Leukocytosis - Some Learning Points Koh Liang Piu Department of Hematology-Oncology National University Cancer Institute National University Health System
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.
Simple Approach to Abnormal FBC results High White Blood Counts Causes: 1. Central: Myeloproliferative/lymphoproliferative disease Leukaemia 2. Peripheral: Stress, Infection, inflammation, Malignancy, splenectomy
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
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? - +++
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)
42 Male Abnormal FBC during health screen
42 Male Abnormal FBC during health screen 1. Take good history 2. Look for Hepatosplenomegaly 3. Look at PBF MPD??
Leukemoid Reaction PBF of a patient with severe postoperative sepsis due to a Gramnegative organism. WBC 92 x 10 9 /L - Neutrophil count of 74 10 9 /l (80%) - Monocyte count of 16 10 9 /l (17%) Hb 12g/dL Platelet 100 x 10 9 /L PBF shows a band form, a macropolycyte and monocytes with increased cytoplasmic basophilia.
Neutrophilia Reactive (Leukemoid Reaction) Infection Inflammation Malignancy Drugs - Steroids, GCSF, Psychiatric Medications Myeloid Malignancy CML MPD Chronic Neutrophilic Leukemia (rare)
Reactive Neutrophilia band forms showing vacuolation and marked toxic granulation
45 / Chinese/ female Presenting Complaints: -Vague epigastric discomfort x few months. Clinical Examinations: - Massive splenomegaly
45 / Chinese/ female Presenting Complaints: -Vague epigastric discomfort x few months. Clinical Examinations: - Massive splenomegaly
45 / Chinese/ female Presenting Complaints: -Vague epigastric discomfort x few months. Clinical Examinations: - Massive splenomegaly
Chronic Myeloid Leukaemia Peripheral Blood Film Marrow Aspirate
Normal Hematopoiesis
In CML myelocytes and neutrophils being the most frequent cells. CML
FBC of a patient with Acute Leukemia
Peripheral Blood Film AML CML
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.
A 56 year old man with epistaxis. Clinically: Small cervical Lymphadenopathy Massive splenomegaly
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)
CLL
Hairy Cell Leukemia Mantle Cell Lymphoma Follicular Lymphoma
Cell Surface Markers of Lymphocytes in B/T LPD
34 / Male Presenting Complaints: -LHC fullness for many months, a/w LOW Clinical Examination: - Massive splenomegaly
34 / Male Presenting Complaints: -LHC fullness for many months, a/w LOW Clinical Examination: - Massive splenomegaly
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)
Eosinophilia Primary Clonal Hypereosinophilic Syndrome (HES) Secondary Parasite Drugs Allergic conditions Vasculitides Lymphoma (T-NHL, Hodgkin) Metastatic Cancer
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.
Basophilia Rare Seen in CML and Chronic Basophilic Leukemia (extremely rare) Refer Hematology Bone Marrow Biopsy
59 / Chinese/ Male Presenting Complaints: -LHC fullness for many months, a/w LOW Clinical Examination: - Massive splenomegaly
Tear Drop Cells
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
Conclusions
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
Any doubt, ask a haematologist
Thank you for your attention Email : liang_piu_koh@nuhs.edu.sg