Approach to the patient with neutrophilia
- Thomas D Coates, MD
Thomas D Coates, MD
- Professor of Pediatrics and Pathology
- University of Southern California School of Medicine
- Section Editors
- Donald H Mahoney, Jr, MD
Donald H Mahoney, Jr, MD
- Section Editor — Pediatric Hematology
- Professor of Pediatrics
- Baylor College of Medicine
- Laurence A Boxer, MD
Laurence A Boxer, MD
- Section Editor — White Cell Disorders
- Henry and Mala Family Professor of Pediatric Hematology/Oncology
- University of Michigan
The normal total white blood cell (WBC) count in adults varies from 4400 to 11,000 cells/microL (4.4 to 11.0 x 109/L), the majority of which (approximately 60 percent) are mature neutrophils. Leukocytosis is defined as a total WBC more than two standard deviations above the mean, or a value of greater than 11,000/microL in adults. By convention, leukocytosis to values in excess of 50,000 cells/microL, when due to causes other than leukemia, is termed a leukemoid reaction or hyperleukocytosis.
While leukocytosis is most commonly due to an increase in the absolute number of mature neutrophils (neutrophilia), it can also reflect a marked increase in the absolute numbers of lymphocytes, eosinophils, monocytes, or, more rarely, basophils. Granulocytosis is generally used interchangeably with neutrophilia, although the two terms are somewhat different, since granulocytosis can also reflect leukocytosis due to increased numbers of eosinophils or basophils.
The absolute neutrophil count (ANC) is equal to the product of the white blood cell count (WBC) and the percentage of polymorphonuclear cells (PMNs) and band forms noted on the WBC differential, and is calculated as follows:
ANC (cells/microL) = WBC (cells/microL) x percent (PMNs + bands) ÷ 100
An ANC above 7700/microL in patient with a total WBC less than 11,000/microL is called neutrophilia. An example of a setting in which this might occur is the patient with AIDS in whom an increase in neutrophils may be offset by the presence of significant lymphopenia. However, for the purposes of this discussion, neutrophilia will be synonymous with neutrophilic leukocytosis.
- Hollowell JG, van Assendelft OW, Gunter EW, et al. Hematological and iron-related analytes--reference data for persons aged 1 year and over: United States, 1988-94. Vital Health Stat 11 2005; :1.
- Chabot-Richards DS, George TI. Leukocytosis. Int J Lab Hematol 2014; 36:279.
- Miller ST, Sleeper LA, Pegelow CH, et al. Prediction of adverse outcomes in children with sickle cell disease. N Engl J Med 2000; 342:83.
- Wanahita A, Goldsmith EA, Musher DM. Conditions associated with leukocytosis in a tertiary care hospital, with particular attention to the role of infection caused by clostridium difficile. Clin Infect Dis 2002; 34:1585.
- Ward HN, Reinhard EH. Chronic idiopathic leukocytosis. Ann Intern Med 1971; 75:193.
- Caramihai E, Karayalcin G, Aballi AJ, Lanzkowsky P. Leukocyte count differences in healthy white and black children 1 to 5 years of age. J Pediatr 1975; 86:252.
- Solanki DL, Blackburn BC. Spurious leukocytosis and thrombocytopenia. A dual phenomenon caused by clumping of platelets in vitro. JAMA 1983; 250:2514.
- Savage RA. Pseudoleukocytosis due to EDTA-induced platelet clumping. Am J Clin Pathol 1984; 81:317.
- Patel KJ, Hughes CG, Parapia LA. Pseudoleucocytosis and pseudothrombocytosis due to cryoglobulinaemia. J Clin Pathol 1987; 40:120.
- Morris MW, Williams WJ, Nelson DA. Automated blood cell counting. In: Williams' Hematology, 5th ed, Beutler E, Lichtman MA, Coller BS, Kipps TJ (Eds), McGraw-Hill, New York 1995. p.L3.
- Seebach JD, Morant R, Rüegg R, et al. The diagnostic value of the neutrophil left shift in predicting inflammatory and infectious disease. Am J Clin Pathol 1997; 107:582.
- Banez EI, Bacaling JH. An evaluation of the Technicon H-1 automated hematology analyzer in detecting peripheral blood changes in acute inflammation. Arch Pathol Lab Med 1988; 112:885.
- Dueholm S, Bagi P, Bud M. Laboratory aid in the diagnosis of acute appendicitis. A blinded, prospective trial concerning diagnostic value of leukocyte count, neutrophil differential count, and C-reactive protein. Dis Colon Rectum 1989; 32:855.
- Fitzpatrick MM, Shah V, Trompeter RS, et al. Interleukin-8 and polymorphoneutrophil leucocyte activation in hemolytic uremic syndrome of childhood. Kidney Int 1992; 42:951.
- Robson WL, Fick GH, Wilson PC. Prognostic factors in typical postdiarrhea hemolytic-uremic syndrome. Child Nephrol Urol 1988-1989; 9:203.
- Bellanné-Chantelot C, Clauin S, Leblanc T, et al. Mutations in the ELA2 gene correlate with more severe expression of neutropenia: a study of 81 patients from the French Neutropenia Register. Blood 2004; 103:4119.
- - Left shift
- - Leukemoid reaction
- Neutrophilic leukocytosis
- Lymphocytic leukocytosis
- Monocytic leukocytosis
- Eosinophilic and basophilic leukocytosis
- INITIAL APPROACH
- The history
- - Medications
- The physical examination
- INITIAL LABORATORY TESTING
- Normal variation
- Spurious leukocytosis
- - Platelet clumping
- - Cryoglobulinemia
- EVALUATION OF THE COMPLETE BLOOD COUNT
- Detection of infection or inflammation
- Complete blood counts in family members
- Combined abnormalities on the complete blood count
- - Anemia
- - Increased hematocrit
- - Increased platelet count
- - Decreased platelet count
- - Left shift in the WBC differential
- - Nucleated RBC and leukoerythroblastic picture
- - Monocytosis
- Bone marrow examination
- Other tests