Leukocytosis - Some Learning Points

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1 Leukocytosis - Some Learning Points Koh Liang Piu Department of Hematology-Oncology National University Cancer Institute National University Health System

2 Objectives of this talk: 1. To provide some useful practical diagnostic algorithms when confronted with abnormal FBC. 2. To help the non-haematologist to decide when you can circumvent yourself and when haematology consult is necessary.

3 Simple Approach to Abnormal FBC results High White Blood Counts Causes: 1. Central: Myeloproliferative/lymphoproliferative disease Leukaemia 2. Peripheral: Stress, Infection, inflammation, Malignancy, splenectomy

4 Simple Approach to Abnormal FBC results High White Blood Counts Important Clues to look for 1. History 2. Physical Exam: Liver/Spleen,, Lymphadenopathy etc 3. Peripheral Blood Film (Most Important) 4. WBC: Differentials 5. Biochemisry: ESR/CRP, LDH 6. PT/PTT/DIC screen. 7. Septic/ Malignancy screen

5 Important Questions for Leucocytosis : Is this Reactive? Is this Neoplastic (Clonal)? Which subset of WBC is elevated? Reactive Neoplastic Neutrophil? ++ + Lymphocytes? ++ + Monocytes? ++ + Eosinophil? ++ + Basophil? + Blast? - +++

6 Important Questions for Leucocytosis : Is this affecting the other 2 cell lines (lineages), i.e. RBC/Hb and platelet count? - If yes, this is probably neoplastic (although not absolute)

7 42 Male Abnormal FBC during health screen

8 42 Male Abnormal FBC during health screen 1. Take good history 2. Look for Hepatosplenomegaly 3. Look at PBF MPD??

9 Leukemoid Reaction PBF of a patient with severe postoperative sepsis due to a Gramnegative organism. WBC 92 x 10 9 /L - Neutrophil count of /l (80%) - Monocyte count of /l (17%) Hb 12g/dL Platelet 100 x 10 9 /L PBF shows a band form, a macropolycyte and monocytes with increased cytoplasmic basophilia.

10 Neutrophilia Reactive (Leukemoid Reaction) Infection Inflammation Malignancy Drugs - Steroids, GCSF, Psychiatric Medications Myeloid Malignancy CML MPD Chronic Neutrophilic Leukemia (rare)

11 Reactive Neutrophilia band forms showing vacuolation and marked toxic granulation

12 45 / Chinese/ female Presenting Complaints: -Vague epigastric discomfort x few months. Clinical Examinations: - Massive splenomegaly

13 45 / Chinese/ female Presenting Complaints: -Vague epigastric discomfort x few months. Clinical Examinations: - Massive splenomegaly

14 45 / Chinese/ female Presenting Complaints: -Vague epigastric discomfort x few months. Clinical Examinations: - Massive splenomegaly

15 Chronic Myeloid Leukaemia Peripheral Blood Film Marrow Aspirate

16 Normal Hematopoiesis

17 In CML myelocytes and neutrophils being the most frequent cells. CML

18 FBC of a patient with Acute Leukemia

19 Peripheral Blood Film AML CML

20 Differentiating acute versus chronic myeloid leukemia based on FBC AML Leucocytosis. Predominant population of blasts. Anemia and thrombocytopenia more sig. Eosinophilia/ basophilia unusual. CML Leukocytosis. Mixture of blasts amd immature cells. Anemia usually mild. Plts may be mildly low, normal or even high. Eosinophilia and basophilia common.

21 A 56 year old man with epistaxis. Clinically: Small cervical Lymphadenopathy Massive splenomegaly

22 Lymphocytosis Reactive causes present (infection, postsplenectomy) PBF and Flow Cytometry Clonal disorder present No Clonal disorder (Reactive Lymphocytosis) Exclude Infectious etiologies Viral (HIV, EBV, Hepatitis). Other Infections (TB, Toxoplasmosis)

23 CLL

24 Hairy Cell Leukemia Mantle Cell Lymphoma Follicular Lymphoma

25 Cell Surface Markers of Lymphocytes in B/T LPD

26 34 / Male Presenting Complaints: -LHC fullness for many months, a/w LOW Clinical Examination: - Massive splenomegaly

27 34 / Male Presenting Complaints: -LHC fullness for many months, a/w LOW Clinical Examination: - Massive splenomegaly

28 Monocytosis Reactive Chronic Infectious/ Inflammatory/ Granulomatous Metastatic Cancer Lymphoma Follow AMI Relative Recovery from Chemotherapy or druginduced neutropenia Neoplastic Marker of MPD (eg: Chronic Myelomonocytic Leukemia, CMMoL)

29 Eosinophilia Primary Clonal Hypereosinophilic Syndrome (HES) Secondary Parasite Drugs Allergic conditions Vasculitides Lymphoma (T-NHL, Hodgkin) Metastatic Cancer

30 Eosinophilia 1. Obtaining a good patient history 2. Stool test for ova and parasites In patients with primary eosinophilia - Bone marrow biopsy recommended - distinguish between clonal eosinophilia and HES In patients with suspected HES - Cytogenetic studies, - FISH for FIP1L1-PDGFRA mutation, - Immunohistochemical stains for tryptase - Mast cell immunophenotyping.

31 Basophilia Rare Seen in CML and Chronic Basophilic Leukemia (extremely rare) Refer Hematology Bone Marrow Biopsy

32 59 / Chinese/ Male Presenting Complaints: -LHC fullness for many months, a/w LOW Clinical Examination: - Massive splenomegaly

33

34 Tear Drop Cells

35 Leukoerythroblastic Reaction Bone Marrow Infiltration (the M s) Malignancy Metastasis Myelofibrosis Marble Bone Disease (metabolic disease) Mycobacterial Tuberculosis (infection) Peripheral Stress/ Destruction/ Loss Infection Hemolysis Hemorrhage

36 Conclusions

37 Simple Approach to Leukocytosis High White Blood Cells: Which subtype Important Clues to look for 1. Obtain good history 2. Physical Exam: Liver/Spleen,, Lymphadenopathy etc 3. Peripheral Blood Film (Most Important) 4. WBC: Differentials 5. Biochemisry: ESR/CRP, LDH 6. PT/PTT/DIC screen. 7. Septic/ Malignancy screen

38 Any doubt, ask a haematologist

39 Thank you for your attention liang_piu_koh@nuhs.edu.sg

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