©UFS

Understanding Complete Blood Counts

The ABCs of CBCs

Robert Miceli, MD
MetLife
The Good, The Bad, and The Ugly

Common Abnormal but • Mild iron deficiency anemia in pre-menopausal women

Benign CBCs • Beta thalassemia minor

(CBC may be accepted without • Chronic benign neutropenia

repeat CBC or clinical evaluation) • Reactive thrombocytosis

• Iron deficiency anemia in men or post-menopausal women

Abnormal / Worrisome CBCs • Mild or moderate anemia, not fully evaluated

(may require additional follow-up • Unexplained thrombocytopenia or thrombocytosis

or clinical evaluation) • Mild abnormalities involving all 3 cell lines (red cells, white
cells, and platelets), mild pancytopenia

• Leukemia
Markedly Abnormal CBCs • Severe anemia
• Severe leukopenia or severe pancytopenia

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What Are the Major Components of Blood?

• Red Blood Cells

(also called erythrocytes)
• White Blood Cells
(also called leukocytes)
• Platelets
(also called thrombocytes)
• Plasma

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Fancy Words for High and Low

Cell Type Too High Too Low

Erythrocytosis or
Red Blood Cells (Erythrocytes) Anemia
Polycythemia
Thrombocytosis or
Platelets (Thrombocytes) Thrombocytopenia
Thrombocythemia

White Blood Cells (Leukocytes) Leukocytosis Leukopenia

Neutrophils Neutrophilia Neutropenia

Lymphocytes Lymphocytosis Lymphopenia

Eosinophils Eosinophilia ---

Monocytes Monocytosis ---

Basophils Basophilia ---

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Symptoms

Factor Too Much Too Little

Shortness of breath
RBCs Clots, strokes (dyspnea), hypoxia, fatigue,
pallor

WBCs Clots, strokes Infections

Platelets Clots, strokes Bleeding

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Hematology Tests

• Specialized tests
– Bone Marrow aspiration and biopsy
• All of the formed elements of the blood
are produced primarily in the bone
marrow
• They are produced by progenitor cells –
cells which grow and differentiate into
mature formed elements
• This test can detect the lack or
overabundance of these progenitor cells,
and can find other problems such as
cancer

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How Are Blood Cells Formed?

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Red Blood Cells (RBCs)

• Largest cellular component of

blood, about 40-45% of blood
volume
• Comprised mostly of
hemoglobin
• Transport oxygen
• Red blood cells normally last
about 120 days before they
are removed by the spleen

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Hemoglobin

• Red pigment molecule which

gives RBCs (and blood) its
color
• Contains 4 molecules of heme
and 4 of globin (2 alpha chains
and 2 beta chains)
• Each molecule of heme
contains one iron ion

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White Blood Cells

• There are several types of White Blood Cells

• They are all involved in immunity but in somewhat different ways
– Granulocytes (neutrophils, PMNs, polymorphonuclear leukocytes, or
“polys”) – involved in acute infections with bacteria. Immature form is
called a “band”
– Lymphocytes – involved in many types of infection, especially
viruses -Produce antibodies and “memory cells” - Are further
divided into T-cells and B-cells
– Eosinophils – involved in parasitic infections and allergies
– Basophils – involved in parasitic infections and allergies
– Monocytes – involved in bacterial and parasitic infections

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White Blood Cells (WBCs)

• Neutrophils – also called a

variety of other names on
CBC reports, including:
– polys
– PMNs
– segs
– grans
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils

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Platelets

• Really more of a fragment of a

cell
– They are broken off from a
very large cell in the bone
marrow called a
megakaryocyte
– Primary function is to aid in
blood clotting
– Lifetime in the blood is 7-10
days after which they are
destroyed in the spleen
– Their clotting function is
permanently inhibited by
aspirin

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Plasma

• Plasma is the liquid

component of blood
• Comprised mostly of water,
but also includes:
– Protein (albumin, globulin,
fibrinogen)
– Lipids (cholesterol,
triglycerides)
– Dissolved salts and minerals
(sodium, calcium, potassium)
– Glucose

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Case # 1

• 32 yo female applying for $1 million whole life

• Insurance labs show elevations of total cholesterol at 240 and alkaline
phosphatase at 170, other labs are normal
• Medical records include CBC from 1 month prior to application, done during
routine office visit.
TEST RESULT UNITS REF RANGE
WBC 10.8 x 1000/mm3 3.9 - 11.1
RBC 3.73 L x 106/mm3 4.00 - 5.20
HGB 10.8 L g/dL 12.0 - 16.0
HCT 32.4 L % 38.5 - 49.0
MCV 84 fl 80 - 97
MCH 31.0 pg 27.5 - 33.5
MCHC 33.3 % 32.0 - 36.0
PLT 310 x 1000/mm3 150 - 350

• Paramedical exam: currently pregnant

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“Anemia” of Pregnancy

• During pregnancy, the volume of red blood cells increases by

about 20%, but the plasma volume increases by 45%.
• Net result is ≈ 15% decrease in hemoglobin and hematocrit.

