Extreme lymphocytopenia associated with toxic shock syndrome

Effects of synbiotic supplementation on the serum endotoxin level, inflammatory status, and clinical outcomes of adult patients with critical illness: A randomized controlled trial

BACKGROUND

 Gutmicrobiota dysbiosis, endotoxemia, and systemic inflammation are major factors contributing to disease pathophysiology in patients with critical illness. The present study aimed to assess the effects of synbiotic supplementation on serum endotoxin and inflammationof adult patients with critical illness.

METHODS

 This double-anonymized, randomized controlled trial was conducted at the intensive care unit (ICU) of Imam Reza Hospital in Mashhad, Iran. In the intervention group, 20 patients received synbiotic capsules (containing a combination of Lactobacillus, Bifidobacterium, Streptococcus, and fructooligosaccharides) twice per day for a maximum of 14 days. In the control group, 18 patients received placebo capsules. The serum levels of endotoxin and C-reactive protein and the neutrophil to lymphocyte ratio (NLR) were measured before and after the intervention. In addition, clinical outcomes and Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores were recorded.

RESULTS

 Basic characteristics were similar in the intervention and control groups. The NLR and serum endotoxin levels (median [IQR]) significantly declined in the synbiotic group (7.83 [4.58-12.57] to 6.01 [4.25-9.38]; P = .04; and 11.98 [10.64-12.65] to 10.58 [9.41-12.34]; P = .03, respectively). However, no significant changes were observed in the mentioned parameters in the placebo group. The clinical outcomes were also similar in the study groups, such as the length of hospital/ICU stay and hospital/28-day mortality rate.

CONCLUSION

 Although synbiotic supplementation (500 mg twice daily for 14 days) could reduce serum endotoxin and inflammatory markers, it had no effects on the clinical outcomes of the patients.

Leukocyte differential for acute abdominal pain in adults

BACKGROUND

Abdominal pain is a common symptom underlying a variety of disorders with different prognoses. Neutrophilia or lymphopenia have been used as prognostic markers in several stress- or infection-mediated disorders. We studied the clinical relevance of the leukocyte differential in the initial workup of adult patients presenting with abdominal pain.

METHODS

We reviewed all leukocyte differentials and medical records of 441 consecutive patients admitted for abdominal pain in an emergency department. Patients were matched by age and sex with controls and were assigned to 4 groups: functional disorders (group FUN), infectious medical disorders (group INF) and noninfectious medical disorders (group MED), and surgical disorders (group SUR). Patients of groups INF and SUR were pooled into group INF+SUR to predict severe illness, and this group was compared with others with nonsevere illness.

RESULTS

All patients exhibited neutrophilia, along with a neutrophil count that increased with illness severity. Lymphopenia, eosinopenia, and basopenia characterized patients of group INF+SUR. Neutrophilia, eosinopenia, and lymphopenia were independent predictors of the most severely affected patients. The association of a neutrophil count >9.0 × 10⁹/L with lymphopenia (<1.4 × 10⁹L) and eosinopenia (<0.04 × 10⁹/L) had a specificity of 94.9% (95% confidence interval, 91.2%-97.1%) for inclusion in group INF+SUR, although with a low sensitivity (27.5%).

CONCLUSION

Lymphocyte, eosinophil, and neutrophil counts should be considered in medical admissions of adults with abdominal pain. Lymphopenia associated with eosinopenia and significant neutrophilia is highly suggestive of a more severe illness.

[Clinical relevance of leukocyte differential in patients with marked leukocytosis in the emergency room]

PURPOSE

We analyzed the characteristics of the leukocyte differential and the clinical outcome in patients admitted in an emergency department with marked leukocytosis greater than 20×10(9)G/L.

METHODS

We studied a case series of consecutive patients admitted in an emergency department. The medical records were retrospectively reviewed after patient discharge. Three groups were defined: patients with infectious disorders (group I), noninfectious disorders (group II), and trauma (group III). Admission in intensive care unit (ICU), consciousness impairment or death defined the subgroup S of high severity.

