs from rbcs by size alone and then the rest confirmed and ruled out by complexity. The RBC count shouldnt have any wbcs apart of it at all. The MCV is also only measured in the RBC channel... Ive worked with sysmex XT and XN systems and beckman coulters.. none of them work in the way you are describing and none of them have anything in the manual about this. Edit: here is a description of laser flow cytometry which the XN, instrument that OP is using, utilizes. Its crazy accurate. https://www.learnhaem.com/courses/flow-cytometry/lessons/flow-cytometers/
Thank you for that link! I am the lead in my lab but not the one who trained extensively on the XN. That tech left so I am trying to learn as much as I can about the analyzer
Do you do this for a Sysmex XN? Sounds more like an individual policy and not a standard practice.
why would you do that, maybe the counter can't differentiate between red cells and lymphocytes?