Pemeriksaan Hematologi (I)

dr.Teguh Sarry Hartono. SpMK

•HB

•Hematokrit,

•Leukosit,

•Trombosit/Platelet

• Data demografik dan sosial ekonomik• Nama, jns kelamin,tgl lahir, alamat no MRData

administratif• Informed consent yang telah ditanda tangani

dan kewenangan pelepasan informasiData Legal

• Berkaitan dengan pembiayaan

Data finansial

• Baik pasien IGD, IRNA atau IRJA

Data klinis

4 komponen utama MR

Diagnosis

Tatalaksana / terapiEvaluasi

Siklus penatalaksanaan pasien

Diagnosis

Anamnesis

Pemeriksaan fisik

Pemeriksaan laboratorium

Pemeriksaan penunjang lainnya

Alur siklus diagnosis

Pemeriksaan Hematologi

Haematologi

Hematologi darah

Rutin Koagulasi Bank darah

Kimia darah / kimia klinik

Fungsi organ Kadar zat

blood cells

Haemopoiesis

Fraksi darah

Nilai normal bervariasi;

demografi usia, ras

Interpretasi hasil

Haemoglobin (Hb)

• Komponen utama eritrosit• Transport O2 dan CO2

• Tersusun atas senyawa heme (feritin / zat besi dan pigmen merah / porfirin) dan globin (protein)

• Berkaitan dengan anemia• Konsentrasi O2 dan CO2

Laki-laki : 14.0 - 17.4 g/dL

Women : 12.0 - 16.0 g/dL Nilai normal

Haemoglobin………

Implikasi klinis

1. Kadar Hb menurun :Pada kondisi anemia (terjadi pengurangan Hb, Ht dan atau Eritrosit)

• Evaluasi bersama Ht dan eritrosit• Iron deficiency, thalassemia, pernicious anemia,

hemoglobinopathies• Liver disease, hypothyroidism• Hemorrhage (chronic or acute)• Hemolytic anemia

• Hemolytic anemia caused by:1. Transfusions of incompatible blood2. Reactions to chemicals or drugs3. Reactions to infectious agents4. Reactions to physical agents (eg, severe burns,

artificial heart valves)5. Various systemic diseases:

• Hodgkin's disease• Leukemia• Lymphoma• SLE• Carcinomatosis• Sarcoidosis• Renal cortical necrosis

Haemoglobin………

2. Kadar Hb meningkat:• Polycythemia vera• Congestive heart failure• Chronic obstructive pulmonary disease (COPD)

3. Variasi kadar HB:• Occurs after transfusions, hemorrhages, burns. (Hb and

Hct are both high during and immediately after hemorrhage.)

• The Hb and Hct provide valuable information in an emergency situation if they are interpreted not in an isolated fashion but in conjunction with other pertinent laboratory data

Haemoglobin………

• Secara tidak langsung mengukur massa sel darah merah (sdm).

• Hasil dinyatakan dengan prosentasie volume sdm (packed RBC) dalam whole blood .

Hematokrit (Hct)

Laki-laki : 42 – 52%

Women : 36 – 48% Nilai normal

Hamatokrit………

Implikasi klinis

1. Kadar Ht menurun :1. Indikator anemia (berkurangnya whole blood)2. Ht <30% (<0.30) : anemia berat3. Kadar Ht menurun juga terjadi pada:

• Leukemias, lymphomas, Hodgkin's disease, myeloproliferative disorders

• Adrenal insufficiency• Chronic disease• Acute and chronic blood loss• Hemolytic reaction: this condition may be found in

transfusion of incompatible blood or as a reaction to chemicals or drugs, infectious agents, or physical agents (eg, severe burns, prosthetic heart valves).

Hamatokrit………

2. Kadar Ht meningkat:• Eritrositosis• Polycythemia vera• Syok (bila Ht sangat meningkat)

3. Kondisi lain yang berkaitan dengan Ht:• Tidak reliable setelah pendarahan sedang atau

transfusi• Dapat normal setelah pendarahan akut. Saat

recovery, Ht dan sdm dapat sangat turun • Fisiologis meningkat dalam kehamilan (hydremia)

Leukosit

• The WBC serves as a useful guide to the severity of the disease process.

