A prospective study of hospitalized patients with leukemoid reaction; causes, prognosis and value of manual peripheral smear review

Etiologies of Extreme Leukocytosis

OBJECTIVE

The objective of this study was to determine the etiologies and co-morbidities associated with extreme leukocytosis, which is characterized by a white blood cell (WBC) count ≥ 35 × 10⁹ leukocytes/L.  Method: Retrospective chart review was conducted for all patients, aged 18 years and older, admitted to the internal medicine department between 2015 and 2021 with an elevated WBC count ≥ 35 × 10⁹ leukocytes/L within the first 24 hours of admission.  Results: Eighty patients were identified to have WBC count ≥ 35 × 10⁹ leukocytes/L. The overall mortality was 16% and increased to 30% in those presenting with shock. Mortality increased from 2.8% in patients with WBC count in the range of 35-39.9 × 10⁹ leukocytes/L to 33% in those with WBC count in the range of 40-50 × 10⁹ leukocytes/L. There was no correlation with underlying co-morbidities or age. Pneumonia was the most common infection (38%), followed by UTI or pyelonephritis (28%) and abscesses (10%). There was no predominant organism responsible for these infections. The most common etiology for WBC count between 35-39.9 × 10⁹ leukocytes/L and 40-50 × 10⁹ leukocytes/L was infections, while malignancies (especially chronic lymphocytic leukemia) were more common with WBC count > 50 × 10⁹ leukocytes/L.  Conclusion: For WBC counts in the range of 35-50 × 10⁹ leukocytes/L, infections were the main reason for admission to the internal medicine department. Mortality increased from 2.8% to 33% as WBC counts increased from 35-39.9 × 10⁹ leukocytes/L to 40-50 × 10⁹ leukocytes/L. Overall, mortality for all WBC counts ≥ 35 × 10⁹ leukocytes/L was 16%. The most common infections were pneumonia, followed by UTI or pyelonephritis and abscesses. The underlying risk factors did not correlate with WBC counts or mortality.

A 57-Year-Old Man With COVID-19 Pneumonia Who Required Venovenous Extracorporeal Life Support With a Rapidly Escalating WBC Count

A 57-year-old man who had been intubated and placed on venovenous extracorporeal membrane oxygenation for hypoxemic respiratory failure due to COVID-19 pneumonia was transferred to our facility. He underwent anticoagulation with IV heparin titrated to an anti-Factor Xa goal of 0.1 to 0.3 international unit/mL. Over extracorporeal membrane oxygenation days 13 to 17, his WBC count rose from 17,500 to 47,000 cells/μL. He simultaneously experienced the development of fluid-refractory shock that required multiple vasopressors and received stress-dose hydrocortisone when his WBC was 30,000 cells/μL. He remained afebrile and was started on broad-spectrum antimicrobials that included antifungal and anthelminthic therapy.

Leukemoid reaction with severe thrombocytopenia in a dying patient: a case report and literature review

Leukemoid reaction complicated by thrombocytopenia is rare, usually seen in patients with malignant conditions, and is often associated with poor prognosis. Here, the case of a 28-year-old healthy female without exceptional past medical history, who suffered from severe vaginal infection, is reported. Although symptoms improved, the white blood cell (WBC) count continued to increase up to 78 460 cells/µl, however, the patient continued to improve and the outcome was good. The case revealed that an increasing WBC count may not change in synchrony with clinical symptoms. When faced with this scenario, procalcitonin measurements may play an important role in differentiating diagnosis and guiding treatment.

Deep learning shows no morphological abnormalities in neutrophils in Alzheimer's disease

INTRODUCTION

Several studies have provided evidence of the key role of neutrophils in the pathophysiology of Alzheimer's disease (AD). Yet, no study to date has investigated the potential link between AD and morphologically abnormal neutrophils on blood smears.

METHODS

Due to the complexity and subjectivity of the task by human analysis, deep learning models were trained to predict AD from neutrophil images. Control models were trained for a known feasible task (leukocyte subtype classification) and for detecting potential biases of overfitting (patient prediction).

RESULTS

Deep learning models achieved state-of-the-art results for leukocyte subtype classification but could not accurately predict AD.

DISCUSSION

We found no evidence of morphological abnormalities of neutrophils in AD. Our results show that a solid deep learning pipeline with positive and bias control models with visualization techniques are helpful to support deep learning model results.

Disseminated cryptococcosis and hemochromatosis: clues to diagnosis

Hepatic cirrhosis, diabetes mellitus and iron overload can each independently predispose to cryptococcosis. Hereditary hemochromatosis leads to all three of these predispositions. This report is the case of a patient with chronic hepatitis B virus infection and cirrhosis, who had markedly elevated serum ferritin and 99% transferrin saturation, and developed a leukemoid reaction. Autopsy revealed disseminated cryptococcosis for which the leukemoid reaction was a clue and possible hereditary hemochromatosis of which elevated ferritin and transferrin saturation can be clues. Hereditary hemochromatosis is an important diagnosis clinicians should never miss because early treatment with phlebotomy can be life-saving. Disseminated cryptococcosis can be rapidly diagnosed with serum cryptococcal antigen test and is treatable.