Leukocytosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2] Lakshmi Gopalakrishnan, M.B.B.S. [3]

Synonyms and keywords: Elevated white blood cell count; Right-shift leukocytosis; Left-leukocytosis

Overview

Leukocytosis is an elevation of the white blood cell count above the normal range (greater than 11,000 per mm3). Leukocytosis is frequently a sign of an inflammatory response, most commonly the result of infection, but may also occur following certain parasitic infections, bone tumors, strenuous exercise, emotional stress, pregnancy, anesthesia, and epinephrine administration. Leukocytosis may be classified into 5 subtypes: neutrophilia (most common), lymphocytosis, monocytosis, eosinophilia, and basophilia. Other classification, include: Left shift or right shift leucocytosis. The pathogenesis of leukocytosis is characterized by the increase of leukocytes (primarily neutrophils), followed by the proliferation and release of granulocyte and monocyte precursors in the bone marrow which is stimulated by several products of inflammation including C3a and G-CSF.

Historical Perspective

• Leukocytosis was first discovered by Paul Kautchakoff, in 1846.

Classification

• Leukocytosis may be classified into 5 subtypes:

• Neutrophilia (most common)
• Lymphocytosis
• Monocytosis
• Eosinophilia
• Basophilia.

• Leukocytosis may also be classified into 2 groups:

• Left shift (most common)

• Immature leukocytes increase
• Proliferation and release of granulocyte and monocyte precursors in the bone marrow
• Usually stimulated by several products of inflammation including C3a and G-CSF

• Right shift

• Reduced count or lack of "young neutrophils"
• Associated with the presence of "giant neutrophils

• Other variant of leukocytosis is the leukemoid reaction.
• The image below demonstrates a graphic figure that illustrates hematopoietic growth factors in leukocytosis.

• 
  Hematopoietic growth factors in leukocytosis
  Courtesy of Wikipedia

Pathophysiology

• The pathogenesis of leukocytosis is characterized by:

• An increased release of leukocytes from bone marrow storage pools
• Decreased margination of leukocytes onto vessel walls
• Decreased extravasation of leukocytes from the vessels into tissues
• Increase in number of precursor cells in the marrow

Causes

• To see a comprehensive list of all causes of leukocytosis, please click here

Causes of leukocytosis
Neutrophilic leukocytosis (neutrophilia)	Acute bacterial infections, especially pyogenic infections Sterile inflammation Tissue necrosis Myocardial infarction Burns
Eosinophilic leukocytosis (eosinophilia)	Allergic disorders Asthma Hay fever Drug allergies Allergic skin diseases Pemphigus Dermatitis herpetiformis Parasitic infections Some forms of malignancy Hodgkin's lymphoma Some forms of Non-Hodgkin lymphoma Systemic autoimmune diseases (e.g. SLE) Some forms of vasculitis Cholesterol embolism (transiently)
Basophilic leukocytosis Basophilia	Myeloproliferative disease, e.g. Chronic myelogenous leukemia
Monocytosis	Chronic infections Tuberculosis Bacterial endocarditis Rickettsiosis Malaria Systemic autoimmune diseases, e.g. SLE Inflammatory bowel diseases, e.g. ulcerative colitis
Lymphocytosis	Chronic infections Tuberculosis Brucellosis Viral infections Hepatitis Cytomegalovirus infection Infectious mononucleosis Pertussis Some forms of malignancy, such as lymphocytic leukæmias

Epidemiology and Demographics

• Leukocytosis is very common.

Age

• Patients of all age groups may develop leukocytosis.
• Normal white blood count differential changes with age.
• Leukocytosis in neonates is more common, compared to children and adults.

Gender

• Leukocytosis affects men and women equally.

Race

• There is no racial predilection for leukocytosis.

Risk Factors

• Common risk factors in the development of leukocytosis, include:

• Physiologic processes (eg, stress, exercise, pregnancy)
• Drugs (e.g.corticosteroids, lithium, beta agonists)
• Trauma
• Stress

Natural History, Complications and Prognosis

• The majority of patients with leukocytosis are initially symptomatic.
• Early clinical features, include:

• Fever
• Hyperhidrosis
• Fatigue

• Common complications of leukocytosis, include:

• Tumor lysis syndrome
• Disseminated intravascular coagulopathy
• Acute respiratory failure
• Pulmonary hemorrhage
• CNS infarction
• Splenic infarction
• Myocardial ischemia
• Renal failure

• Prognosis is generally depends on the underlying etiologies.

Diagnosis

Symptoms

• Leukocytosis is usually symptomatic.
• Symptoms of leukocytosis are often unspecific, such as:

• Weight loss
• Fevers of unknown origin
• Hyperhidrosis
• Chronic pain
• Fatigue
• Dyspnea
• Malaise

• Obtain history of the following:

• Clinical features
• Duration (e.g. days, weeks, months)
• Remainder of complete blood count

Laboratory Findings

• Laboratory findings consistent with the diagnosis of leukocytosis, include:

• White blood cell count above the normal range

• Greater than 11,000 per mm3

Differential for leukocytosis

Infection
Inflammation
Aspelenia
Stress/Exercise
Chronic myeloid leukemia
Juvenile myelo-monocytic leukemia
Polycythemia vera
Essential thrombocythemia
Chronic myelomonocytic leukemia,
Chronic neutrophilic leukemia
Mixed cryoglobulinemia
Leukocyte adhesion deficiency
Hereditary chronic neutrophilia
Down syndrome
Cryopyrin-associated periodic syndromes

Treatment

Medical Therapy

• The treatment for leukocytosis will depend on the underlying condition.

References

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