1. Immature granulocytes (IGs) are white blood cells in early stages of development that can indicate the presence of bacterial infection. 2. Manual microscopic examination and hematology analyzers can detect and quantify IGs to calculate ratios like the IT ratio that correlate with infection and sepsis. 3. Studies have found IG counts and IT ratios above certain levels to be predictive of infection and sepsis with high sensitivity and specificity, and can serve as early indicators even when blood cultures are negative.

1. CLINICAL UTILITIES
OF
IMMATURE GRANULOCYTES
1

2. What is Immature Granulocyte ?
Thymus Lymph nodes
and spleen
Pluri potent
Stem Cell
Lymphatic
T0-Lymphocyte stem cell Makrophage
T1-Lymphocyte B1-Lymphocyte Myeloblast
Megakaryoblast
Basophil in tissue
Proerythroblast Promyelocyte
T-Immuno- Centro- B-Immuno- Reticulum cell
blast blast blast Megakaryocyte
Polychr. Myelocyte
Erythroblast Baso-
Eosino
0 phil Neutrophil phil Monoblast
Plasmoblast
Reticulocytes
Orthochr.
Centrocyte Plasma cell 1
Erythroblast
Blood-bone marrow barrier Metamyelocyte
2
Plasma cell
Plasma
3 Bands
B22-Lymphocyte
B -Lymphocyte
T -Lymphocyte
T22-Lymphocyte
4 Monocyte
Monocyte
Peripheral Blood Thrombocytes Erythrocytes Segmented Cells
Segmented
Juli Soemarsono SURAMADE I - 2011

3. 3
MANUAL
MICROSCOPIC
IMMATURE
GRANULOCYTE
Text1 Text1 Text1 Text1
Juli Soemarsono
SURAMADE I - 2011

4. 4
Diana Aulia, Arief I. Sanjaya, and Ina S. Timan ;J. Lab. Med. & Quality Assurance 2003：25：237-242
MANUAL / MICROSCOPIC
IMMATURE GRANULOCYE
Text1 Text1 Text1 Text1
Juli Soemarsono
SURAMADE I - 2011

5. 5
HEMATOLGY ANALYZER
IMMATURE GRANULOCYE
Text1 Text1 Text1
Juli Soemarsono
SURAMADE I - 2011

6. 6
BAND
COUNT
BAND / ANC
(IT-RATIO)
DETECTION
of
INFECTION
Juli Soemarsono
SURAMADE I - 2011

7. 7
Diana Aulia, Arief I. Sanjaya, and Ina S. Timan ; J. Lab. Med. & Quality Assurance 2003：25：237-242
•Ratio 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.
•Immature neutrophils are cells at younger stage than neutrophil bands
metamyelocytes,
myelocytes,
promyelocytes
myeloblast).
Juli Soemarsono
SURAMADE I - 2011

8. 8
Clinical utility of the band count.
has a long clinical tradition as
a diagnostic test for bacterial infection
imprecise BAND inaccurate
COUNT
required to calculate an
immature to total neutrophil
ratio
Juli Soemarsono
(I:T ratio)
SURAMADE I - 2011

9. 9
Diagram
neutrophils more immature than bands
DETECTION
absolute neutrophil count of
INFECTION
I / T RATIO
Ardron MJ, Westengard JC, Dutcher TF. Am J Clin Pathol. 1994 Nov;102(5):646-9
Juli Soemarsono SURAMADE I - 2011

10. 10
Immature granulocyte Reference Value
Juli Soemarsono SURAMADE I - 2011

11. Immature granulocyte Reference Value
Samples size:
• 156 healthy blood donors
• Male: 80
• Female: 76
Reference values
Male 0.03X109/L 0.5%
Female 0.03X109/L 0.4%
** No age dependency
Juli Soemarsono
SURAMADE I - 2011

12. 12
Juli Soemarsono
SURAMADE I - 2011

13. 13
Correlation with flow cytometric reference method & manual reference method
Flow cytometric method:
• Anti-CD16, aniti-CD11b & anti-CD45
• Epics XL-MCL (BC)
Manual Differential Count
•400 WBC count (NCCLS protocol)
Correlation Tests:
XE-IG count vs flow cytometric ref. method using monoclonal antibodies demonstrated excellent
results (r=0.96 on data without asterisks)
XE-IG count vs. manual ref. count was lower (r=0.78). Reasons being
Smaller number of cells counted with manual method
Subjectivity involved in morphological classification of IG
Briggs et al. ;Hematology. 2003;9:117-124
Juli Soemarsono SURAMADE I - 2011

