Hyperleukocytosis

The leukocytosis is defi ned by a number of white blood cells than 10,000 / mm3. Such a value but draws attention:

– Moderate leukocytosis (<12,000 / mm3) may not be accompanied by arithmetically no increase of the various components of the formula leukocyte absolute (absolute neutrophil count <7500 / mm3, lymphocytes <4000 / mm3, eosinophils <500 / mm3, monocytes <1000 / mm3) and have no pathological significance; conversely a number of normal white blood cells does not exclude the pathological increase of leukocyte lineages beyond values ​​indicated above.

DIAGNOSIS:

It is limited to the analysis of the differential count, line by line, in absolute terms, and to specify whether leukocytosis results from:

– Neutrophilia;

– Eosinophilia;

– Lymphocytosis;

– Monocytosis;

– Or the presence of abnormal cells in the blood (myelemia, blasts, mononucleosis …).

Note: the presence of erythroblasts in large numbers in the blood is not alone responsible for leukocytosis, because these cells are counted in addition to the percentage of these leukocytes.

ETIOLOGY:

Neutrophilia:

Definition:

It is the presence in the blood picture of excessive neutrophil count greater than 7500 / mm3.

Technical problem: there is virtually no possibility of error, except in very rare cases significantly disrupting cryoglobulinemia automatic counting.

Diagnosis:

It is located in two completely different settings depending on whether the polynucleosis is associated with a disease or isolated (Box 1).

Box 1. What to do before a neutrophilia Emergency
The leukocytosis is not a per se. It can only come from the associated pathology. Blood disorders, involved in rare cases, are not generally emergencies.
Specialized consultation
Necessary only in the case of really isolated polynucleosis. In other cases, its only justification is to calm the anxiety of patients. Therapeutic
The neutrophilia not justify any by itself.

Polynucleosis associated pathology:

This is a common sign of any localized pyogenic infection (tonsillitis, appendicitis, paronychia) or generalized (septicemia). It also accompanies many acute and chronic inflammatory diseases (rheumatoid arthritis) and most acute tissue necrosis (myocardial infarction). Probably by a combination of these various mechanisms, it often accompanies advanced cancers. It is an element of some hematologic the table: polycythemia vera (also evident on hematocrit) and other myeloproliferative diseases (but there was then myelemia, anemia, thrombocytosis very often) and Hodgkin’s disease.

Polynucleosis isolated:

The leukocytosis is a diagnostic problem if it is apparently isolated.

It is usually mild and rarely translated into a blood disease. Therefore, do not unnecessarily worry the patient but look carefully four causes:

– Obvious physiological causes (pregnancy: moderate leukocytosis recent months) or treatment (corticosteroids, lithium);

– Pyogenic infection cryptic: examination often reveals the origin. Think of the most common infections: ENT, urinary, gynecological and dental. Think also to skin infections and recurrent wounds (fishmongers for example);

– In the absence of infection, inflammation, with sedimentation rate (ESR) will have to search high deep cancer (kidney, lung, etc.);

– Smoking is a very common cause of leukocytosis. Only the stopping test may enter, 1-2 months (the correlation between leukocytosis and cardiac vascular risk is an argument that can help convince the subject to stop smoking).

Polynucleosis insulated with normal ESR:

Very exceptional family forms are described. For others, they represent long-term most often benign anomalies. In a few cases, they sometimes precede by several years myeloproliferative disorders (polycythemia vera and chronic myelogenous leukemia rarely).

This justifies control platelets and regular monitoring by a specialist without renewed exploration as long as it does not appear other events.

Hyperlymphocytosis:

Definition:

It is the presence of a complete blood count

excessive rate of lymphocytosis ≥ 4000 / mm3 in adults. It is considering in this context that hyperlymphocytosis without mononucleosis (Box 2).

Box 2. What to do before an emergency hyperlymphocytosis
Lymphocytosis in is never itself.
Specialized consultation
Essential for a scalable hyperlymphocytosis or hematological accompanying symptoms exist immediately (lymphadenopathy, splenomegaly, anemia, thrombocytopenia, protein electrophoresis revealed a monoclonal peak). It is useless to earlier practice other explorations that fall primarily in the specialty, including bone marrow aspiration or exploring electrophoretic anomaly.
The isolated and moderate lymphocytosis (<20,000 / mm3) requires no specialist consultation. Clinical and biological half-yearly monitoring is sufficient, possibly leading to specialist consultation in the event of progression. However, often the patient’s anxiety leads to specialist consultation “security” will be specified where the diagnosis and monitoring spaced attitude confirmed.

Technical problem: mistakes are not uncommon. Besides ignorance of mononucleosis, the confusion between lymphocytes and cells of other kinds is sometimes seen in non-specialized laboratories.

Main error: lymphoblasts acute leukemia (fortunately rare).

Diagnosis:

Do not forget the physiological lymphocytosis small child. They can exceed 7,000 / mm3 in the first two years and continue to a lesser degree until 5-8 years of age.

Exclude mononucléosiques syndromes (smear shows in this case hyperbasophilic lymphocytes).

Think first infectious cases with acute lymphocytosis observed especially in children. They occur in:

– Whooping cough, lymphocytosis sometimes considerable, often unrecognized assumption in adults;

– Viral infections: measles, mumps, respiratory viruses, hepatitis, rubella, etc. (The latter two rather give plasmocytoses)

– Disease Carl Smith, almost asymptomatic responsible for a very high lymphocytosis in children.

Chronic lymphocytosis adult first evoke chronic hematologic malignancies.

It must be remembered that they do not exist in children, are exceptional and rare before age 30 to age 40. In practice, persistent lymphocytosis for more than two months in the adult enters this framework, including:

– Chronic lymphocytic leukemia revealed in over half of cases by an isolated lymphocytosis in a routine blood count;

– Other blood diseases chronic lymphocytic, identified on the morphology of the cells and immunophenotyping (hematological B: prolymphocytaires leukemia, hairy, leukemic forms of lymphoma [marginal zone, mantle, follicular] rarely hematological T: Prolymphocytic leukemia with “large granular lymphocytes”);

– The dise ase Waldenstrom (rarely hyperleucocytaire) where VS is still very high;

– The polyclonal lymphocytosis which is very rare and curiously observed almost exclusively in women smoke heavily.

TREATMENT:

Processing polyclonal hyperlymphocytosis of smoking cessation is a test of at least one to two months. Treatment of hyperlymphocytosis pertussis consists of antibiotics (eg, erythromycin 3g / day for 2 weeks).

The treatment of hematological malignancies is extremely variable, since no treatment in lymphoid leukemias without strong nodal mass without cytopenia (stage A) to aggressive chemotherapy in some prolymphocytaires leukemia; it is a matter for specialists.