Condensed Case

A hemoglobin and hematocrit were ordered on a patient for a surgical floor. The test was performed on the Coulter LH 750, and the hemoglobin and hematocrit were compatible with previous results. However, the instrument routinely reports the complete CBC, and while observing the entire nine parameters, the operator noticed that the platelet count was only 23,000, a critical value. The delta check on the patient from the previous day showed that the platelet count was 257,000, a significant difference. Corrective action needed to be taken. The operator decided to check the tube that she has just cycled through the instrument for clots, and a small clot was found. How many times should a purple top tube be inverted once drawn to prevent clotting?


The specimen that was sent from the floor was an improper sample that had probably not been properly collected. When drawing blood into a purple top tube, the tube must be inverted five to seven times for proper mixing of the anticoagulant and blood. Once the technologist noticed a small clot, corrective action needed to be taken. The technologist now had the responsibility of notifying the nurse of the erroneous results and asking for a redraw. Additionally, the erroneous results needed to be removed from the computer and the documentation of the situation and corrective action needed to be recorded. The sharp eye of the technologist/technician in this case made it possible for reliable results to eventually be obtained.

Summary Points

• Infections and inflammation will increase the number of neutrophils in the peripheral smear.

• Leukocytosis means an increase in white count.

• Eosinophils will be increased in skin diseases, parasitic infections, and transplant rejection.

• A left shift signifies that younger white cells will appear in the peripheral smear such as occasional metamyelocytes, many bands, and segmented neu-trophils.

• Leukemoid reaction is an exaggerated response to infection or inflammation.

• In the leukoerythroblastic picture, young white cells, young red cells, and abnormal platelets will be seen.

• Phagocytosis is a process by which bacteria and other infectious agents are recognized and destroyed by neutrophils and monocytes.

• Toxic changes in white cells are observed as toxic granulation, toxic vacuolization, and Döhle bodies.

• Hereditary white cell disorders include May-Hegglin anomaly, Pelger-Huet anomaly, and Chediak-Higashi syndrome.

• Pelger-Huet anomaly is a hyposegmentation disorder in which the lobes of the segmented neutrophils are peanut shaped or bilobed.

• A hypersegmented nucleus, five lobes or more, is seen in megaloblastic disorders.

• Chediak-Higashi syndrome is a rare autosomal disorder of neutrophilic granules.

• Human ehrlichiosis represents a group of tickborne diseases caused by Rickettsia Ehrlichia chafeen-sis and Ehrlichia phagocytophilia. Inclusions may be seen in the granulocytes and monocytes in the bone marrow.

• Reactive lymphocytes are lymphocytes transformed by viral infections or other disorders.

• Reactive lymphocytes are characterized by abundant basophilic cytoplasm, a lower N:C ratio, and clumped chromatin material.

• Infectious mononucleosis is caused by the Epstein-Barr virus, and patients show low-grade fever, sore throat, swollen glands, anorexia, and headache.

• Individuals with AIDS show a pancytopenia and a reversal in CD4 and CD8.

• Bacteria may appear intracellularly in neutrophils or may appear within the peripheral smear.

• Lipid storage diseases represent a group of inherited disorders in which a key metabolic enzyme is missing or inactive.

• Gaucher's disease and Niemann-Pick disease are lipid storage disorders showing large histiocytic-like cells in the bone marrow.

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