血常规的儿科临床实践教学中的解读（原创）课件

Ding ZhouzhiDing ZhouzhiDepartment of Pediatrics Department of Pediatrics Bengbu Medical CollegeBengbu Medical CollegeDing ZhouzhiDepartment of PedCBCBlood RoutineRedBloodCellRBCHemoglubinHbRedbloodcellindices:MCV,MCH,MCHCHematocritHCTReticulocyteRetWhiteBloodCellWBC,leukocyteWhitebloodcelltypesWBCdifferentialNeutrophils,Lymphocytes,Monocytes,Eosinophils,andBasophilsPlatelet(thrombocyte)PLT,BPCMean platelet volume MPV5/26/20245/26/20242 2儿科学教研室儿科学教研室.临床实践教学临床实践教学CBCBlood RoutineRed Blood CeWhy It Is DoneFindthecauseofsymptomssuchasfatigue,weakness,fever,bruising,orweightloss.Checkforanemia.Seehowmuchbloodhasbeenlostifthereisbleeding.DiagnosepolycythemiaorCheckforaninfection.Diagnosediseasesoftheblood,suchasleukemia.Checkhowthebodyisdealingwithsometypesofdrugorradiationtreatment.Checkhowabnormalbleedingisaffectingthebloodcellsandcounts.Screenforhighandlowvaluesbeforeasurgery.Seeiftherearetoomanyortoofewofcertaintypesofcells.Thismayhelpfindotherconditions,suchastoomanyeosinophilsmaymeananallergyorasthmaispresent.5/26/20245/26/20243 3儿科学教研室儿科学教研室.临床实践教学临床实践教学Why It Is DoneFind the cause oRBC&Hb正常值随着年龄的变化而变化。5/26/20245/26/20244 4Red blood cell(RBC)countMen4.55.5millionRBCs/mcLor4.55.51012/LWomen4.05.0millionRBCs/mcLor4.05.01012/LChildren3.86.0millionRBCs/mcLor3.86.01012/LNewborn 4.16.1millionRBCs/mcLor4.16.11012/L5/26/20245/26/20244 4儿科学教研室儿科学教研室.临床实践教学临床实践教学RBC&Hb正常值随着年龄的变化而变化。8/5/2023RBC&Hb正常值随着年龄的变化而变化。5/26/20245/26/2024Hematocrit(HCT)Men42%52%or0.420.52volumefractionWomen36%48%or0.360.48volumefractionChildren29%59%or0.290.59volumefractionNewborn 44%64%or0.440.64volumefraction5/26/20245/26/20245 5儿科学教研室儿科学教研室.临床实践教学临床实践教学RBC&Hb正常值随着年龄的变化而变化。8/5/2023RBC&Hb5/26/20245/26/20246 6Hemoglobin(Hgb)Men1417.4gramsperdeciliter(g/dL)or140174gramsperliter(g/L)Women1216g/dLor120160g/LChildren9.520.5g/dLor95205g/LNewborn14.524.5g/dLor145245g/L5/26/20245/26/20246 6儿科学教研室儿科学教研室.临床实践教学临床实践教学RBC&Hb8/5/20236Hemoglobin(H5/26/20245/26/20247 7生后红细胞计数变化生后红细胞计数变化5/26/20245/26/20247 7儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/20237生后红细胞计数变化8/5/20237儿科学5/26/20245/26/20248 8生后生后Hb的变化的变化 The change of the level of postnatal hemoglobinThe change of the level of postnatal hemoglobin回目录25/26/20245/26/20248 8儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/20238生后Hb的变化 The change o红细胞增多症红细胞增多症红细胞数目、血红蛋白、红细胞压积和血液总容量显著地超过正常水平。新生儿期RBC7.0109/L，Hb220g/L。儿童时期RBC5.0109/L，Hb180g/L(16g/dl)，红细胞压积大于55%和每公斤体重红细胞容量绝对值超过35ml，排除因急性脱水或烧伤等所致的血液浓缩而发生的相对性红细胞增多，即可诊断。原发性的即真性红细胞增多症继发性的主要是由组织缺氧所引起的。5/26/20245/26/20249 95/26/20245/26/20249 9儿科学教研室儿科学教研室.