血常规的儿科临床实践教学中的解读原创.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,BBMC,*,*,血常规的儿科临床实践教学中的解读(ji d)原创,第一页，共67页。,CBCBlood Routine,Red Blood CellRBCHemoglubinHbRed blood cell indices:MCV,MCH,MCHCHematocritHCT ReticulocyteRet,White Blood CellWBC,leukocyte,White blood cell types WBC differential,Neutrophils,Lymphocytes,Monocytes,Eosinophils,and Basophils,Platelet(thrombocyte),PLT,BPCMean platelet volume,MPV,2026/1/24 周六,2,第二页，共67页。,Why It Is Done,Find the cause of symptoms such as fatigue,weakness,fever,bruising,or weight loss.Check for anemia.,See how much blood has been lost if there is bleeding.,Diagnosepolycythemia or Check for an infection.,Diagnose diseases of the blood,such as leukemia.,Check how the body is dealing with some types of drug orradiation treatment.,Check how abnormal bleeding is affecting the blood cells and counts.,Screen for high and low values before a surgery.,See if there are too many or too few of certain types of cells.This may help find other conditions,such as too many eosinophils may mean anallergyorasthmais present.,2026/1/24 周六,3,第三页，共67页。,RBC&Hb,正常值随着(su zhe)年龄的变化而变化。,2026/1/24 周六,4,Red blood cell(RBC)count,Men,4.55.5 million RBCs/mcL or 4.55.510,12,/L,Women,4.05.0 million RBCs/mcL or 4.05.010,12,/L,Children,3.86.0 million RBCs/mcL or 3.86.010,12,/L,Newborn,4.16.1 million RBCs/mcL or 4.16.110,12,/L,2026/1/24 周六,4,第四页，共67页。,RBC&Hb,正常值随着年龄(ninlng)的变化而变化。,2026/1/24 周六,Hematocrit(HCT),Men,4252%or 0.420.52 volume fraction,Women,36%48%or 0.360.48 volume fraction,Children,29%59%or 0.290.59 volume fraction,Newborn,44%64%or 0.440.64 volume fraction,2026/1/24 周六,5,第五页，共67页。,RBC&Hb,2026/1/24 周六,6,Hemoglobin(Hgb),Men,1417.4grams per deciliter(g/dL)or140174grams per liter(g/L),Women,1216 g/dL or 120160 g/L,Children,9.520.5 g/dL or 95205 g/L,Newborn,14.524.5 g/dL or 145245 g/L,2026/1/24 周六,6,第六页，共67页。,2026/1/24 周六,7,生后红细胞计数(j sh)变化,2026/1/24 周六,7,第七页，共67页。,2026/1/24 周六,8,生后Hb的变化(binhu)The change of the level of postnatal hemoglobin,回目录(ml)2,2026/1/24 周六,8,第八页，共67页。,红细胞增多(zn du)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(zzh)缺氧所引起的。,2026/1/24 周六,9,2026/1/24 周六,9,第九页，共67页。,2026/1/24 周六,10,最低标准,Hb minimum standard in normal children,年龄,Neonate,14m,46m,6m59m,511y,1214y,Hb,最低值,(g/L)HCT,145,*,90,#,100,#,110,0.33,*,115,0.34,*,120,0.36,*,*-WHO标准(biozhn)(1972)#-联合国儿童 会标准(biozhn)(1986)*-国内标准(biozhn)(1989),(海拔每1000米，相应诊断标准(biozhn)中Hb4%),2026/1/24 周六,10,第十页，共67页。,2026/1/24 周六,11,RBC&Hb,生理性贫血(pnxu)Physiologic anemia:,Physiologic hemolysis,Increased blood volume,Temporary hypofunction of myeloid hematopoiesis,使RBC生成(shn chn)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(binhu),2026/1/24 周六,11,第十一页，共67页。,2026/1/24 周六,12,Graduation of anemia in children,Graduation,Hb,Neonate Hb,轻度,90g/L,120g/L,中度,60g/L,90g/L,重度,30g/L,60g/L,极重度,30g/L,94 32 3238 单纯小细胞性 80 28 3238 小细胞低色素性 80 28 32,2026/1/24 周六,13,第十三页，共67页。,2026/1/24 周六,14,形态学与病因学的关系(gun x)(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(pnxu),药物性贫血(pnxu),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(pnxu),地中海贫血(pnxu),铁 粒幼性贫血(pnxu).,慢性失血，铅中毒,2026/1/24 周六,14,第十四页，共67页。,网织红细胞的意义(yy),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(o d)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。,2026/1/24 周六,15,2026/1/24 周六,15,第十五页，共67页。,2026/1/24 周六,16,Disaster of Leukecytes,Neoplastic Disorders of Leukocytes,MDS;,Myelodysplastic syndrome,Non-Neoplastic Disorders of Leukocytes,2026/1/24 周六,16,第十六页，共67页。,2026/1/24 周六,17,不同(b tn)年龄的白细胞水平变化,Cord blood:152010,9,/L,612h:212810,9,/L,1w:1210,9,/L,6y:4.513.510,9,/L,L,eucocyte,2026/1/24 周六,27,第二十七页，共67页。