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Complete Blood Count (CBC)
TEST RESULT UNITS REF RANGE
WBC 5.2 x 1000/mm3 3.9 - 11.1
RBC 3.81 L x 106/mm3 4.20 - 5.70
HGB 14.5 g/dL 13.2 - 16.9
HCT 41.2 % 38.5 - 49.0
MCV 98 H fl 80 - 97
MCH 33.7 H pg 27.5 - 33.5
MCHC 35.3 % 32.0 - 36.0
RDW 11.8 % 11.0 - 15.0
PLT 172 x 1000/mm3 140 - 390
MPV 7.6 fl 7.5 - 11.5
NEUT % 40.1 % 38.0 - 80.0
LYMPH % 46.1 % 15.0 - 49.0
MONO % 12.9 % 0.0 - 13.0
EOS % 0.6 % 0.0 - 8.0
BASO % 0.3 % 0.0 - 2.0
NEUT, ABS 2085 cells/mm3 1650 - 8000
LYMPH, ABS 2397 cells/mm3 1000 - 3500
MONO, ABS 671 cells/mm3 40 - 900
EOS, ABS 31 cells/mm3 30 - 600
BASO, ABS 16 cells/mm3 0 - 125
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Red Blood Count and RBC Indices
TEST RESULT UNITS REF RANGE
WBC 5.2 x 1000/mm3 3.9 - 11.1
RBC 3.81 L x 106/mm3 4.20 - 5.70
HGB 14.5 g/dL 13.2 - 16.9
HCT 41.2 % 38.5 - 49.0
MCV 98 H fl 80 - 97
MCH 33.7 H pg 27.5 - 33.5
MCHC 35.3 % 32.0 - 36.0
RDW 11.8 % 11.0 - 15.0
PLT 172 x 1000/mm3 140 - 390
MPV 7.6 fl 7.5 - 11.5
NEUT % 40.1 % 38.0 - 80.0
LYMPH % 46.1 % 15.0 - 49.0
MONO % 12.9 % 0.0 - 13.0
EOS % 0.6 % 0.0 - 8.0
BASO % 0.3 % 0.0 - 2.0
NEUT, ABS 2085 cells/mm3 1650 - 8000
LYMPH, ABS 2397 cells/mm3 1000 - 3500
MONO, ABS 671 cells/mm3 40 - 900
EOS, ABS 31 cells/mm3 30 - 600
BASO, ABS 16 cells/mm3 0 - 125
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Measuring RBCs (and the “Rule of Threes”)

• Hematocrit (HCT) is the percent of a volume of whole blood occupied

by intact red blood cells. Measured in percent.
– Normal range for women: 36 - 46%
– Normal range for men: 41 - 53%
• Hemoglobin (HGB) measures the concentration of hemoglobin
expressed as grams of hemoglobin per deciliter (100 ml) of whole
blood.
– Normal range for women: 12 - 16 g/dL
– Normal range for men: 13.5 - 17.5 g/dL
• RBC count is the number of red blood cells per microliter of whole
blood. Measured in millions of RBCs per microliter of whole blood.
– Normal range for women: 4.0 - 5.2 x106/mm3
– Normal range for men: 4.5 - 5.9 x106/mm3

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Red Blood Cell Indices
• Mean Corpuscular Volume (MCV) is the average size of red blood
cells.
– Normal range: 80-100 fL
– Low = “microcytic” (“too small”) High = “macrocytic” (“too big”)
Normal = “normocytic” (“just right”)
• Red Cell Distribution Width (RDW) measures the variability in the
size of red blood cells.
– Normal range: 11.5-14.5%
– On a peripheral blood smear, high RDW is described as “anisocytosis”
• Mean Corpuscular Hemoglobin (MCH) is the amount of hemoglobin
in an average red blood cell.
– Normal range: 26-34 pg/cell
• Mean Corpuscular Hemoglobin Concentration (MCHC) is the
average concentration of hemoglobin in an average RBC.
– Normal range: 31-37 g/dL
– “Hypochromic” = “too pale” “Normochromic” = “just right”
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Red Blood Cell Indices
• Mean Corpuscular Volume (MCV) is the average size of red blood
cells.
– Normal range: 80-100 fL
– Low = “microcytic” (“too small”) High = “macrocytic” (“too big”)
Normal = “normocytic” (“just right”)
• Red Cell Distribution Width (RDW) measures the variability in the
size of red blood cells.
– Normal range: 11.5-14.5%
– On a peripheral blood smear, high RDW is described as “anisocytosis”
• Mean Corpuscular Hemoglobin (MCH) is the amount of hemoglobin
in an average red blood cell.
– Normal range: 26-34 pg/cell
• Mean Corpuscular Hemoglobin Concentration (MCHC) is the
average concentration of hemoglobin in an average RBC.
– Normal range: 31-37 g/dL
– “Hypochromic” = “too pale” “Normochromic” = “just right”
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Red Blood Cell Indices

• Mean Corpuscular Volume (MCV) is the average size of

red blood cells.
– If anemia is present, MCV is a useful tool to guide further testing
– If anemia is not present, MCV is of little value:
• Low MCV without anemia suggests thalassemia minor (trait)
• High MCV without anemia can be caused by certain medications
(Dilantin, oral contraceptives, methotrexate) and is a “soft” marker
of possible alcohol overuse

• Red Cell Distribution Width (RDW) measures the

variability in the size of red blood cells.
– Not useful in the absence of anemia

