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CBC / Haematology Report - Full Analysis
Summary of Values
| Parameter | Result | Reference | Status |
|---|---|---|---|
| Haemoglobin | 5.0 g/dL | 12-15 | 🔴 Critically LOW |
| RBC Count | 1.97 x10⁶/µL | 4.50-5.50 | 🔴 Very LOW |
| Haematocrit | 16.1% | 40.0-50.0 | 🔴 Very LOW |
| MCV | 81.7 fL | 83.0-101.0 | 🟡 Low-normal (borderline) |
| MCH | 25.4 pg | 28.0-33.0 | 🔴 LOW |
| MCHC | 31.1 g/dL | 31.5-34.5 | 🟡 Slightly low |
| RDW-CV | 14.6% | 11.6-14.0 | 🟡 Elevated |
| Total WBC | 10,750/µL | 4000-10000 | 🟡 Mildly elevated |
| Neutrophils | 74% | 43-78 | ✅ Normal |
| Lymphocytes | 18% | 14-45 | ✅ Normal |
| Monocytes | 5% | 0-10 | ✅ Normal |
| Eosinophils | 3% | 0-6 | ✅ Normal |
| Basophils | 0% | 0-1 | ✅ Normal |
| Platelet Count | 326 x10³/µL | 150-410 | ✅ Normal |
| MPV | 7.3 fL | 7-12 | ✅ Normal |
| Absolute Neutrophil Count | 7,955/µL | 1300-6000 | 🔴 HIGH |
Key Findings & Interpretation
1. Severe Anaemia (Critical)
- Haemoglobin of 5.0 g/dL is critically low - less than half the lower limit of normal. This is life-threatening and almost always requires urgent blood transfusion.
- RBC count (1.97) and haematocrit (16.1%) are both approximately 1/3 of normal, confirming severe, true anaemia - not a dilutional artefact.
2. Morphological Pattern - Microcytic Hypochromic Tendency
- MCV 81.7 fL is borderline low (just below normal lower limit of 83 fL) - near-microcytic
- MCH 25.4 pg is frankly low - hypochromic (less haemoglobin per RBC)
- MCHC 31.1 g/dL is slightly below normal - further evidence of hypochromia
- RDW-CV 14.6% is elevated - indicates anisocytosis (variation in RBC size), which is characteristic of iron deficiency or mixed deficiencies
3. Most Likely Diagnosis: Iron Deficiency Anaemia (IDA) - Severe
The combination of:
- Severely low Hb + low RBC
- Low MCV (borderline/mildly microcytic)
- Low MCH (hypochromic)
- Elevated RDW (anisocytosis)
...is the classic fingerprint of iron deficiency anaemia. The elevated RDW with borderline-low MCV is especially characteristic - in IDA, newly-formed small cells mix with older normal/larger cells, driving RDW up before MCV drops significantly.
Differential diagnoses to consider:
- Thalassaemia trait - also microcytic, but RDW is usually normal and MCV/RBC ratio (Mentzer index) would be < 13 (here: 81.7/1.97 = ~41, well above 13, favoring IDA)
- Anaemia of chronic disease - usually normocytic; less likely here
- Mixed IDA + folate/B12 deficiency - can give a similar picture with elevated RDW
4. Leukocytosis with Absolute Neutrophilia
- WBC 10,750/µL is mildly elevated
- Absolute Neutrophil Count (ANC) 7,955/µL exceeds the reference upper limit of 6,000/µL
- Per Robbins Pathology, neutrophilia (ANC > 7,500/mm³) is commonly associated with bacterial infection
- This suggests a concurrent bacterial infection or active inflammatory state, which is also a common cause of chronic blood loss leading to iron deficiency
5. Platelets - Normal
Platelet count 326 x10³/µL is entirely within range, which argues against bone marrow failure or consumptive coagulopathy as primary causes.
Clinical Urgency
| Priority | Action |
|---|---|
| Immediate | Assess symptoms (chest pain, dyspnoea, altered consciousness) - Hb 5.0 may need emergency packed RBC transfusion |
| Urgent | Serum ferritin, serum iron, TIBC to confirm IDA |
| Urgent | Investigate source of blood loss (GI endoscopy, gynaecological evaluation) |
| Concurrent | Peripheral blood smear for RBC morphology |
| Workup | Blood cultures / CRP / ESR to evaluate the concurrent neutrophilia |
| Follow-up | Reticulocyte count to assess bone marrow response |
Important note: This analysis is for educational interpretation only. All clinical decisions must be made by the treating physician in the context of the full patient history, symptoms, and examination findings.
DCT 4 plus
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DCT 4+ - What This Means for This Patient
What is the DCT (Direct Coombs Test)?
The Direct Antiglobulin Test (DAT) / Direct Coombs Test detects antibodies or complement proteins already bound to the surface of the patient's own red blood cells (RBCs). It is performed by adding antihuman immunoglobulin to a sample of the patient's washed RBCs - if agglutination (clumping) occurs, the test is positive.