临床实践教学临床实践教学红细胞增多症红细胞数目、血红蛋白、红细胞压积和血液总容量显著5/26/20245/26/20241010最低标准最低标准 Hb Hb minimum standard in normal childrenminimum standard in normal children年龄年龄Neonate14m46m6m59m511y1214yHb最低值(g/L)HCT145*90#100#1100.33*1151150.34*1200.36*-WHO标准(1972)#-联合国儿童基金会标准(1986)*-国内标准(1989)(海拔每海拔每1000米，相应诊断标准中米，相应诊断标准中Hb4%)5/26/20245/26/20241010儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202310最低标准 Hb minimum stan5/26/20245/26/20241111RBC&Hb生理性贫血PhysiologicanemiaPhysiologicanemia:PhysiologichemolysisIncreasedbloodvolumeTemporaryhypofunctionofmyeloidhematopoiesis使RBC生成不足,约23月时:RBC降至3.01012/L Hb降到100g/L左右，最低90g/L生后Hb变化5/26/20245/26/20241111儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202311RBC&Hb生理性贫血 Physio5/26/20245/26/20241212Graduation of anemia in childrenGraduationHbNeonate Hb轻度轻度90g/L120g/L中度中度60g/L 90g/L 重度重度30g/L 60g/L极重度极重度30g/L94323238单纯小细胞性80283238小细胞低色素性8028325/26/20245/26/20241313儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202313形态分类 Classification 5/26/20245/26/20241414形态学与病因学的关系形态学与病因学的关系(Relation between morphology and etiology)RBC形态病因正细胞性急性失血,溶血,再障,脾亢,肿瘤,急性感染大细胞性DNA合成障碍:Vit.B12、叶酸缺乏,幼年性恶性贫血,药物性贫血,红白血病单纯小细胞性缺铁早期,慢性感染,慢性疾病小细胞低色素性Hb合成障碍:缺铁性贫血,地中海贫血,铁粒幼性贫血.,慢性失血，铅中毒5/26/20245/26/20241414儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202314形态学与病因学的关系(Relatio网织红细胞的意义网织红细胞的意义网织红细胞增多：表示骨髓红细胞生成旺盛，常见于溶血性贫血，特别是急性溶血（高达0.60.8）。急性失血后510天网织红细胞达高峰，2周后恢复正常。网织红细胞减少：提示骨髓增生功能低下。见于再生障碍性贫血，溶血性贫血再生危象、药物性骨髓抑制时，典型再生障碍性贫血，网织红细胞计数常低于0.005.网织红细胞绝对值低于15109/L为再生障碍性贫血的诊断标准之一。5/26/20245/26/202415155/26/20245/26/20241515儿科学教研室儿科学教研室.临床实践教学临床实践教学网织红细胞的意义网织红细胞增多：表示骨髓红细胞生成旺盛，常见5/26/20245/26/20241616Disaster of LeukecytesNeoplasticDisordersofLeukocytesMDS;Myelodysplastic syndrome Non-NeoplasticDisordersofLeukocytes5/26/20245/26/20241616儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202316Disaster of Leukecyt5/26/20245/26/20241717不同年龄的白不同年龄的白细胞水平变化细胞水平变化Cord blood:1520109/L612h:2128109/L1w:12109/L50109/L，或外周血白细胞计数505/26/20245/26/20243838LymphocytosisAbsolute lymphocytosis：the absolute lymphocyte countAdult:4109/LOlderchildren7109/LInfants9109/LRelative lymphocytosisAdult:40%Children:5/26/20245/26/20243838儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202338LymphocytosisAbsolut5/26/20245/26/20243939Cause of LymphocytosisInfections:Acuteinfection:Infectiousmononucleosis,infectiouslymphocytosis,hepatitisandCMV,pertussis(百日咳)，chickenpoxChronicinfection:TB,Brucellosis(布氏杆菌病)Someprotozoalinfections:toxoplasmosisandAmericantrypanosomiasis(锥虫病)Post-Splenectomy StateAn autoimmune disorder causing ongoing(chronic)inflammation：Crohns disease，Ulcerative colitis，Vasculitis5/26/20245/26/20243939儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202339Cause of Lymphocytos5/26/20245/26/20244040淋巴细胞型类白血病反应淋巴细胞型类白血病反应白细胞数明显增多，超过50109/L，其中40%以上为淋巴细胞；若白细胞20%，并出现幼淋巴细胞；骨髓象除了有淋巴细胞增生外，没有白血病细胞的形态异常5/26/20245/26/20244040儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202340淋巴细胞型类白血病反应白细胞数明显增多，5/26/20245/26/20244141Monocytosis0.95109/L 或比值明显升高Causes:ChronicInflammation：Infections:tuberculosis,brucellosis,listeriosis,subacutebacterialendocarditis,syphilis,andotherviralinfectionsandmanyprotozoalandrickettsialinfections(e.g.kalaazar,malaria).Immunologicdisorders:Autoimmunediseasesandvasculitischronicneutropeniaandmyeloproliferativedisorders.5/26/20245/26/20244141儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202341Monocytosis0.951095/26/20245/26/20244242单核细胞型类白血病反应单核细胞型类白血病反应白细胞30l09/L，单核细胞30%；若白细胞5%；骨髓象除了有单核细胞增生外，没有白血病细胞的形态异常5/26/20245/26/20244242儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202342单核细胞型类白血病反应白细胞30l05/26/20245/26/20244343Eosinophilia0.45109/L