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Classification of Anemias Using MCV and RDW

Low MCV Normal MCV High MCV

(Microcytic) (Normocytic) (Macrocytic)

Low RDW
Thalassemia minor
(low variability)

Anemia of chronic
Thalassemia minor Aplastic anemia
disease
Normal RDW Anemia of chronic Myelodysplastic
Hereditary
disease syndrome
spherocytosis

Early deficiency of B12 or folate

High RDW iron, B12, or folate deficiency
Iron deficiency
(high variability)
Sickle cell anemia Hemolytic anemia

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Descriptive Terms Used on Peripheral Smears

• Anisocytosis: marked variation in RBC sizes (visual

counterpart of increased RDW)
• Hypochromia or hypochromasia: RBCs are paler than
normal because they contain less hemoglobin (visual
counterpart of decreased MCH)
• Macrocytosis: increased number of large RBCs (visual
counterpart of increased MCV)
• Microcytosis: increased number of small RBCs (visual
counterpart of decreased MCV)
• Poikilocytosis: marked variation in the shape of RBCs
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Reticulocyte Count

• Reticulocytes are “young” red blood cells that

were recently released from the bone marrow.
• Normally, reticulocytes comprise 0.5 - 2.5% of all
red blood cells.
• Increased reticulocytes (reticulocytosis) is a
normal response to blood loss or anemia. Since
reticulocytes are larger, the MCV (and RDW)
may be elevated.
• The combination of anemia with a low or normal
reticulocyte count indicates that the bone
marrow is unable to respond normally, either
due to lack of essential ingredients (iron
deficiency, vitamin B12 or folate deficiency),
bone marrow disease, or chronic disease.
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 Anemia
• Low RBCs – two ways to get there: Too little production, or increased destruction
• Low production
– Aplastic anemia (no production)
– Iron Deficiency Anemia
• Increased Destruction
– Hemolytic anemia
– Spherocytosis
– Hemoglobin disorders (thalassemia, sickle cell, others)
– Hemorrhage (blood loss)
– Hypersplenism (an overactive spleen which destroys formed elements
prematurely)
• Regardless of the type of anemia, once the level of hemoglobin/hematocrit gets
sufficiently low, mortality may result
• Mortality Concerns
– Severe anemia may cause a critical lack of oxygen to the brain or heart
– Less severe anemia may still worsen chronic heart or lung conditions
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 Iron deficiency/hemorrhagic anemia
• The oxygen-carrying protein heme contains iron, and gives blood its red color
• If iron levels are low, RBCs cannot be produced fast enough to match losses
• Iron-deficiency anemia is the most common form of anemia world-wide
– May be due to poor intake of iron or chronic loss of blood
– Blood is lost most commonly from the GI tract

• The most important factor to consider when underwriting this condition is –

What is the cause?
– Possibilities include
• Stomach ulcers
• Colon cancer
• Vascular malformations in the GI tract
• Endometrial cancer
• Recent surgery or trauma
• Multiple blood donations
• Can be treated with iron supplements, blood transfusion and/or eradication of the
cause For Financial Professional Use Only 26
Case # 2
TEST RESULT UNITS REF RANGE
WBC 7.5 x 1000/mm3 3.9 - 11.1
• 57 yo male applying for RBC 3.46 L x 106/mm3 4.60 - 6.20
$250,000 whole life HGB 10.1 L g/dL 14.0 - 18.0
HCT 29.6 L % 40.0 - 54.0

• Paramedical exam: mild type 2 MCV 85.6 fl 80 – 94

MCH 29.3 pg 27 - 33
diabetes, controlled on oral MCHC 34.2 % 32.0 - 36.0
RDW 13.9 % 11.0 - 15.0
medications, HbA1c 6.1% PLT 222 x 1000/mm3 140 - 390
NEUT % 58.0 % 40 - 79
• APS: routine follow-up for LYMPH % 29.5 % 15 - 45
diabetes, no complications, MONO % 7.0 % 0 - 11
EOS % 5.2 % 0-6
CBC done as routine test BASO % 0.3 % 0-3
NEUT, # 4.4 x103 uL 1.8 - 8.7
LYMPH, # 2.2 x103 uL 0.7 - 5.0
MONO, # 0.5 x103 uL 0.0 - 1.2
EOS, # 0.4 x103 uL 0.0 - 0.7
BASO, # 0 x103 uL 0.0 - 0.3

For Financial Professional Use Only 27

Case # 2 (continued)

• Serum vitamin B12 and folate

levels were normal
• Iron studies showed low serum
ferritin and a low transferrin
saturation, consistent with iron
deficiency
• Colonoscopy was normal
• Upper endoscopy showed
moderate gastritis and
esophagitis with no evidence of Iron-poor RBCs are pale and small
(low MCV and MCH)
active bleeding
• Hemoglobin improved with
administration of iron

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 Megaloblastic Anemia
• A diverse group of anemias, all of which show elevated MCV on the blood count
• May be caused by:
– Vitamin deficiency (usually B12 or folic acid)
– Alcohol intake (moderately high levels)
– Leukemia (WBCs would be abnormal, too)
– Certain medications
• Pernicious anemia – vitamin B12 deficiency caused by an inability to absorb the
vitamin from the GI tract. May cause neuropathy, weakness, or even psychiatric
problems
• Usually treated by
– Determining and eliminating the cause
– Correcting the vitamin deficiency (if any)
• May require injections of vitamin B12 if the cause is pernicious anemia
• Mortality concerns – determined by the underlying cause and severity of anemia