• Specific patterns of leukocyte response can be expected in various types of diseases as determined by the differential count (percentages of the different types of leukocytes).

• Leukocyte and differential counts, by themselves, are of

little value as aids to diagnosis unless the results are related to the clinical condition of the patient; only then is a correct and useful interpretation possible

Leukosit….

4,5 – 10,5 x 103 sel/mm3Nilai normal

Implikasi klinis

1. Leukositosis (>11,000/mm3) 1. Infeksi akut : derajat lekositosis tergantung beratnya infeksi, daya

tahan pasien, usia dan efisinesi sumsun tulang)2. Penyebab lain :

1. Leukemia, myeloproliferative disorders2. Trauma or tissue injury (eg, surgery)3. Malignant neoplasms, especially bronchogenic carcinoma4. Toxins, uremia, coma, eclampsia, thyroid storm5. Drugs, especially ether, chloroform, quinine, epinephrine

(Adrenalin), colony-stimulating factors6. Acute hemolysis7. Hemorrhage (acute)8. After splenectomy9. Polycythemia vera10. Tissue necrosis

3. Occasionally, leukocytosis is found when there is no evidence of clinical disease. Such findings suggest the presence of:• Sunlight, ultraviolet irradiation• Physiologic leukocytosis resulting from excitement, stress,

exercise, pain, cold or heat, anesthesia• Nausea, vomiting, seizures

4. Steroid therapy modifies the leukocyte response.• When corticotropin (adrenocorticotropic hormone, or ACTH) is

given to a healthy person, leukocytosis occurs.• When ACTH is given to a patient with severe infection, the

infection can spread rapidly without producing the expected leukocytosis; therefore, what would normally be an important sign is obscured

Leukositosis…….

2. Leukopenia (<4,000/mm3)

1. Viral infections, some bacterial infections, overwhelming bacterial infections

2. Hypersplenism3. Bone marrow depression caused by heavy-metal

intoxication, ionizing radiation, drugs:• Antimetabolites, Barbiturates, Benzene, Antibiotics,

Antihistamines, Anticonvulsives, Antithyroid drugs, Arsenicals, Cancer chemotherapy (causes a decrease in leukocytes; leukocyte count is used as a link to disease), Cardiovascular drugs, Diuretics, Analgesics and antiinflammatory drugs

4. Primary bone marrow disorders:• Leukemia (aleukemic), Pernicious anemia, Aplastic

anemia, Myelodysplastic syndromes, Congenital disorders, Kostmann's syndrome, Reticular agenesis, Cartilage-hair hypoplasia, Shwachman-Diamond syndrome

5. Immune-associated neutropenia6. Marrow-occupying diseases (fungal infection, metastatic

tumor)7. Pernicious anemia

Leukopenia……..

Differential White Blood Cell Count (Diff; Differential Leukocyte Count) / Hitung jenis

Cell These Cells Function to Combat

Neutrophils Pyogenic infections (bacterial)

Eosinophils Allergic disorders and parasitic infestations

Basophils Parasitic infections, some allergic disorders

Lymphocytes Viral infections (measles, rubella, chickenpox, infectious mononucleosis)

Monocytes Severe infections, by phagocytosis

Function of Circulating WBCs According to Leukocyte Type

Neutrofil batang (%)

Neutrofil segmen (%)

Eosinofil (%)

Basosil (%)

Limfosit (%)

Monosit (%)

