TOC | HEME
Neutrophilia or Granulocytosis (a neutrophil count greater than 10,000/mm3)
Serious bacterial infections and chronic inflammation are usually associated with changes include increased numbers of young cells (bands), of cells with residual endoplasmic reticulum (Dohle bodies), and of cells with more prominent primary granules (toxic granulation).
Evaluation of neutrophilia
When there is uncertainty, bone marrow aspiration and biopsy, chromosomal analysis, and marrow cultures for bacteria (e.g., Salmonella, Brucella, Mycobacteria, and fungi) are warranted. The results of these tests will enable the clinician to make a diagnosis of CML (or another myeloproliferative disorder), a granulomatous infection, inflammatory disease, or metastatic malignancy. If no such cause can be found in an otherwise healthy-appearing person, a diagnosis of idiopathic or familial neutrophilia may be considered and repeated neutrophil counts performed at monthly intervals until the diagnosis is clarified.
Scientific American Medicine October 1999
REF: 2010-04 Heme Dept
Leukocytosis - Definition: WBC >11,000 per mm3 (11 X 109 per L)
Appropriate evaluation by primary care physician:
a. review chart - chronic or acute, progressive or non-progressive
b. smoking history: smokers often have mild chronic neutrophilia. Best intervention: help patient stop smoking.
c. Clinical symptoms: infection, malignancy, chronic inflammatory conditions
2. Physical examination:
a. Weight: obesity may cause neutrophilia (increases inflammatory mediators)
b. Lymph nodes, spleen
c. General condition of patient (i.e, is the patient sick or not)
3. Laboratory investigation: Always do CBC with differential as first step to determine which category of leukocytosis is present
a. Neutrophilia (segs, with or without bands)
c. Immature cells (blasts, promyelocytes, metamyelocytes)
d. Associated abnormalities in red cells/platelets
a. Chronic, idiopathic or benign neutrophilia: Nonprogressive mild neutrophilia (ie, WBC <20,000) without associated signs or symptoms is unlikely to be due to a serious disease entity and intensive investigation is likely not going to be helpful; especially in obese patients and smokers.
b. Neutrophilia due to chronic infection, chronic inflammatory diseases; patient's underlying condition is generally obvious. This includes conditions such as COPD with chronic or recurrent bronchitis.
c. Neutrophilia due to medication: steroids is most common; lithium.
d. Neutrophilia due to malignancy: lung cancer is most common, usually in more advanced cancers, clinical picture should be suggestive (new onset, cough, weight loss, etc.).
e. Neutrophilia with eosinophilia: gastric cancer, Hodgkin's disease. Look for clinical signs/symptoms.
f. Neutrophilia with left shift, especially when progressive: myeloproliferative disorders, including chronic myelogenous leukemia
g. Recovery: after severe sepsis, major surgery, trauma, post-neutropenia, there may be a transient increase in neutrophils; this should resolve. Give it enough time before sending heme referral (1-2 months).
a. Mature lymphocytosis in an adult is most commonly due to chronic lymphocytic leukemia.
b. Lymphocytosis may occur in pertussis
c. Atypical lymphocytosis may occur in viral infections such as mononucleosis. Can be confused with acute leukemia (atypical lymphs interpreted as blasts).
6. Blasts: call Hematology. Leukemia, myelodysplastic syndromes, marrow infiltration, lymphoma may present with leukocytosis/blasts. Usually the CBC is completely abnormal (anemia, thrombocytopenia).
7. Eosinophilia: "worms, wheezes, weird diseases (rheumatic, etc.)"; persistent significant eosinophilia can be primary heme disorder; if no clinical evidence for these underlying entities, heme referral is appropriate.
When you should refer to Hematology?
When it is likely that hematology will have something to add to the evaluation and management of the patient. In other words, if you have a patient who has had leukocytosis for a few years and has no symptoms of serious hematologic disease, continued observation (by PCP) is appropriate. It is very unlikely that we will do anything more than take a good history and perform physical examination.
Other tests which can be useful:
" Leukocyte alkaline phosphatase: for evaluation of neutrophilia, particularly important if progressive and/or associated with left shift in neutrophil series (eg bands, metas, myelos, pros, and even blasts); if low, highly likely to be chronic myelogenous leukemia. If normal or elevated, clinical evaluation as above is enough.
" CXR for smoker with new leukocytosis, cough, weight loss, or any worrisome symptoms that might suggest malignancy.
Dr. Advice: if you are not certain whether patient needs additional
investigation, we now have Dr. Advice available for "econsult":
Open telephone encounter
Enter Dr Advice in "reason for message"
Documentation: brief history/workup, and questions you have
Forward to Bellflower Oncology pool
Basophilia (basophil actual count > 150/mm3)
Basophilia is an uncommon cause of leukocytosis. Basophils are inflammatory mediators of substances such as histamine. These cells, along with similar tissue-based cells (mast cells), have receptors for IgE and participate in the degranulation of white blood cells that occurs during allergic reactions, including anaphylaxis.
Causes of basophilia, some of uncertain origin, are listed in Table below.
Infections: viral infections (varicella), chronic sinusitis
Inflammatory conditions: inflammatory bowel disease, chronic airway inflammation, chronic dermatitis
Myeloproliferative disorders: chronic myelogenous leukemia (CML), polycythemia vera, myelofibrosis, myeloid metaplasia
Alteration of marrow and reticuloendothelial compartments: chronic hemolytic anemia, Hodgkin's disease, splenectomy
Endocrinologic causes: hypothyroidism, ovulation, estrogens
Can be seen in ulcerative colitis.
Etiology of Eosinophilia
Infections: scarlet fever, chorea, leprosy, genitourinary infections
Immunologic disorders: rheumatoid arthritis, periarteritis, lupus erythematosus, eosinophilia-myalgia syndrome
Pleural and pulmonary conditions: Löffler's syndrome, pulmonary infiltrates and eosinophilia
Malignancies: non-Hodgkin's lymphoma, Hodgkin's disease
Myeloproliferative disorders: chronic myelogenous leukemia, polycythemia vera, myelofibrosis
Adrenal insufficiency: Addison's disease
Etiology of Lymphocytosis (Absolute count > 4,000/mm3)
* Lymphocytopenia is defined as total count < 1,000/mm3.
Primary lymphocytosis (Lymphoproliferative disorders)
Leukemia: acute or chronic lymphocytic leukemia, Hairy-cell leukemia; large granular lymphocyte leukemia
Monoclonal B cell lymphocytosis
Secondary lymphocytosis (Reactive lymphocytosis)
Acute infections: viral infections; as cytomegalovirus infection, Epstein-Barr virus infection, pertussis, hepatitis, toxoplasmosis
Chronic infections: tuberculosis, brucellosis
Chronic lymphocytosis: autoimmune disorders, cancer, hyosplenism, sarcoidosis, cigarette smoking
Acute lymphocytosis: cardiovascular collapse, septic shock, sickle cell crisis, status epilepticus, trauma, surgery, drugs; hypersensitivity
Thyrotoxicosis; Addison's disease
Splenomegaly with splenic sequestration