Grading scale:
| Grade | Agglutination | Meaning |
|---|---|---|
| 1+ | Weak | Few antibodies on RBCs |
| 2+ | Moderate | Moderate coating |
| 3+ | Strong | Heavy coating |
| 4+ | Very strong | Maximal - dense antibody coating |
A DCT of 4+ is the strongest possible result - indicating very heavy coating of RBCs with antibody and/or complement.
Revised Diagnosis: Autoimmune Haemolytic Anaemia (AIHA)
Combined with the CBC from earlier, the DCT 4+ completely changes and clarifies the picture:
| Finding | Significance |
|---|---|
| Hb 5.0 g/dL (critically low) | Massive haemolysis destroying RBCs faster than production |
| RBC 1.97 x10⁶/µL | Severe RBC destruction |
| Low MCH / borderline MCV | Hypochromia from rapid RBC turnover, not necessarily iron deficiency |
| Elevated RDW 14.6% | Anisocytosis - mix of old coated cells and new reticulocytes |
| WBC 10,750 + ANC 7,955 | Reactive leukocytosis from haemolysis stress / underlying trigger |
| DCT 4+ | Confirms antibodies on RBC surface = AIHA |
Type of AIHA - Most Likely: Warm AIHA
Per Goldman-Cecil Medicine, warm AIHA accounts for 70-80% of all AIHA cases in adults. The DAT pattern in warm AIHA is either:
- IgG-positive alone, or
- IgG + C3 positive
Warm autoantibodies (mainly IgG1 isotype) bind RBCs optimally at 37°C and cause predominantly extravascular haemolysis in the spleen.
In contrast, cold AIHA (15-20%) shows a C3-positive but IgG-negative DAT pattern - less likely here.
Causes to Investigate (Secondary AIHA)
50-60% of warm AIHA cases are secondary to an underlying disease. This patient must be worked up for:
| Category | Specific Conditions |
|---|---|
| Autoimmune | SLE, rheumatoid arthritis, Sjogren syndrome |
| Lymphoid malignancy | Non-Hodgkin lymphoma, CLL (chronic lymphocytic leukaemia) |
| Infections | EBV, CMV, HIV, Mycoplasma pneumoniae |
| Drugs | Penicillins, cephalosporins, methyldopa, fludarabine |
| Other | Solid tumours, inflammatory bowel disease |
Important: A primary (idiopathic) warm AIHA can precede a non-Hodgkin lymphoma by many years - so long-term follow-up is mandatory even if no cause is found now. - Goldman-Cecil Medicine
Additional Lab Tests Now Required
| Test | Purpose |
|---|---|
| Peripheral blood smear | Look for spherocytes (present in 30-40% of AIHA), polychromasia, reticulocytes |
| Reticulocyte count | Elevated in haemolysis (regenerative anaemia) |
| Serum indirect bilirubin | Elevated due to RBC breakdown |
| LDH (lactate dehydrogenase) | Elevated with haemolysis |
| Serum haptoglobin | Decreased/absent - free Hb binds and depletes haptoglobin |
| DCT specificity | IgG vs C3 to classify warm vs cold AIHA |
| Indirect Coombs test (ICT) | Detect free antibodies in serum |
| Urine for haemoglobinuria | If intravascular haemolysis suspected |
| ANA, anti-dsDNA | Rule out SLE |
| CT scan chest/abdomen/pelvis | Rule out lymphoma |
| Serum protein electrophoresis | Rule out monoclonal gammopathy |
Treatment Approach
| Priority | Intervention |
|---|---|
| Immediate | Packed RBC transfusion (carefully - cross-matching difficult due to antibody coating; haematologist input essential) |
| First-line | Corticosteroids (prednisolone 1 mg/kg/day) - mainstay of treatment |
| Second-line | Rituximab (anti-CD20 antibody) if steroid-refractory or steroid-dependent |
| Third-line | Splenectomy after failure of medical management |
| Treat underlying cause | If secondary AIHA is identified |
Per Current Surgical Therapy and Schwartz's Surgery: splenectomy is third-line after corticosteroids and rituximab have failed. Some patients unfortunately experience haemolytic episodes even post-splenectomy.
Summary
This patient has severe AIHA (Hb 5.0 g/dL, DCT 4+) - almost certainly warm-type, with IgG autoantibodies massively coating their RBCs leading to extravascular haemolysis mainly in the spleen. The concurrent neutrophilia likely reflects either the haemolytic stress response or an underlying trigger (infection, lymphoma, autoimmune disease). This is a haematological emergency requiring urgent transfusion, steroid therapy, and full workup for secondary causes.
Clinical note: This interpretation is for educational purposes. Management must be guided by the treating haematologist.
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