Nilai normal 3 - 6 50 - 62 0 - 3 0 - 1 25 - 40 3 - 7

Nilai normal hitung jenis

1. Neutrophilia (increased absolute number and relative percentage of neutrophils)a. Acute, localized, and general bacterial infections. Also, fungal and

spirochetal and some parasitic and rickettsial infections.b. Inflammation (eg, vasculitis, rheumatoid arthritis, pancreatitis, gout),

and tissue necrosis (myocardial infarction, burns, tumors).c. Metabolic intoxications (eg, diabetes mellitus, uremia, hepatic

necrosis)d. Chemicals and drugs causing tissue destruction (eg, lead, mercury,

digitalis, venoms)e. Acute hemorrhage, hemolytic anemia, hemolytic transfusion reactionf. Myeloproliferative disease (eg, myeloid leukemia, polycythemia vera,

myelofibrosis)g. Malignant neoplasms—carcinomah. Some viral infections (noted in early stages) and some parasitic

infections

Implikasi klinis hitung jenis netrofil

2. Ratio of segmented neutrophils to band neutrophils: normally 1% - 3% of PMNs are band forms (immature neutrophils).b. Degenerative shift to left: in some overwhelming infections, there is

an increase in band (immature) forms with no leukocytosis (poor prognosis).

c. Regenerative shift to left: there is an increase in band (immature) forms with leukocytosis (good prognosis) in bacterial infections.

d. Shift to the right: decreased band (immature) cells with increased segmented neutrophils can occur in liver disease, megaloblastic anemia, hemolysis, drugs, cancer, and allergies.

e. Hypersegmentation of neutrophils with no band (immature) cells is found in megaloblastic anemias (eg, pernicious anemia) and chronic morphine addiction.

Implikasi klinis neutrofil….

3. Neutropenia (decreased neutrophils)1. Causes associated with decreased or ineffective production:

1. Inherited stem cell disorders and genetic disorders or cellular development

2. Acute overwhelming bacterial infections (poor prognosis) and septicemia

3. Viral infections (eg, mononucleosis, hepatitis, influenza, measles)4. Some rickettsial and parasitical (protozoan) diseases (malaria)5. Drugs, chemicals, ionizing radiation, venoms6. Hematopoietic diseases (eg, aplastic anemia, megaloblastic

anemias, iron-deficiency anemia, aleukemic leukemia, myeloproliferative diseases)

2. Causes associated with decreased survival:1. Infections mainly in persons with little or no marrow reserves,

elderly people, and infants2. Collagen vascular diseases with antineutrophil antibodies (eg,

systemic lupus erythematosus [SLE] and Felty's syndrome)3. Autoimmune and isoimmune causes4. Drug hypersensitivity 5. Splenic sequestration

Implikasi klinis neutrofil….

3. Neutropenia in neonates (<5000/mm3 or <5.0 — 109/L or <1000/mm3 or <1.0 — 109/L after first week of life)1. Maternal neutropenia, maternal drug ingestion, maternal

isoimmunization to fetal leukocytes (maternal immunoglobulin G [IgG] antibodies to fetal neutrophils)

2. Inborn errors of metabolism (eg, maple syrup urine disease)3. Immune deficits acquired4. Deficits and disorders of myeloid stem cell (eg, Kostmann's

agranulocytosis, benign chronic granulocytopenia of childhood)5. Congenital neutropenia

4. Pregnancy progressive decrease until labor

Implikasi klinis neutrofil….

3. Neutropenia (decreased neutrophils)…………

Implikasi klinis hitung jenis eosinofil

1. Eosinophilia (increased circulating eosinophils)a. Allergies, hay fever, asthmab. Parasitic disease and trichinosis tapeworm, especially with tissue

invasionc. Some endocrine disorders, Addison's disease, hypopituitarismd. Hodgkin's disease and myeloproliferative disorders, chronic myeloid

leukemia, polycythemia verae. Chronic skin diseases (eg, pemphigus, eczema, dermatitis

herpetiformis)f. Systemic eosinophilia associated with pulmonary infiltrates (PIE)g. Some infections (scarlet fever, chorea), convalescent stage of other

infectionsh. Familial eosinophilia (rare), hypereosinophilic syndrome (HES)i. Polyarteritis nodosa, collagen vascular diseases (eg, SLE), connective

tissue disorders

j. Eosinophilic gastrointestinal diseases (eg, ulcerative colitis, Crohn's disease)

k. Immunodeficiency disorders (Wiskott-Aldrich syndrome, immunoglobulin A deficiency)

l. Aspirin sensitivity, allergic drug reactionsm. Loffler’s syndrome (related to Ascaris species infestation), tropical

eosinophilia (related to filariasis)n. Poisons (eg, black widow spider, phosphorus)o. Hypereosinophilic syndrome (>1.5 - 109/L), persistent extreme

eosinophilia with eosinophilic infiltration of tissues causing tissue damage and organ dysfunction