14. 14
Clinical Significance
Positive sample rate in samples with high IG (2.0% or higher).
Good correlation
• CRP
• ESR
• CD64
• IL-6
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 (e.g. Neutropils) are in the overall
normal range and are generally non-specific
as indicators.
Reference:
Briggs et al. Evaluation of Immature Granulocyte Counts by the XE-IG Masrer: Upgraded software for the XE-2100
Automated Hematology Analyzer. Laboratory Hematology. 2003;9:117-124
Juli Soemarsono SURAMADE I - 2011

15. 15
IG count in infection and sepsis
Juli Soemarsono SURAMADE I - 2011

16. 16
IG as a predictor of infections and sepsis
• IG% is higher in infected patients and positive blood cultures
• IG % is better predictor of infection than WBC count
• IG % is comparable to the absolute neutrophil count
• High IG helps direct molecular testing, leading to a more rapid diagnosis of severe infection
• 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.
• > 3% IG is a very specific predictor of sepsis (>90%)
(Ansari-Lari et al, 2003)
Reference:
Ansari-ari et al. Immature Immature Granulocyte Measurement using the Sysmex XE-2100: Relationship of Infection
and Sepsis. Am J Clin Pathol. 2003;120:795-799
Juli Soemarsono SURAMADE I - 2011

17. 17
IG ratio & 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
Juli Soemarsono SURAMADE I - 2011

18. 18
Comparison of IG ratio and IT ratio with blood culture
All 7 patients with negative blood culture showed IT ratio > 0.65
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
Juli Soemarsono SURAMADE I - 2011

19. 19
IT ratio vs IG ratio as indicator of Sepsis
• IG Ratio of 0.35 gives the best
sensitivity & specificity
IT Ratio of 0.65 gives the best
sensitivity & specificity
Juli Soemarsono SURAMADE I - 2011

20. 20
IT ratio vs IG ratio as indicator of Sepsis
• IT ratio though has the same sensitivity & specificity as IG ratio, it gives a better
overall positive and negative predictive values than IG ratio.
• IT ratio provides a useful tool in diagnosing those sepsis patients who have a
negative blood culture (100 PPV).
Juli Soemarsono SURAMADE I - 2011

21. 21
IT ratio and the day of Diagnosis
• 12 (71%) of 17 patients studied showed
an IT ratio > 0.65 in samples taken on 3
days pre diagnosis
• => IT ratio can be used as early indicator
of sepsis
29% 71%
18 (72%) of 25 septic patients studied
3 days post diagnosis showed an IT ratio > 0.65 in samples on 3
days post diagnosis
=> post sample detected 1 more patient
=> IT ratio can be used throughout the
course of disease
=> may be used to monitor patient
recovery
Juli Soemarsono SURAMADE I - 2011

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How to measure IG ?
XE-seeries (5 +1) part diff automated hematology analyzer!
XE-5000
XE-2100 (w/ XE IG Master)
XE-2100L (w/ XE IG Master)
XE -2100D (w/ XE IG Master)
Juli Soemarsono SURAMADE I - 2011

23. 23
IG count
Measure in Diff Channel and report in
IG # (103/µl)
IG %
Detect in IMI channel and display as flags
Constitute of Promyelocytes, Myelocytes & Metamyelocytes
Juli Soemarsono SURAMADE I - 2011

24. 24
Benefits of quantitative IG count Using Sysmex XE
“Anti-smear campaign”
• Automated enumeration of IG using proprietary Fluorescent Flow Cytometery, eliminates
– immature granulocyte flag
– false positives
– the need to perform unneccessary manual smear reviews
• Improved sensitivity & accuracy compared to manual Diff-Count
– Small no of IG, particularly in leukopenic sample are often missed in a std 100-cell DC
– Wide inter-examiner and inter-laboratory variation
• Reduce manual reviews
– saves times & effort of MT
– allow results to be delivered to physicians sooner -> reduce TAT
• User defineable setting for Diff Review: (IG > 2%, 3%, 4% or 5%)
• Fast, simple and inexpensive method
Juli Soemarsono SURAMADE I - 2011

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Clinical Utilities of XE’s 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.
Juli Soemarsono SURAMADE I - 2011

26. Juli Soemarsono
SURAMADE I - 2011