RESULTS

Groups I, II and III comprised, respectively, 150, 95 and 86 patients. The group I presented with higher temperature and neutrophilia (22,2±4.9 vs 20.9±4.0 and 21.1±3.9×10(9)G/L; P<0.001), and more profound eosinopenia (0.058±0.094 versus 0.098±0.170 and 0.092±0.104×10(9)G/L; P<0.001) and lymphopenia (1.16±0.98 vs 1.53±1.04 and 1.73±1.10×10(9)G/L; P<0.001) than the two other groups. Both neutrophilia and lymphopenia were independent predictors of infection by multivariate analysis. Frequencies of admission in ICU were, respectively, 8.7%, 40% and 43% (P<0.001). Leukocyte and neutrophil counts were significantly higher and basophil count significantly lower in subgroup S. Overall, 13.6% of the patients died and were characterized by basopenia.

CONCLUSION

Marked leukocytosis indicated severe illness. Lymphopenia, eosinopenia and temperature were significant predictors of infection. A more severe clinical course was correlated with higher neutrophilia and basopenia.

Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit

Introduction

Absolute lymphocytopenia has been reported as a predictor of bacteremia in medical emergencies. Likewise, the neutrophil-lymphocyte count ratio (NLCR) has been shown a simple promising method to evaluate systemic inflammation in critically ill patients.

Methods

We retrospectively evaluated the ability of conventional infection markers, lymphocyte count and NLCR to predict bacteremia in adult patients admitted to the Emergency Department with suspected community-acquired bacteremia. The C-reactive protein (CRP) level, white blood cell (WBC) count, neutrophil count, lymphocyte count and NLCR were compared between patients with positive blood cultures (n = 92) and age-matched and gender-matched patients with negative blood cultures (n = 92) obtained upon Emergency Department admission.

Results

Significant differences between patients with positive and negative blood cultures were detected with respect to the CRP level (mean ± standard deviation 176 ± 138 mg/l vs. 116 ± 103 mg/l; P = 0.042), lymphocyte count (0.8 ± 0.5 × 10⁹/l vs. 1.2 ± 0.7 × 10⁹/l; P < 0.0001) and NLCR (20.9 ± 13.3 vs. 13.2 ± 14.1; P < 0.0001) but not regarding WBC count and neutrophil count. Sensitivity, specificity, positive and negative predictive values were highest for the NLCR (77.2%, 63.0%, 67.6% and 73.4%, respectively). The area under the receiver operating characteristic curve was highest for the lymphocyte count (0.73; confidence interval: 0.66 to 0.80) and the NLCR (0.73; 0.66 to 0.81).

Conclusions

In an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.

[Changes in hemogram parameters in infections]

PURPOSE

Leukocytosis is considered as an argument for infection. We have compared leukocytosis with the other data available with the white blood cell count.

METHODS

White blood cell counts obtained from 187 patients (age: 18 to 81 years), admitted to an emergency room for abdominal pain, were analysed using an automate (Bayer Technicon H2, Dublin, Ireland), and compared with matched healthy subjects. The patients were classified into two groups: diseases of the biliary or of the urinary tract, and subsequently in two subgroups: infectious diseases (angiocholitis, cholecystis, pyelonephritis) or non-infectious diseases (hepatic and nephritic colic).

RESULTS

Leukocytes and neutrophils were significantly increased, and eosinophils significantly decreased in all subjects by comparison with controls. These abnormalities were more important in infected patients. Lymphocytes were significantly decreased in infectious disease. For predicting infection, sensitivity and specificity of leukocytosis (> 1,000/mm3) were respectively 66% and 56%, while that of eosinopenia (< 100/mm3) were respectively 91% and 38%, and that of lymphopenia (< 1,200/mm3) respectively 58% and 73%. The probability of infection was less than 3% when neutrophils were less than 7,000/mm3, and eosinophils and lymphocytes respectively more than 100/mm3 and 1,200/mm3.

CONCLUSION

This study shows that leukocytosis, eosinopenia or lymphopenia are poor indicators of infection, when considered alone or in combination. However, eosinopenia and lymphopenia appear as better criteria of infection than leukocytosis. A detailed analysis of the white blood cell count allows the exclusion of infection with an acceptable risk of error.