•Eosinophilic leukemia•Trichinosis invasion•Dermatitis herpetiformis• Idiopathic

Implikasi klinis hitung jenis eosinofil……

2. Eosinopenia (decreased circulating eosinophils) usually caused by an increased adrenal steroid production that accompanies most conditions of bodily stress and is associated with:b. Cushing's syndrome (acute adrenal failure): <50/mm3

c. Use of certain drugs such as ACTH, epinephrine, thyroxine, prostaglandins

d. Acute bacterial infections with a marked shift to the left (increase in immature leukocytes)

Implikasi klinis hitung jenis eosinofil……

1. Basophilia (increased count)a. Granulocytic (myelocytic) leukemiab. Acute basophilic leukemiac. Myeloid metaplasia, myeloproliferative disordersd. Hodgkin's disease

2. It is less commonly associated with the following:a. Inflammation, allergy, or sinusitisb. Polycythemia verac. Chronic hemolytic anemiad. After splenectomye. After ionizing radiationf. Hypothyroidismg. Infections, including tuberculosis, smallpox, chickenpox,

influenzah. Foreign protein injection

Implikasi klinis hitung jenis basofil

3. Basopenia (decreased count)c. Acute phase of infectiond. Hyperthyroidisme. Stress reactions (eg, pregnancy, myocardial infarction)f. After prolonged steroid therapy, chemotherapy, radiationg. Hereditary absence of basophilsh. Acute rheumatic fever in children

4. Presence of numbers of tissue mast cells (tissue basophils) is associated with:• Rheumatoid arthritis, Urticaria, asthma, Anaphylactic shock,

Hypoadrenalism, Lymphoma, Macroglobulinemia, Mast cell leukemia, Lymphoma invading bone marrow, Urticaria pigmentosa, Chronic liver or renal disease, Osteoporosis, Systemic mastocytosis

Implikasi klinis hitung jenis basofil……………………..

1. Monocytosis• most common causes are bacterial infections, tuberculosis,

subacute bacterial endocarditis, and syphilis.2. Other causes of monocytosis:

1. Monocytic leukemia and myeloproliferative disorders2. Carcinoma of stomach, breast, or ovary3. Hodgkin's disease and other lymphomas4. Recovery state of neutropenia (favorable sign)5. Lipid storage diseases (eg, Gaucher's disease)6. Some parasitic mycotic and rickettsial diseases7. Surgical trauma8. Chronic ulcerative colitis, enteritis, and sprue9. Collagen diseases and sarcoidosis10. Tetrachlorethane poisoning

Implikasi klinis hitung jenis monosit

Implikasi klinis hitung jenis monosit………

3. Phagocytic monocytes (macrophages) may be found in small numbers in the blood in many conditions:a. Severe infections (sepsis)b. Lupus erythematosusc. Hemolytic anemias

4. Decreased monocyte count is not usually identified with specific diseases:a. Prednisone treatmentb. Hairy cell leukemiac. Overwhelming infection that also causes neutropeniad. Human immunodeficiency virus (HIV) infectione. Aplastic anemia (bone marrow injury)

1. Lymphocytosisa. Lymphatic leukemia (acute and chronic) lymphomab. Infectious lymphocytosis (occurs mainly in children)c. Infectious mononucleosis:

• Caused by Epstein-Barr virus• Most common in adolescents and young adults• Characterized by atypical lymphocytes (Downey cells) that are

large, deeply indented, with deep blue (basophilic) cytoplasm• Differential diagnosispositive heterophil test

d. Other viral diseases:• Viral infections of the upper respiratory tract (pneumonia)• Cytomegalovirus• Measles, mumps, chickenpox• HIV infection• Infectious hepatitis (acute viral hepatitis)• Toxoplasmosis