,2026/1/24 周六,28,Blood Cell Indices During Gestation and at Birth,Week of Gestation,Corrected WBC Counts,(10,9,/L),Platelets,(10,9,/L),RBC,(10,9,/L),Hb,(g/dL),18,21,(n=760),2.57 0.42,234 57,2.85 0.36,11.69 1.27,22,25,(n=1,200),3.73 2.17,247 59,3.09 0.34,12.2 1.6,26,29,(n=460),4.08 0.84,242 69,3.46 0.41,12.91 1.38,30,(n=440),6.40 2.99,232 87,3.82 0.64,13.64 2.21,Term,18.1(9.0,30.0),290 100,4.70 0.40,16.5 1.5,2026/1/24 周六,28,第二十八页，共67页。,Older children 7109/L,Some forms of malignancy,第三十二页，共67页。,第六十六页，共67页。,红白血病型类白血病反应(fnyng),Primary ITP is an autoimmune disorder characterized by isolated thrombocytopenia(peripheral blood platelet count 50109/L，或外周血白细胞(xbo)计数 410,9,/L,Older children 710,9,/L,Infants 910,9,/L,Relative lymphocytosis,Adult:40%,Children:,2026/1/24 周六,38,第三十八页，共67页。,2026/1/24 周六,39,Cause of Lymphocytosis,Infections:,Acute infection:Infectious mononucleosis,infectious lymphocytosis,hepatitis and CMV,pertussis(,百日咳,),，,chicken pox,Chronic infection:TB,Brucellosis(,布氏杆菌病,),Some protozoal infections:toxoplasmosis and American trypanosomiasis(,锥虫病,),Post-Splenectomy State,An autoimmune disorder causing ongoing(chronic)inflammation,：,Crohn,s disease,，,Ulcerative colitis,，,Vasculitis,2026/1/24 周六,39,第三十九页，共67页。,2026/1/24 周六,40,淋巴细胞型类白血病反应(fnyng),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(xngti)异常,2026/1/24 周六,40,第四十页，共67页。,2026/1/24 周六,41,Monocytosis,0.95109/L 或比值(bzh)明显升高,Causes:,Chronic Inflammation：,Infections:tuberculosis,brucellosis,listeriosis,subacute bacterial endocarditis,syphilis,and other viral infections and many protozoal and rickettsial infections(e.g.kala azar,malaria).,Immunologic disorders:Autoimmune diseases and vasculitis,chronic neutropenia and myeloproliferative disorders.,2026/1/24 周六,41,第四十一页，共67页。,2026/1/24 周六42,单核细胞型类白血病反应(fnyng),白细胞30l09/L，单核细胞30%；若白细胞5%；,骨髓象除了(ch le)有单核细胞增生外，没有白血病细胞的形态异常,2026/1/24 周六,42,第四十二页，共67页。,2026/1/24 周六,43,Eosinophilia,0.45109/L,Causes:,Allergic disorders,Parasitic infections,Some forms of malignancy,Systemic autoimmune diseases(e.g.SLE),Some forms of vasculitis,Coccidioidomycosis(球孢子(boz)菌病),Interstitial nephropathy,Hyperimmunoglobulin E syndrome,2026/1/24 周六,43,第四十三页，共67页。,2026/1/24 周六,44,嗜酸粒细胞型类白血病反应(fnyng),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(znggo)，嗜酸性粒细胞形态无异常,2026/1/24 周六,44,第四十四页，共67页。,2026/1/24 周六,45,特发性嗜酸粒细胞增多(zn du)综合征 Idiopathic 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(jx)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。,2026/1/24 周六,45,第四十五页，共67页。,2026/1/24 周六,46,嗜酸粒细胞增多(zn du)-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(f yn)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。,2026/1/24 周六,46,第四十六页，共67页。,2026/1/24 周六,47,Basophilia,0.210,9,/L,Allergic disordersInfection,viral,TB,Inflammation,juvenile rheumatoid arthritis,ulcerative colitis,Neoplasms,chronic myeloproliferative disorders,basophilic leukemia,carcinoma,Endocrine,diabetes mellitus,myxedema,estrogen therapy,2026/1/24 周六,47,第四十七页，共67页。,2026/1/24 周六,48,红白血病型类白血病反应(fnyng),外周血白细胞及有核红细胞总数(zngsh)50109/L并有幼稚粒细胞；若白细胞总数(zngsh)2%,骨髓中除粒细胞系增生外，尚有红细胞系增生,2026/1/24 周六,48,第四十八页，共67页。,2026/1/24 周六,49,浆细胞型类白血病反应(fnyng),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(yunsh)细胞明显增生等白血病征象,2026/1/24 周六,49,第四十九页，共67页。,2026/1/24 周六,50,Leukopenia,外周血白细胞绝对计数(j sh)持续低于4.0109/L,Granulopenia：Neutropenia，eosinopenia，basopenia,Lymphocytopenia,2026/1/24 周六,50,第五十页，共67页。,2026/1/24 周六,51,Neutropenia,中性粒细胞减少(jinsho)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),2026/1/24 周六,51,第五十一页，共67页。,2026/1/24 周六,52,发病(f bng)机制,粒细胞生成(shn chn)减少或无效生成(shn chn),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。,2026/1/24 周六,52,第五十二页，共67页。,2026/1/24 周六,53,Causes of Neutropenia,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(ychng)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,2026/1/24 周六,53,第五十三页，共67页。