Causes:AllergicdisordersParasiticinfectionsSomeformsofmalignancySystemicautoimmunediseases(e.g.SLE)SomeformsofvasculitisCoccidioidomycosis(球孢子菌病),InterstitialnephropathyHyperimmunoglobulinEsyndrome5/26/20245/26/20244343儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202343Eosinophilia0.45105/26/20245/26/20244444嗜酸粒细胞型类白血病反应嗜酸粒细胞型类白血病反应外周血嗜酸性粒细胞明显增加但无幼稚嗜酸粒细胞；骨髓中原始细胞比例不增高，嗜酸性粒细胞形态无异常5/26/20245/26/20244444儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202344嗜酸粒细胞型类白血病反应外周血嗜酸性粒细5/26/20245/26/20244545特发性嗜酸粒细胞增多综合征Idiopathic hypereosinophilic syndromeIdiopathic hypereosinophilic syndrome血中嗜酸粒细胞数量大于1.5109/L，并持续达6个月以上而无明显病因的一种疾病。主要损害心、肺、肝、皮肤以及神经系统。若不采取治疗，80以上的病人会在2年之内死亡；而治疗后80以上的病人能继续存活。治疗：强的松或羟基脲若病人对强的松和羟基脲无效，可选择其他各种药物，或白细胞去除术。5/26/20245/26/20244545儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202345特发性嗜酸粒细胞增多综合征 Idiop5/26/20245/26/20244646嗜酸粒细胞增多嗜酸粒细胞增多-肌痛综合征肌痛综合征一种嗜酸粒细胞增多并伴有肌痛、压痛、疲乏、肿胀、关节痛、咳嗽、呼吸急促、皮疹以及神经系统异常的疾病。该综合征少见。见于服用了大量色氨酸的患者停用色氨酸后可持续数周至数月，并能引起持久的神经损害，甚至偶可导致死亡目前不能治愈；一般建议理疗康复。5/26/20245/26/20244646儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202346嗜酸粒细胞增多-肌痛综合征一种嗜酸粒细胞5/26/20245/26/20244747Basophilia0.2109/LAllergicdisordersInfectionviral,TBInflammationjuvenilerheumatoidarthritis,ulcerativecolitisNeoplasmschronicmyeloproliferativedisorders,basophilicleukemia,carcinomaEndocrinediabetesmellitus,myxedema,estrogentherapy5/26/20245/26/20244747儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202347Basophilia0.2109/L5/26/20245/26/20244848红白血病型类白血病反应红白血病型类白血病反应外周血白细胞及有核红细胞总数50109/L并有幼稚粒细胞；若白细胞总数2%骨髓中除粒细胞系增生外，尚有红细胞系增生5/26/20245/26/20244848儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202348红白血病型类白血病反应外周血白细胞及有核5/26/20245/26/20244949浆细胞型类白血病反应浆细胞型类白血病反应白细胞总数增多或不增多，外周血浆细胞2%骨髓中除浆细胞系增生外，无原始细胞明显增生等白血病征象5/26/20245/26/20244949儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202349浆细胞型类白血病反应白细胞总数增多或不增5/26/20245/26/20245050Leukopenia外周血白细胞绝对计数持续低于4.0109/L Granulopenia：Neutropenia，eosinopenia，basopeniaLymphocytopenia 5/26/20245/26/20245050儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202350Leukopenia外周血白细胞绝对计数5/26/20245/26/20245151Neutropenia中性粒细胞减少症是血循环池中性多形核细胞(PMN)绝对值1.5 109/L(儿童期)，或1.0109/L(婴儿期)时所出现的一组综合征。轻型(1.01.5109/L)中型(0.51.0109/L)重型(0.5 109/L)(Agranulocytosis)5/26/20245/26/20245151儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202351Neutropenia中性粒细胞减少症是5/26/20245/26/20245252发病机制粒细胞生成减少或无效生成粒细胞破坏丧失过多，粒细胞寿命缩短粒细胞分布异常综合前3种机制。5/26/20245/26/20245252儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202352发病机制粒细胞生成减少或无效生成8/55/26/20245/26/20245353Causes of Neutropenia1.