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 Gram- negative organism. WBC 92 x 109/L - Neutrophil count of 74 × 109/l (80%) - Monocyte count of 16 × 109/l (17%) Hb 12g/dL PBF shows a band form, a Platelet 100 x 109/L 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 CML • Leucocytosis. • Leukocytosis. • Predominant population • Mixture of blasts amd of blasts. immature cells. • Anemia and • Anemia usually mild. Plts thrombocytopenia more may be mildly low, normal sig. or even high. • Eosinophilia/ basophilia • Eosinophilia and basophilia unusual. 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 No Clonal disorder present (Reactive Lymphocytosis) Exclude Infectious etiologies • Viral (HIV, EBV, Hepatitis). • Other Infections (TB, Toxoplasmosis) CLL Mantle Cell Lymphoma Follicular Lymphoma Hairy Cell Leukemia 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 drug- induced 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 : [email protected] .