Case 100 (part B) – summary

Our patient had a mild neutrophilia. Neutrophilia can be seen in:

  • Neonates
  • Infection
    • Especially bacterial (note marrow depletion may occur leading to neutropenia)
  • Inflammation, autoimmune diseases etc.
  • Acute gout
  • Stressed states with high adrenaline e.g. myocardial infarction, exercise, acidosis, eclampsia, seizures, acute haemorrhage
  • Malignancy e.g. Hodgkin lymphoma, ovarian carcinoma
  • Leucoerythroblastic anaemia
    • Metastatic marrow infiltration
    • Myeloproliferative neoplasm
    • Miliary TB
    • Osteopetrosis
  • Drugs
    •  Steroids
      • Lead to increased neutrophils from reserve to circulating pool but reduced neutrophils from circulating pool to tissue leading to increased peripheral blood neutrophilia
    • Beta agonists
    • Lithium
    • Tetracycline
    • GCSF
  • Smoking
  • Uraemia
  • Hyposplenism
  • Myeloproliferative neoplasms
    • Chronic myeloid leukaemia
    • Atypical chronic myeloid leukaemia
    • Chronic myelomonocytic leukaemia
    • Chronic neutrophillic leukaemia
    • Myelofibrosis
    • Polycythaemia vera
  • Leucocyte adhesion deficiency
  • Familial cold urticarial and leucocytosis

 

The most common causes of neutrophilia are reactive and secondary causes should be looked for in the history and examination. Where there is a cause usually no further investigations are needed but clinicians may want to repeat the test to ensure it is resolving as expected.

Pointers towards something more serious includes:

  • Abnormalities on the blood film – tear drop cells, nucleated red cells
  • Basophilia (can be seen in reactive state but would want to monitor)
  • Non-resolution as expected and greater than 15×109/l
  • Patient unwell with systemic symptoms
  • Splenomegaly

CML annotated

  • 1 Neutrophil
  • 2 Basophil
  • 3 Myelocyte
  • 4 Eosinophil

In this case chronic phase CML was the most likely diagnosis due to the persisting leucocytosis and basophilia without reactive causes. Left shifted granulocytes were seen on the film. This was confirmed by peripheral blood fluorescence in situ hybridisation looking for t(9;22) BCRABl1 which was detected.

Tyrosine kinase inhibitors such as imatinib are used to treat CML and the outcome for patients is now excellent.

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