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 Autoimmune Hemolytic Anemia
• A condition where the immune system attacks and destroys red blood
cells
• Two forms:
– Warm antibody
– Cold Agglutinin disease
• Both cause:
– Normocytic anemia with antibodies against red blood cells (positive
Coomb’s test)
• Mortality concerns
– Severity of anemia (hemolytic crises may be fatal)
– Presence of an underlying cause (such as infection or rheumatologic
disease – like rheumatoid arthritis)
– Need for side-effect prone treatments such as steroids,
immunosuppressants, or frequent blood transfusions
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Hereditary Spherocytosis/Elliptocytosis

• A disorder of red cell shape where the misshapen cells are

taken up by the spleen and destroyed prematurely
• Leads to anemia and splenomegaly
• Splenectomy will normalize the blood count and resolve the
anemia, but the cells will still be misshapen
• Mortality Concerns:
– Severity of hemolysis or anemia
– Overwhelming infection after splenectomy

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Anemia of Chronic Disease

• Also known as anemia of chronic inflammation

• May occur in association with a wide variety of chronic
diseases, especially inflammatory conditions, chronic
infection, liver disease, congestive heart failure, diabetes,
and cancer.
• Anemia is usually mild (Hgb 9-12, Hct 27-35), but can be
lower in about 20% of cases.
• MCV is usually normal or low normal
• Platelets may be elevated, especially if inflammation is
prominent
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Hemoglobin Disorders

• These are various, largely genetic, disorders which affect

hemoglobin
• Those which affect globin:
– Thalassemias
– Sickle cell and related disorders

• Those which affect heme:

– Porphyrias

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 Thalassemias
• Inherited disorders of the globin gene leading to low levels of alpha or beta globin chains
• Fatalities are unusual in all but the most severe forms
• Alpha Thalassemia: Beta Thalassemia major
– Hemoglobin H disease
– Alpha Thalassemia Trait
• Beta Thalassemia:
– Beta Thalassemia major
– Beta Thalassemia intermedia
– Beta Thalassemia minor (trait)
• Prevalence as high as 10% in Mediterranean, African, and Southeast Asian
populations
• Typically mild anemia with marked microcytosis
• Can coexist with other hemoglobin abnormalities, with increased severity of the
anemia and increased mortality concern, but true beta-thalassemia minor (trait)
has no excess mortality concerns
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 Case # 3

TEST RESULT UNITS REF RANGE

• 47 yo female applying for $1.5
WBC 4.7 x 109/L 4.4 - 11.3
million term
RBC 5.6 x 1012/L 4.7 - 6.1
• Paramedical exam: all
questions answered “no” HGB 10.5 L g/dL 12.3 - 15.3

• Insurance labs normal HCT 31.6 L % 35.9 - 44.6

MCV 65.8 L fL 80 - 96
• Medical records: routine
gynecologic visits, CBC done MCH 19.9 L pg 27.5 - 33.2

as part of routine exam last MCHC 26.7 L % 33.4 - 35.5

year
RDW 13.0 % 11.5 - 14.5

PLT 249 x 109/L 100 - 450

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Underwriting Tip: Identifying β-thalassemia minor

Beta-Thalassemia Minor Iron Deficiency Anemia

• RBC count normal or high- • RBC count low-normal or low,

normal, usually over 5 almost always less than 5

• Violates “Rule of 3s” • Usually follows “Rule of 3s”

(hemoglobin is less than 3 times (hemoglobin is roughly 3 times the
the RBC count) RBC count)

• MCV usually quite low (60-70) • MCV doesn’t become that low
even when anemia is mild unless anemia is quite severe

• RDW is usually normal or low • RDW is often high

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 Sickle Cell Disease
• Forms of hemoglobin:
– “A” – adult normal hemoglobin
– “S” – sickle cell hemoglobin
– “C” – mutant hemoglobin, but with a different result
• Since each person has 2 genes, several combinations are possible
– “SA” – Sickle trait, may have minimal sickle cell formation, but
otherwise is basically a carrier
– “SS” – affected with sickle cell disease can be mild to severe
– “SC” – similar to SS but milder
– “CC”- similar to SS but quite a bit milder

Sickle Cell Disease:

• When oxygen level is low, RBCs assume a sickle shape, and block
capillaries, leading to severe bone pain, and infarctions in various organs
• Death can occur from infection, severe
For Financial anemia,
Professional stroke or heart attack
Use Only 37
Porphyria

• A large variety of genetic disorders which affect the

biosynthesis of heme
• All are rare
• May cause episodes of severe abdominal pain, sensitivity
to sunlight, even psychiatric problems or paralysis
• Mortality Concerns
– Fatalities are quite rare, may occur in the most severe case

