Leukocytosis
Leukocytosis
Leukocytosis
Overview
Leukocytosis is defined as a white blood cell (WBC) count greater than 11,000/uL (11 109/L) in adults.1 It is usually due to an increase in the absolute value
of neutrophils > 7700/uL (neutrophilia), but can also be due to an increase in lymphocytes > 4000/uL (lymphocytosis), eosinophils > 450/uL (eosinophilia),
monocytes > 800/uL (monocytosis), and rarely basophils > 200/uL (basophilia).2 Because the cutoffs are set as 2 standard deviations above the mean, 2.5% of
the normal population will have leukocytosis, with no clinical significance.2
Definitions
a) Myeloid: The common myeloid progenitor gives rise to most WBCs including neutrophils, eosinophils, basophils, and macrophages.3
b) Lymphocytes (B cells and T cells): Arise from the common lymphoid progenitor.3
c) Polymorphonuclear Neutrophils (PMNs): Are the final cell type arising from the development pathway of myeloblast -> promyelocyte -> myelocyte -> meta-
myelocyte -> band -> PMN.2 The peripheral blood lab value for absolute neutrophil count (ANC) includes both PMNs and bands.4
d) Demargination: More than one-half of the neutrophils in the peripheral circulation are attached to the vascular endothelium. These "marginated" neutrophils
can be released within minutes (i.e.,"demarginated") due to physiological or psychological stress, as well as due to certain drugs, increasing the measured
ANC.4,5
e) Left shift: Band count greater than 700/uL. (i.e. increase in the precursors of the mature PMN).2
f) Leukemoid reaction: By convention, a historical term to describe WBC > 50 000/uL when due to causes other than leukemia. It is usually due to a relatively
benign cause (e.g. infection or inflammation), though leukemia must be ruled out.1,2
Diagnostic Considerations
Most often, an elevated WBC count is due to the bone marrows normal response to an external stimulus such as infection or inflammation. This leukocytosis
most commonly presents as an increase in PMNs and with a left shift (due to release of stored leukocytes). But every now and then, a leukocytosis may reflect
a primary bone marrow disorder, i.e. acute or chronic leukemia or a myeloproliferative disorder.1
Infectious source
bruising, petechiae, enlargement of liver/spleen/lymph nodes, life threatening
Cardio/respiratory examination
infection or immunosuppression, lethargy, significant weight loss.1
Hepatosplenomegaly
Joint swelling/erythema/tenderness
Lymphadenopathy
Dr. Michael Evans developed the One-Pager concept to provide clinicians with useful clinical information on primary care topics.
3) Bloodwork:
LEUKOCYTOSIS
Consider variant or lab error if clinical picture inconsistent:
CBC + differential o Repeat prior to launching extensive investigations4,5
o (NB WBC > 100 x 109/L represents a medical emergency because of o Consider normal variant
the risk of brain infarction and haemorrhage Needs urgent haematological o Examining the parents or siblings CBC may demonstrate a normal
consult)1 genetic variant4
o Other clues:
neutrophilia + polycythemia consider 4) Bone Marrow Biopsy
polycythemia vera4 Rarely indicated in the workup of simple neutrophilia6
leukocytosis + thrombocytopenia consider Would consider in some cases of leukemoid reactions, or when there
sepsis (+/- DIC), TTP-HUS4 is an abnormal peripheral blood smear, which warrants a bone marrow
unexplained WBC > 15 consider C. difficile biopsy as well as fungal and mycobacterial cultures to rule out tubercu-
even without diarrhea8,9 losis or fungal infection, tumour, or marrow fibrosis,4,6 +/- cytogenic and
Peripheral blood smear molecular studies6
+/- ESR and CRP elevated in occult inflammation or infection; can be help-
ful in an asymptomatic patient with leukocytosis4
Bottom Line
Most often, an elevated WBC count is due to the bone marrows normal response to an external stimulus such as infection or inflammation. The etiology can
usually be found by a thorough history and physical coupled with analyzing the WBC differential and peripheral blood smear. However make sure to inquire
about red flags. Consider referral to a specialist if there are red flags or an abnormal blood smear.