骨髓(1)骨髓损伤：药物：包括细胞毒和非细胞毒药物；放射线；化学物质：如苯、DDT、二硝基苯酚、砷酸、铋、一氧化氮等；某些先天性和遗传性中性粒细胞减少：如Kostmann综合征、伴先天性白细胞缺乏的网状发育不全、伴粒细胞生成异常的中性粒细胞减少等；免疫性疾患：如系统性红斑狼疮、类风湿性关节炎等；感染：细菌性感染，如伤寒、副伤寒、布鲁菌病、粟粒性结核；病毒感染，如肝炎、艾滋病等；血液病：如骨髓转移瘤、骨髓纤维化、淋巴瘤、白细胞减少的白血病、再生障碍性贫血、多发性骨髓瘤、恶性组织细胞增生症等5/26/20245/26/20245353儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202353Causes of Neutropeni5/26/20245/26/20245454Causes of Neutropenia1.骨髓(2)成熟障碍：获得性：如叶酸缺乏、维生素B12缺乏、恶性贫血、严重的缺铁性贫血等；恶性和其他克隆性疾病：如骨髓增生异常综合征、阵发性睡眠性血红蛋白尿症等5/26/20245/26/20245454儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202354Causes of Neutropeni5/26/20245/26/20245555Causes of Neutropenia2.外周血(1)中性粒细胞外循环池转换至边缘池(即假性中性粒细胞减少)：遗传性良性假性中性粒细胞减少症；获得性：如严重鶒的细菌感染，恶性营养不良病，疟疾等。(2)血管内扣留：如由补体介导的白细胞凝集素所致的肺内扣留、脾功能亢进所致的脾内扣留等。5/26/20245/26/20245555儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202355Causes of Neutropeni5/26/20245/26/20245656Causes of Neutropenia3.作用于血管外(1)利用增多鶒：如严重的细菌、真菌、病毒或立克次体感染、过敏性疾患等。(2)破坏增多：如脾功能亢进等。5/26/20245/26/20245656儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202356Causes of Neutropeni5/26/20245/26/20245757Treatmen of Neutropenia1.病因治疗2.抗感染3.升中性粒细胞数的治疗 4.骨髓移植 5/26/20245/26/20245757儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202357Treatmen of Neutrope5/26/20245/26/20245858Treatmen of Neutropenia抗感染只有发热而无脓毒血症表现者，尽量在门诊治疗以避免医院内继发感染严重中性粒细胞减少患者出现发热时，应以急诊患者对待，立即收入院治疗，有条件时应予逆向隔离。在进行皮肤、咽喉、血、尿、大便等部位的病菌培养检查后，立即给予经验性广谱抗生素治疗5/26/20245/26/20245858儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202358Treatmen of Neutrope5/26/20245/26/20245959Treatmen of Neutropenia抗感染若病原菌明确患者，则根据药敏试验改用针对性的窄谱抗生素若未发现病原菌，但经治疗后病情得以控制者在病情治愈后仍应继续给予口服抗生素714天若未发现病原菌，且经前述处理3天后病情无好转，对病情较轻者可停用经验性抗生素治疗，再次进行病原菌培养，若病情较重者应在原有治疗基础上加用抗真菌药，如两性霉素B等5/26/20245/26/20245959儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202359Treatmen of Neutrope5/26/20245/26/20246060Treatmen of Neutropenia升中性粒细胞数的治疗(1)促白细胞生成药：目前在临床上应用的很多，如维生素B6、维生素B4、利血生、肌苷、脱氧核苷酸、雄激素、碳酸锂等，但均缺乏肯定和持久的疗效，因此，初治患者可选用12种，每46周更换一组，直到有效，若连续数月仍不见效者，不必再继续使用。(2)免疫抑制药治疗：如糖皮质激素、硫唑嘌呤、环磷酰胺、大剂量人血丙种球蛋白输注等，对部分患者，如抗中性粒细胞抗体阳性或由细胞毒T细胞介导的骨髓衰竭患者等有效。(3)集落刺激因子治疗(4)中性粒细胞输注:由于中性粒细胞在外周血和组织中的生存期短，因此至少1次/d，连续3天方可起效。5/26/20245/26/20246060儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202360Treatmen of Neutrope5/26/20245/26/20246161Lymphopenia1.5109/L(adults)3.0109/L(children)Decreased productionImmunodeficiencysyndromesHodgkinlymphomaIncreased destructionDrugsRadiationAIDSLoss of lymphocytesCollagenvasculardiseasesLossoflymphIncreasedcentralvenouspressure5/26/20245/26/20246161儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202361Lymphopenia1.5109/5/26/20245/26/20246262Blood routineLiuhong,male,2 years old,Fever and sore throat for 2 daysRBC 3.021012/L Hb 92g/LWBC 11109/LN:0.68,L:0.32catalogue25/26/20245/26/20246262儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202362Blood routineLiuhong5/26/20245/26/20246363blood platelet100300109/L回目录25/26/20245/26/20246363儿科学教研室儿科学教研室.临床实践教学临床实践教学8/5/202363blood platelet10030血小板增多症血小板增多症原发性血小板增多症是一种原因不明的骨髓增生性疾病，本病的主要特点是外周血中血高，伴有出血倾向，血栓形成，肝脾肿大和粒细胞增多等。到底达到多少才能诊断？到底达到多少需要治疗？