For Financial Professional Use Only 38

White Blood Count with Differential
TEST RESULT UNITS REF RANGE
WBC 5.2 x 1000/mm3 3.9 - 11.1
RBC 3.81 L x 106/mm3 4.20 - 5.70
HGB 14.5 g/dL 13.2 - 16.9
HCT 41.2 % 38.5 - 49.0
MCV 98 H fl 80 - 97
MCH 33.7 H pg 27.5 - 33.5
MCHC 35.3 % 32.0 - 36.0
RDW 11.8 % 11.0 - 15.0
PLT 172 x 1000/mm3 140 - 390
MPV 7.6 fl 7.5 - 11.5
NEUT % 40.1 % 38.0 - 80.0
LYMPH % 46.1 % 15.0 - 49.0
MONO % 12.9 % 0.0 - 13.0
EOS % 0.6 % 0.0 - 8.0
BASO % 0.3 % 0.0 - 2.0
NEUT, ABS 2085 cells/mm3 1650 - 8000
LYMPH, ABS 2397 cells/mm3 1000 - 3500
MONO, ABS 671 cells/mm3 40 - 900
EOS, ABS 31 cells/mm3 30 - 600
BASO, ABS 16 cells/mm3 0 - 125
For Financial Professional Use Only 39
Absolute Neutrophil Count
TEST RESULT UNITS REF RANGE
WBC 5.2 x 1000/mm3 3.9 - 11.1
RBC 3.81 L x 106/mm3 4.20 - 5.70
HGB 14.5 g/dL 13.2 - 16.9
HCT 41.2 % 38.5 - 49.0
MCV 98 H fl 80 - 97
MCH 33.7 H pg 5.2 x 1000 = 5200
27.5 - 33.5
MCHC 35.3 % 32.0 - 36.0
RDW 11.8 % 5200 x .401 = 2085
11.0 - 15.0
PLT 172 x 1000/mm3 140 - 390
MPV 7.6 fl 7.5 - 11.5
NEUT % 40.1 % 38.0 - 80.0
LYMPH % 46.1 % 15.0 - 49.0
MONO % 12.9 % 0.0 - 13.0
EOS % 0.6 % 0.0 - 8.0
BASO % 0.3 % 0.0 - 2.0
NEUT, ABS 2085 cells/mm3 1650 - 8000
LYMPH, ABS 2397 cells/mm3 1000 - 3500
MONO, ABS 671 cells/mm3 40 - 900
EOS, ABS 31 cells/mm3 30 - 600
BASO, ABS 16 cells/mm3 0 - 125
For Financial Professional Use Only 40
Underwriting Tip

• If the total white blood count (WBC) is normal, the red cells
and platelets are normal, and your applicant is otherwise
healthy, don’t worry about the differential white blood count,
especially if the absolute counts are normal.
• The percentage of neutrophils, lymphocytes, etc. often
fluctuate in response to an infection; this is not a big
underwriting concern.

For Financial Professional Use Only 41

Types of White Blood Cells - What’s the Diff?

• Neutrophils – also called a

variety of other names on CBC
reports, including:
– polys
– PMNs
– segs
– bands or stabs (immature
neutrophils indicate acute
infection)
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
For Financial Professional Use Only 42
WBC Differential: Neutrophils

Possible Causes of Possible Causes of

Neutrophilia: Neutropenia:

Common: chronic benign

Common: bacterial infections,
neutropenia (some forms are
inflammatory disorders, stress,
familial), chemotherapy
certain drugs (especially
prednisone), pregnancy Uncommon: systemic lupus
erythematosus, immunodeficiency
Rare: leukemias
states

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Leukocytosis

• An elevated WBC count is termed “leukocytosis”

• Normal level is 4,400 to 10,000 WBC per mm3
• This can result from many causes, principally infections,
inflammatory disorders, and medications
• Cancer and myeloproliferative disorders can also cause
high, sometimes extremely high, WBC counts
• Treatment is aimed at the underlying cause
• Death may result from the underlying cause such as severe
infection or cancer (leukemia)

For Financial Professional Use Only 44

 Neutropenia
• The relative lack of neutrophils (the most common type of WBC, also called
granulocytes)
• Normally humans have at least 1500 neutrophils/mm3
• Severe neutropenia (almost no neutrophils) is “agranulocytosis”
• May be cause by gene defects, various drugs, or medical conditions
• Treatment is usually aimed at the underlying cause
• Some may require antibiotics to prevent infection or medications to stimulate
production of neutrophils
• Death may occur due to overwhelming infection

Chronic Benign Neutropenia:

• Overall risk of infection is low, usually asymptomatic
• Two forms – familial and non-familial
• Key features from underwriting perspective are the absence of significant infections
and stability over time
For Financial Professional Use Only 45
Case # 4
TEST RESULT UNITS REF RANGE

• 44 yo male applying for WBC

RBC
2.8
5.02
L x 1000/mm3
x 106/mm3
3.9 - 11.1
4.20 - 5.70
$2,000,000 whole life HGB 14.9 g/dL 13.2 - 16.9
HCT 45.2 % 38.5 - 49.0
• Paramedical exam: rotator cuff MCV 95 fl 80 - 97
MCH 34.0 H pg 27.5 - 33.5
injury to right shoulder, getting MCHC 35.1 % 32.0 - 36.0

physical therapy, elevated RDW 13.8 % 11.0 - 15.0

PLT 212 x 1000/mm3 140 - 390

cholesterol on Lipitor NEUT % 50.2 % 38.0 - 80.0
LYMPH % 36.0 % 15.0 - 49.0
• Insurance labs are normal MONO % 13.3 % 0.0 - 13.0

• Medical records only included EOS % 0.3 % 0.0 - 8.0

BASO % 0.2 % 0.0 - 2.0

labs, no office notes.
Total WBC x % Neutrophils =
ANC
2800 x 50.2% = 1406
For Financial Professional Use Only 46
Case # 4: Additional Information

• Office notes arrive for review with no history of recurrent or

serious infections, and WBC has been stable in 2.5 - 4.0
range for the past 5 years. Absolute neutrophil counts are
always greater than 1000.

