clinical utilities of immature granulocytes

CLINICAL UTILITIES OF

IMMATURE GRANULOCYTES

1

What is Immature Granulocyte

Lymph nodes

and spleenThymus

Peripheral Blood

Blood-bone marrow barrier

Eosino

philNeutrophil

Baso-

phil

Myelocyte

Metamyelocyte

Bands

Segmented Cells

Promyelocyte

Myeloblast

Makrophage

Basophil in tissue

Reticulum cell

Monoblast

Monocyte

Pluri potent

Stem Cell

B1-Lymphocyte

Plasma cell

Lymphatic

stem cell

T2-LymphocyteB2-Lymphocyte

Plasma cell

Plasmoblast

B-Immuno-

blast

Centro-

blast

T-Immuno-blast

T0-Lymphocyte

T1-Lymphocyte

Centrocyte

Monocyte

Bands

Segmented Cells

Re

ticu

locy

tes

3

4

ErythrocytesThrombocytes


Plasma cell Re

ticu

locy

tes

Proerythroblast

PolychrErythroblast

OrthochrErythroblast

0

1

2

3

4

Erythrocytes

Megakaryocyte

Thrombocytes

Megakaryoblast

Juli Soemarsono SURAMADE I - 2011

MANUAL

MICROSCOPIC

Text1Text1Text1Text1

IMMATURE

GRANULOCYTE

3

Juli SoemarsonoSURAMADE I - 2011

MANUAL MICROSCOPIC


Diana Aulia Arief I Sanjaya and Ina S Timan J Lab Med amp Quality Assurance 200325237-242

IMMATURE GRANULOCYE

4


HEMATOLGY ANALYZER

IMMATURE GRANULOCYE

Text1Text1Text1

5


DETECTION

of

INFECTION

BAND

COUNT

BAND ANC

(IT-RATIO)

6


7

bullRatio between immature neutrophyls to total neutrophils (IT ratio)

is the ratio between

the amount of immature neutrophils

against

the amount of total neutrophils

in a blood smear preparation

bullImmature neutrophils are cells at younger stage than neutrophil bands

metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND

COUNTinaccurateimprecise

required to calculate an

immature to total neutrophil

ratio

(IT ratio)

has a long clinical tradition as

a diagnostic test for bacterial infection

Clinical utility of the band count

8


Diagram

neutrophils more immature than bands

absolute neutrophil count

I T RATIO

DETECTION

of

INFECTION

Ardron MJ Westengard JC Dutcher TF Am J Clin Pathol 1994 Nov102(5)646-9

9


Immature granulocyte Reference Value

10


Samples size

bull 156 healthy blood donors

bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12


Correlation with flow cytometric reference method amp manual reference method

Briggs et al Hematology 20039117-124

Correlation Tests

XE-IG count vs flow cytometric ref method using monoclonal antibodies demonstrated excellent results (r=096 on data without asterisks)

XE-IG count vs manual ref count was lower (r=078) Reasons being

Smaller number of cells counted with manual method

Subjectivity involved in morphological classification of IG

Flow cytometric method

bull Anti-CD16 aniti-CD11b amp anti-CD45

bull Epics XL-MCL (BC)

Manual Differential Count

bull400 WBC count (NCCLS protocol)

13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6

Clinical Significance

ReferenceBriggs et al Evaluation of Immature Granulocyte Counts by the XE-IG Masrer Upgraded software for the XE-2100 Automated Hematology Analyzer Laboratory Hematology 20039117-124

Positive sample rate in samples with high IG (20 or higher)

Conclusion

IG count can highlight a potential acute infectious inflammatory response at a relatively early stage of development of clinical features when other blood count parameters (eg Neutropils) are in the overall normal range and are generally non-specific as indicators

14


IG count in infection and sepsis 15


IG as a predictor of infections and sepsis bull IG is higher in infected patients and positive blood cultures

bull IG is better predictor of infection than WBC count

bull IG is comparable to the absolute neutrophil count

bull High IG helps direct molecular testing leading to a more rapid diagnosis of severe infection

bull Low sensitivity as a screening tool but prediction of infection bacteremia may be improved by

incoporating IG measurement with other tests to help in early detection of infection in patients

bull gt 3 IG is a very specific predictor of sepsis (gt90)

(Ansari-Lari et al 2003)

ReferenceAnsari-ari et al Immature Immature Granulocyte Measurement using the Sysmex XE-2100 Relationship of Infection and Sepsis Am J Clin Pathol 2003120795-799

16


IG ratio amp IT ratio inSepsis

Study objectives

To determine if IG IG ratio and IT ratio can be used as a early indicator of sepsis

To determine If IG count can provide a fast reliable and more cost effective method

of diagnosis in comparison with other diagnostic tools such as blood culture or CRP

17


Comparison of IG ratio and IT ratio with blood culture

All 7 patients with negative blood culture showed IT ratio gt 065

6 of the 7 patients with negative blood culture having a raised IG ratio

IT ratio provides a useful tool in diagnosing those sepsis patients who have a negative blood culture

18


bull IG Ratio of 035 gives the best sensitivity amp specificity

IT Ratio of 065 gives the best sensitivity amp specificity

IT ratio vs IG ratio as indicator of Sepsis

19


bull IT ratio though has the same sensitivity amp specificity as IG ratio it gives a better overall positive and negative predictive values than IG ratio

bull IT ratio provides a useful tool in diagnosing those sepsis patients who have a negative blood culture (100 PPV)