,2026/1/24 周六,54,Causes of Neutropenia,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(qt)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,2026/1/24 周六,54,第五十四页，共67页。,2026/1/24 周六,55,Causes of Neutropenia,2.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(xjn)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。,2026/1/24 周六,55,第五十五页，共67页。,2026/1/24 周六,56,Causes of Neutropenia3.作用(zuyng)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。,2026/1/24 周六,56,第五十六页，共67页。,2026/1/24 周六,57,Treatmen of Neutropenia,病因治疗(zhlio),抗感染,升中性粒细胞数的治疗(zhlio),骨髓移植,2026/1/24 周六,57,第五十七页，共67页。,2026/1/24 周六,58,Treatmen 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(jy)经验性广谱抗生素治疗,2026/1/24 周六,58,第五十八页，共67页。,2026/1/24 周六,59,Treatmen 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(chl)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,2026/1/24 周六,59,第五十九页，共67页。,2026/1/24 周六,60,Treatmen 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(cj)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。,2026/1/24 周六,60,第六十页，共67页。,2026/1/24 周六,61,Lymphopenia,1.510,9,/L,(adults),3.0,10,9,/L(children),Decreased production,Immunodeficiency syndromes,Hodgkin lymphoma,Increased destruction,DrugsRadiation,AIDS,Loss of lymphocytes,Collagen vascular diseasesLoss of lymph,Increased central venous pressure,2026/1/24 周六,61,第六十一页，共67页。,2026/1/24 周六,62,Blood routine,Liuhong,male,2 years old,Fever and sore throat for 2 days,RBC 3.0210,12,/L Hb 92g/LWBC 1110,9,/LN:0.68,L:0.32,catalogue2,2026/1/24 周六,62,第六十二页，共67页。,2026/1/24 周六,63,blood platelet,10030010,9,/L,回目录(ml)2,2026/1/24 周六,63,第六十三页，共67页。,血小板增多(zn du)症,原发性血小板增多症是一种原因不明的骨髓(su)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？,2026/1/24 周六,64,2026/1/24 周六,64,第六十四页，共67页。,Primary ITP,Primary ITP is an autoimmune disorder characterized by isolated thrombocytopenia(peripheral blood platelet count 100109/L)in the absence of other causes or disorders that may be associated with thrombocytopenia.,欧洲(u zhu)仍定义为 peripheral blood platelet count 150109/L,The diagnosis of primary ITP remains one of exclusion;no robust clinical or laboratory parameters are currently available,to,establish its diagnosis with accuracy.The main clinical problem of primary ITP is an increased risk of bleeding,although bleeding symptoms may not always be present.,2026/1/24 周六,65,第六十五页，共67页。,The IWG and,American Society of,Hematology,based their recommendations for the use of an upper threshold platelet count of 100 10,9,/L on three considerations:,A study demonstrating that patients presenting with a platelet count between 100 and 15010,9,/L have only a 6.9%chance of developing a persistent platelet count of less than 10010,9,/L over 10 years of follow-up;,Recognition that in non-Western ethnicities normal values in healthy individuals may be between 100 and 15010,9,/L,The hypothesis that a cut-off value of 10010,9,/L would reduce concern over the mild“physiological”thrombocytopenia associated with pregnancy.,2026/1/24 周六,66,第六十六页，共67页。,Primary ITP,Primary ITP is an autoimmune disorder characterized by isolated thrombocytopenia(peripheral blood platelet count 100109/L)in the absence of other causes or disorders that may be associated with thrombocytopenia.,欧洲(u zhu)仍定义为 peripheral blood platelet count 150109/L,The diagnosis of primary ITP remains one of exclusion;no robust clinical or laboratory parameters are currently available,to,establish its diagnosis with accuracy.The main clinical problem of primary ITP is an increased risk of bleeding,although bleeding symptoms may not always be present.,2026/1/24 周六,67,第六十七页，共67页。,