For Financial Professional Use Only 47

WBC Differential: Lymphocytes

Possible Causes of Possible Causes of

Lymphocytosis: Lymphopenia:

Common: viral infections Uncommon: systemic lupus

Uncommon: inflammatory bowel erythematosus, immunodeficiency
disease states

Rare: chronic lymphocytic Rare: aplastic anemia, Hodgkin’s

leukemia, vasculitis disease
For Financial Professional Use Only 48
WBC Differential: Monocytes

Possible Causes of
Decreased Levels:
Monocytosis:
Common: recovery phase after
infections
Uncommon: certain infections (TB,
malaria), inflammatory bowel
disease ---
Rare: myeloproliferative disorders
including myeloid metaplasia,
polycythemia vera, certain forms of
leukemia and lymphoma

For Financial Professional Use Only 49

WBC Differential: Eosinophils

Possible Causes of
Decreased Levels:
Eosinophilia:
Common: allergic disorders
(including drug reactions)
Uncommon: parasite infection,
lupus, rheumatoid arthritis
---
Rare: hypereosinophilic syndrome,
diffuse skin diseases, some forms
of leukemia and lymphoma,
Löffler’s endocarditis

For Financial Professional Use Only 50

Case # 5
TEST RESULT UNITS REF RANGE
• 45 yo female applying for $1 WBC 8.2 x 1000/mm3 3.9 - 11.1
RBC 4.5 x 106/mm3 4.2 - 5.7
million term
HGB 13.0 g/dL 12.0 - 16.0
• Paramedical exam: asthma, HCT 40.5 % 36.0 - 46.0
MCV 94 fl 80 - 97
usually well-controlled with
MCH 28.0 pg 27.5 - 33.5
inhalers MCHC 34.0 % 32.0 - 36.0
• Insurance labs: normal RDW 13.4 % 11.0 - 15.0
PLT 372 x 1000/mm3 140 - 390
• Medical records: records from NEUT % 45.1 % 38.0 - 80.0
primary care physician confirm LYMPH % 37.6 % 15.0 - 49.0
MONO % 5.3 % 0.0 - 13.0
that asthma is generally well-
EOS % 12.0 H % 0.0 - 8.0
controlled, although she did BASO % 0.0 % 0.0 - 2.0
require short-term prednisone in NEUT, ABS 3698 cells/mm3 1650 - 8000
2007. Also followed by a LYMPH, 3083 cells/mm3 1000 - 3500
dermatologist for atopic ABS
MONO, ABS 435 cells/mm3 40 - 900
dermatitis. Records include CBC
EOS, ABS 984 H cells/mm3 30 - 600
from 9/08. BASO, ABS 0 cells/mm3 0 - 125

For Financial Professional Use Only 51

Case # 6
TEST RESULT UNITS REF RANGE
• 45 yo male applying for $1 million WBC 9.2 x 1000/mm3 3.9 - 11.1
term RBC 4.2 x 106/mm3 4.20 - 5.70
HGB 13.3 g/dL 13.2 - 16.9
• Paramedical exam: has seen HCT 40.2 % 38.5 - 49.0
personal physician for cold and MCV 96 fl 80 - 97
cough, last visit 1 month ago MCH 32.0 pg 27.5 - 33.5
MCHC 35.3 % 32.0 - 36.0
• Insurance labs: normal RDW 11.8 % 11.0 - 15.0
• Medical records: seen in January, PLT 390 x 1000/mm3 140 - 390
March, and August of this year NEUT % 40.1 % 38.0 - 80.0

complaining of non-productive cough LYMPH % 29.5 % 15.0 - 49.0

since December 2008. Chest x-ray MONO % 9.5 % 0.0 - 13.0

EOS % 20.1 H % 0.0 - 8.0
showed questionable vague infiltrates
BASO % 0.9 % 0.0 - 2.0
in both lung bases. Did not improve
NEUT, ABS 3689 cells/mm3 1650 - 8000
with 2 courses of antibiotics or
LYMPH, 2714 cells/mm3 1000 - 3500
therapeutic trial of asthma inhalers. ABS
Upper GI series and upper endoscopy MONO, ABS 874 cells/mm3 40 - 900
showed no evidence of GERD. On EOS, ABS 1850 H cells/mm3 30 - 600
August visit, also noted fatigue and BASO, ABS 83 cells/mm3 0 - 125
diarrhea.
For Financial Professional Use Only 52
WBC Differential: Basophils

Possible Causes of Basophilia: Decreased Levels:

Rare: leukemias, myeloid

---
metaplasia, Hodgkin’s disease

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Platelet Count
TEST RESULT UNITS REF RANGE
WBC 5.2 x 1000/mm3 3.9 - 11.1
RBC 3.81 L x 106/mm3 4.20 - 5.70
HGB 14.5 g/dL 13.2 - 16.9
HCT 41.2 % 38.5 - 49.0
MCV 98 H fl 80 - 97
MCH 33.7 H pg 27.5 - 33.5
MCHC 35.3 % 32.0 - 36.0
RDW 11.8 % 11.0 - 15.0
PLT 172 x 1000/mm3 140 - 390
MPV 7.6 fl 7.5 - 11.5
NEUT % 40.1 % 38.0 - 80.0
LYMPH % 46.1 % 15.0 - 49.0
MONO % 12.9 % 0.0 - 13.0
EOS % 0.6 % 0.0 - 8.0
BASO % 0.3 % 0.0 - 2.0
NEUT, ABS 2085 cells/mm3 1650 - 8000
LYMPH, ABS 2397 cells/mm3 1000 - 3500
MONO, ABS 671 cells/mm3 40 - 900
EOS, ABS 31 cells/mm3 30 - 600
BASO, ABS 16 cells/mm3 0 - 125
For Financial Professional Use Only 54
Mean Platelet Volume (MPV)

• “Young” platelets, recently released from the bone marrow,

are typically slightly larger
• Often elevated in immune or idiopathic thrombocytopenic
purpura (ITP)
• In an individual with low platelet count (thrombocytopenia):
– Increased MPV indicates normal bone marrow response
– Decreased or low normal MPV may indicate impaired bone
marrow response

For Financial Professional Use Only 55

Selected Causes of Abnormal Platelet Counts

Possible Causes of Possible Causes of

Thrombocytosis:
Common: “Reactive” thrombocytosis
related to acute trauma, surgery,
blood loss, iron deficiency, chronic
infections (osteomyelitis),
inflammatory diseases including
rheumatoid arthritis and ulcerative
colitis, splenectomy
Uncommon: polycythemia vera,
essential thrombocytosis (plt count
over 600,000), some cancers
For Financial Professional Use Only
Thrombocytopenia:
Common: spurious lab result
caused by platelet clumping,
idiopathic or immune-mediated
thrombocytopenia (ITP),
medications, viral infection
Uncommon: hemolytic-uremic
syndrome, leukemia, sepsis,
hypersplenism
56
Case # 7

• 28 yo female applying for

TEST RESULT UNITS REF RANGE
$100,000 term WBC 10.9 x 1000/mm3 3.9 - 11.1
RBC 4.4 6
x 10 /mm 3 4.20 - 5.70
• Paramedical exam: car HGB 13.5 g/dL 13.2 - 16.9
HCT 41.3 % 38.5 - 49.0
accident 3 months ago MCV 96 fl 80 - 97

• Insurance labs: normal MCH 33.6 H pg 27.5 - 33.5

MCHC 34.9 % 32.0 - 36.0
RDW 11.8 % 11.0 - 15.0
• Medical records: MVA 3 PLT 481 H x 1000/mm3 140 - 390
months ago with airbag MPV 11.3 fl 7.5 - 11.5

deployment, two broken ribs

and fractured foot.

For Financial Professional Use Only 57

 Idiopathic Thrombocytopenic Purpura (ITP)
• Although there are many causes of low platelet counts, including
medications, infections, and hypersplenism, the term “ITP” is reserved
for the autoimmune destruction of platelets; “Immune thrombocytopenic
purpura”
• Immune system attacks and destroys platelets faster than they can be
produced; red rash (purpura) and bleeding
• Some cases will remit with this alone and never recur
• If more severe, can usually be cured with splenectomy, but some will
still have low platelets after splenectomy
• Prognosis depends on the current platelet count and the mode of
treatment
• Mortality Concerns
– Fatalities may occur due to severe bleeding or due to overwhelming
infection after splenectomy

For Financial Professional Use Only 58

 Bone Marrow Disorders
• All formed elements of the blood are made primarily in the bone marrow
• There is particular concern if all 3 cell lines are abnormal (RBCs, WBCs, and platelets),
especially if:
– the applicant is over age 50 and/or
– there is an increased percentage of monocytes
• This suggests the possibility of diseases involving the bone marrow, and many of these
diseases have very significant mortality concerns.
• Aplastic Anemia: diminished-absent precursor cells (pancytopenia)
• Myeloproliferative disorders: bone marrow cells grow too rapidly with over-production
of blood cells and/or platelets
– If this acceleration continues it may transform into cancer (usually leukemia)
– Myeloproliferative disorders include:
• Essential thrombocytosis
• Polycythemia vera
• Myelofibrosis (possible pancytopenia)
• Myelodysplastic syndromes: ineffective blood cell production (pancytopenia)
For Financial Professional Use Only 59
Aplastic Anemia

• A disorder where the bone marrow stops producing blood

cells (pancytopenia - all lines – RBC, WBC and platelets)
• Can be congenital (Fanconi anemia), or acquired
• Acquired form brought on by certain infections or drugs
• Prognosis depends on severity – most cases pose a very
high mortality risk unless spontaneously remitted long ago
• Mortality Concerns:
– The aplastic crisis may result in death due to infection,
bleeding, or severe anemia
– Complications of bone marrow transplant (graft vs. host
disease)
For Financial Professional Use Only 60
Essential Thrombocytosis (ET)