20


bull 12 (71) of 17 patients studied showed an IT ratio gt 065 in samples taken on 3 days pre diagnosis

bull =gt IT ratio can be used as early indicator of sepsis

IT ratio and the day of Diagnosis

29 71

3 days post diagnosis

18 (72) of 25 septic patients studied showed an IT ratio gt 065 in samples on 3 days post diagnosis

=gt post sample detected 1 more patient

=gt IT ratio can be used throughout the course of disease

=gt may be used to monitor patient recovery

21


XE-5000

XE-2100 (w XE IG Master)

XE-2100L (w XE IG Master)

XE -2100D (w XE IG Master)

How to measure IG

XE-seeries (5 +1) part diff automated hematology analyzer

22


IG count

Measure in Diff Channel and report in

IG (103microl)

IG

Detect in IMI channel and display as flags

Constitute of Promyelocytes Myelocytes amp Metamyelocytes

23


bull Automated enumeration of IG using proprietary Fluorescent Flow Cytometery eliminatesndash immature granulocyte flag

ndash false positives

ndash the need to perform unneccessary manual smear reviews

bull Improved sensitivity amp accuracy compared to manual Diff-Count

ndash Small no of IG particularly in leukopenic sample are often missed in a std 100-cell DC

ndash Wide inter-examiner and inter-laboratory variation

bull Reduce manual reviews ndash saves times amp effort of MT

ndash allow results to be delivered to physicians sooner -gt reduce TAT

bull User defineable setting for Diff Review (IG gt 2 3 4 or 5)

bull Fast simple and inexpensive method

ldquoAnti-smear campaignrdquo

Benefits of quantitative IG count Using Sysmex XE

24


Clinical Utilities of XErsquos IG Count

1 provides an rapid accurate and inexpensive method to detect

inflammation and diagnosis of sepsis

2 early indicator of inflammation and sepsis to facilitates timely

treatment

25



What is Immature Granulocyte

Lymph nodes

and spleenThymus

Peripheral Blood

Blood-bone marrow barrier

Eosino

philNeutrophil

Baso-

phil

Myelocyte

Metamyelocyte

Bands

Segmented Cells

Promyelocyte

Myeloblast

Makrophage

Basophil in tissue

Reticulum cell

Monoblast

Monocyte

Pluri potent

Stem Cell

B1-Lymphocyte

Plasma cell

Lymphatic

stem cell


Plasma cell

Plasmoblast

B-Immuno-

blast

Centro-

blast

T-Immuno-blast

T0-Lymphocyte

T1-Lymphocyte

Centrocyte

Monocyte

Bands

Segmented Cells

Re

ticu

locy

tes

3

4

ErythrocytesThrombocytes


Plasma cell Re

ticu

locy

tes

Proerythroblast

PolychrErythroblast

OrthochrErythroblast

0

1

2

3

4

Erythrocytes

Megakaryocyte

Thrombocytes

Megakaryoblast


MANUAL

MICROSCOPIC


IMMATURE

GRANULOCYTE

3


MANUAL MICROSCOPIC



IMMATURE GRANULOCYE

4


HEMATOLGY ANALYZER

IMMATURE GRANULOCYE

Text1Text1Text1

5


DETECTION

of

INFECTION

BAND

COUNT

BAND ANC

(IT-RATIO)

6


7




against




metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



MANUAL

MICROSCOPIC


IMMATURE

GRANULOCYTE

3


MANUAL MICROSCOPIC



IMMATURE GRANULOCYE

4


HEMATOLGY ANALYZER

IMMATURE GRANULOCYE

Text1Text1Text1

5


DETECTION

of

INFECTION

BAND

COUNT

BAND ANC

(IT-RATIO)

6


7




against




metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



MANUAL MICROSCOPIC



IMMATURE GRANULOCYE

4


HEMATOLGY ANALYZER

IMMATURE GRANULOCYE

Text1Text1Text1

5


DETECTION

of

INFECTION

BAND

COUNT

BAND ANC

(IT-RATIO)

6


7




against




metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



HEMATOLGY ANALYZER

IMMATURE GRANULOCYE

Text1Text1Text1

5


DETECTION

of

INFECTION

BAND

COUNT

BAND ANC

(IT-RATIO)

6


7




against




metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



DETECTION

of

INFECTION

BAND

COUNT

BAND ANC

(IT-RATIO)

6


7




against




metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



7




against




metamyelocytes

myelocytes

promyelocytes

myeloblast)



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



BAND




ratio

(IT ratio)




8


Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



Diagram



I T RATIO

DETECTION

of

INFECTION


9



10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25




10


Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



Samples size


bull Male 80

bull Female 76

Reference values

Male 003X109L 05

Female 003X109L 04

No age dependency


Juli Soemarsono

SURAMADE I - 2011

12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



12




Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25





Correlation Tests










13


Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



Good correlation

bull CRP

bull ESR

bull CD64

bull IL-6




Conclusion


14













16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25














16



Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25




Study objectives




17






18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25







18





19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25






19





20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25






20





29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25






29 71






21


XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



XE-5000




How to measure IG


22


IG count


IG (103microl)

IG



23














24






treatment

25



IG count


IG (103microl)

IG



23














24






treatment

25















24






treatment

25







treatment

25



clinical utilities of immature granulocytes

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