Implikasi klinis hitung jenis limfosit

1. Lymphocytosis…………..e. Some bacterial diseases such as tuberculosis,

brucellosis (undulant fever), and pertussisf. Crohn's disease, ulcerative colitis (rare)g. Serum sickness, drug hypersensitivityh. Hypoadrenalism, Addison's diseasei. Thyrotoxicosis (relative lymphocytosis)j. Neutropenia with relative lymphocytosis

Implikasi klinis hitung jenis limfosit………….

2. Lymphopeniaa. Chemotherapy, radiation treatment (immunosuppressive

medications)b. After administration of ACTH or cortisone (steroids); with ACTH-

producing pituitary tumorsc. Increased loss via gastrointestinal tract owing to obstruction of

lymphatic drainage (eg, tumor, Whipple's disease, intestinal lymphectasia)

d. Aplastic anemiae. Hodgkin's disease and other malignanciesf. Inherited immune disorders, acquired immunodeficiency syndrome

(AIDS), and AIDS-immune dysfunctiong. Advanced tuberculosis (miliary tuberculosis), renal failure, SLE�h. Severe debilitating illness of any kindi. Congestive heart failure

Implikasi klinis hitung jenis limfosit………….

3. CD4 count (Normal > 400 sel/µL)A severely depressed CD4 count is the single best indicator of imminent opportunistic infection.a. Decreased CD4 lymphocytes

• Immune dysfunction, especially AIDS• Acute minor viral infections

b. Increased CD4 lymphocytes• Therapeutic effect of drugs• Diurnal variation: peak evening values may be two times

morning values

Implikasi klinis hitung jenis limfosit………….

Trombosit

• Platelets (thrombocytes) are the smallest of the formed elements in the blood.

• Platelet activity is necessary for blood clotting, vascular integrity and vasoconstriction, and the adhesion and aggregation activity that occurs during the formation of platelet plugs that occlude (plug) breaks in small vessels

140 – 400 x 103 sel/mm3Nilai Normal

1. Abnormally increased numbers of platelets (thrombocythemia, thrombocytosis) :a. Essential thrombocythemiab. Chronic myelogenous and granulocytic leukemia,

myeloproliferative diseasesc. Polycythemia vera and primary thrombocytosisd. Splenectomye. Iron-deficiency anemiaf. Asphyxiationg. Rheumatoid arthritis and other collagen diseases, SLEh. Rapid blood regeneration caused by acute blood loss, hemolytic

anemiai. Acute infections, inflammatory diseasesj. Hodgkin's disease, lymphomas, malignanciesk. Chronic pancreatitis, tuberculosis, inflammatory bowel diseasel. Renal failurem. Recovery from bone marrow suppression (thrombocytopenia)

Trombosit………….

2. Abnormally decreased numbers of platelets (thrombocytopenia)b. Idiopathic thrombocytopenic purpura, neonatal purpurac. Pernicious, aplastic, and hemolytic anemiasd. After massive blood transfusion (dilution effect)e. Viral, bacterial, and rickettsial infectionsf. Congestive heart failure, congenital heart diseaseg. Thrombopoietin deficiencyh. During cancer chemotherapy and radiation, exposure to

dichlorodiphenyl-trichloroethane (DDT) and other chemicalsi. HIV infectionj. Lesions involving the bone marrow (eg, leukemias, carcinomas,

myelofibrosis)k. DIC and thrombotic thrombocytopenic purpural. Inherited syndromes such as Bernard-Soulier syndrome, May-Hegglin

anomaly, Wiskott-Aldrich syndrome, Fanconi's syndromem. Toxemia of pregnancy, eclampsian. Alcohol toxicity, ethanol abuseo. Hypersplenismp. Renal insufficiencyq. Antiplatelet antibodies

Trombosit………….

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