• Also called essential thrombocythemia

• Megakaryocytes in the bone marrow produce too many
platelets, which may be misshapen or may function poorly
• They may become so numerous as to cause clotting (risk
of stroke)
• Platelet count at least 600k up to 1.5 million per mm3
• Prognosis depends on frequency of bleeding/clotting
complications
• Also, increased risk for developing leukemia, especially
chronic myelogenous leukemia (CML)
For Financial Professional Use Only 61
Polycythemia (rubra) vera

• Red cell progenitors start to lose control over their growth

• Can be treated with phlebotomy (removing blood) or
marrow-suppressing medications
• Mortality Concerns
– Fatalities can occur due to clotting, or due to
malignant transformation

For Financial Professional Use Only 62

Myelofibrosis

• A condition where the bone marrow becomes fibrotic

(scarred)
• Can cause low counts of all cell lines (pancytopenia)
• Spleen and liver may become enlarged as they begin to
serve as back-up producers of formed elements
(extramedullary hematopoesis)
• Mortality Concerns: Decreasing counts of all formed
elements may lead to death from infection, severe anemia,
or bleeding

For Financial Professional Use Only 63

Myelodysplasia

• A bone marrow disorder of older individuals, where there is

ineffective production of red blood cells, eventually may
also involve the WBC and platelet lines (pancytopenia)
• Can be a precursor to leukemia
• Several subtypes, e.g., refractory anemia (RA) or refractory
anemia with ringed sideroblasts (RARS)
• Treatment is supportive – transfusions and antibiotics
• Prognosis is generally poor
• Mortality Concerns: malignant transformation, severe
anemia, infection, or bleeding
For Financial Professional Use Only 64
 Case # 8
76 yo male applying for $2 million UL
• MD exam: type 2 diabetes, on Avandia
• Insurance labs: glucose 118, hemoglobin A1c 7.9%
• Medical records: mild anemia, normal iron studies, B12 and folate levels normal, no history of
alcohol excess
TEST 7/08 RESULT 1/10 RESULT 8/10 RESULT UNITS REF RANGE
WBC 7.0 5.4 4.7 L K/µL 4.8 - 10.8
RBC 4.37 L 3.97 L 3.82 L x 106/mm3 4.40 - 5.70
HGB 13.7 L 11.8 L 11.5 L g/dL 14.0 - 18.0
HCT 42.1 35.4 L 34.4 L % 42.0 - 52.0
MCV 96.9 101.2 H 102.2 H fl 80 - 97
MCH 33.0 33.6 H 33.1 pg 27.5 - 33.5
MCHC 33.2 33.0 32.9 % 32.0 - 36.0
RDW 13.8 14.9 14.3 % 11.0 - 15.0
PLT 241 199 129 L K/µL 140 - 390
MPV 8.9 9.0 8.3 L fl 8.6 - 11.7
NEUT % 55.0 61.0 55.6 % 30.0 - 75.0
LYMPH % 34.8 27.7 31.7 % 10.0 - 50.0
MONO % 7.2 9.2 11.2 H % 2.0 - 10.0
EOS % 2.5 1.6 1.1 % 0.0 - 6.0
BASO % 0.5 0.5 0.4 % 0.0 - 2.0
For Financial Professional Use Only 65
Case # 8: CBCs dated 7/08, 1/10, 8/10

TEST 7/08 RESULT 1/10 RESULT 8/10 RESULT UNITS REF RANGE
WBC 7.0 5.4 4.7 L K/µL 4.8 - 10.8
RBC 4.37 L 3.97 L 3.82 L x 106/mm3 4.40 - 5.70
HGB 13.7 L 11.8 L 11.5 L g/dL 14.0 - 18.0
HCT 42.1 35.4 L 34.4 L % 42.0 - 52.0
MCV 96.9 101.2 H 102.2 H fl 80 - 97
MCH 33.0 33.6 H 33.1 pg 27.5 - 33.5
MCHC 33.2 33.0 32.9 % 32.0 - 36.0
RDW 13.8 14.9 14.3 % 11.0 - 15.0
PLT 241 199 129 L K/µL 140 - 390
MPV 8.9 9.0 8.3 L fl 8.6 - 11.7
NEUT % 55.0 61.0 55.6 % 30.0 - 75.0
LYMPH % 34.8 27.7 31.7 % 10.0 - 50.0
MONO % 7.2 9.2 11.2 H % 2.0 - 10.0
EOS % 2.5 1.6 1.1 % 0.0 - 6.0
BASO % 0.5 0.5 0.4 % 0.0 - 2.0

For Financial Professional Use Only 66

Q&A

For Financial Professional Use Only 67

Life insurance products are issued by MetLife Investors USA Insurance Company, Metropolitan Life Insurance Company
and in New York only, by First MetLife Investors Insurance Company. All guarantees are based on the claims-paying
ability and financial strength of the issuing insurance company. Variable products are distributed by MetLife Investors
Distribution Company (MetLife Investors), Irvine, CA. September 2012

L0911208105[exp0912][All States][DC,GU,MP,PR,VI]

For Financial Professional Use Only 68