5/26/20245/26/202464645/26/20245/26/20246464儿科学教研室儿科学教研室.临床实践教学临床实践教学血小板增多症原发性血小板增多症是一种原因不明的骨髓增生性疾病Primary ITPPrimaryITPisanautoimmunedisordercharacterizedbyisolatedthrombocytopenia(peripheralbloodplateletcount100109/L)intheabsenceofothercausesordisordersthatmaybeassociatedwiththrombocytopenia.欧洲仍定义为peripheralbloodplateletcount150109/LThediagnosisofprimaryITPremainsoneofexclusion;norobustclinicalorlaboratoryparametersarecurrentlyavailabletoestablishitsdiagnosiswithaccuracy.ThemainclinicalproblemofprimaryITPisanincreasedriskofbleeding,althoughbleedingsymptomsmaynotalwaysbepresent.5/26/20245/26/20246565儿科学教研室儿科学教研室.临床实践教学临床实践教学Primary ITPPrimary ITP is an aThe IWG and The IWG and American Society of Hematology based American Society of Hematology based their recommendations for the use of an upper their recommendations for the use of an upper threshold platelet count of 100 10threshold platelet count of 100 109 9/L on three/L on three considerations:considerations:Astudydemonstratingthatpatientspresentingwithaplateletcountbetween100and150109/Lhaveonlya6.9%chanceofdevelopingapersistentplateletcountoflessthan100109/Lover10yearsoffollow-up;Recognitionthatinnon-Westernethnicitiesnormalvaluesinhealthyindividualsmaybebetween100and150109/L,Thehypothesisthatacut-offvalueof100109/Lwouldreduceconcernoverthemild“physiological”thrombocytopeniaassociatedwithpregnancy.5/26/20245/26/20246666儿科学教研室儿科学教研室.临床实践教学临床实践教学The IWG and American Society oPrimary ITPPrimaryITPisanautoimmunedisordercharacterizedbyisolatedthrombocytopenia(peripheralbloodplateletcount100109/L)intheabsenceofothercausesordisordersthatmaybeassociatedwiththrombocytopenia.欧洲仍定义为peripheralbloodplateletcount150109/LThediagnosisofprimaryITPremainsoneofexclusion;norobustclinicalorlaboratoryparametersarecurrentlyavailabletoestablishitsdiagnosiswithaccuracy.ThemainclinicalproblemofprimaryITPisanincreasedriskofbleeding,althoughbleedingsymptomsmaynotalwaysbepresent.5/26/20245/26/20246767儿科学教研室儿科学教研室.临床实践教学临床实践教学Primary ITPPrimary ITP is an aThe IWG and The IWG and American Society of Hematology based American Society of Hematology based their recommendations for the use of an upper their recommendations for the use of an upper threshold platelet count of 100 10threshold platelet count of 100 109 9/L on three/L on three considerations:considerations:Astudydemonstratingthatpatientspresentingwithaplateletcountbetween100and150109/Lhaveonlya6.9%chanceofdevelopingapersistentplateletcountoflessthan100109/Lover10yearsoffollow-up;Recognitionthatinnon-Westernethnicitiesnormalvaluesinhealthyindividualsmaybebetween100and150109/L,Thehypothesisthatacut-offvalueof100109/Lwouldreduceconcernoverthemild“physiological”thrombocytopeniaassociatedwithpregnancy.5/26/20245/26/20246868儿科学教研室儿科学教研室.临床实践教学临床实践教学The IWG and American Society oSee you next!5/26/20245/26/20246969儿科学教研室儿科学教研室.临床实践教学临床实践教学THE ENDSee you next!8/5/2023695/26/20245/26/20247070儿科学教研室儿科学教研室.临床实践教学临床实践教学儿科学教研室8/5/202370儿科学教研室.临床实践教学