Extreme leukocytosis in pregnancy: Is it always sinister?

Leukemoid reaction in pregnancy is a rare entity which must be diagnosed to mitigate the risks and costs of unnecessary antibiotics and prolonged hospital stays.

A Predictive Algorithm for Discriminating Myeloid Malignancies and Leukemoid Reactions

BACKGROUND

Adults presenting with a neutrophil-predominant leukocytosis (white cell count >50,000/μL) often necessitate urgent medical management. These patients are diagnosed with either acute presentations of chronic myeloid malignancies or leukemoid reactions, yet accurate models to distinguish between these entities do not exist. We used demographic and lab data to build a machine learning model capable of discriminating between these diagnoses.

METHODS

The medical record at a tertiary care medical center was queried to identify adults with instances of white counts greater than 50,000/μL and >50% neutrophils from 2000 to 2021. For each patient, a full set of demographic and lab values were extracted at the time of their first presentation with a white count >50,000/μL. We generated a series of models in which the parameters most predictive of myeloid malignancies were identified, and a supervised machine learning approach was applied to the dataset.

RESULTS

Our best model-using a support vector machine algorithm-produced a sensitivity of 96% and a specificity of 95.9% (area under the curve = 0.982) for identifying myeloid malignancies. We also identified a clinically meaningful and significant disparity in outcomes based on diagnosis-a 6-fold increase in 12-month mortality in those diagnosed with leukemoid reactions.

CONCLUSIONS

These findings need to be validated but fill an unmet need for timely and accurate diagnosis in the setting of profound, neutrophil-predominant leukocytosis and support the use of predictive models as a means to improve patient outcomes.

Retrospective analysis of leukemoid reactions in extremely preterm infants in a tertiary NICU from 2018-2021

BACKGROUND

Neonatal leukemoid reaction is associated with higher risk of mortality, chronic lung disease and has been associated with chorioamnionitis. Literature on extremely low birth weight infants with leukemoid reaction is limited.

OBJECTIVES

The aim of our study was to characterize the maternal and placental factors associated with neonatal leukemoid reaction and to describe outcomes of these ELBW infants. Our objective was to assess if there were maternal factors that would assist the decision-making process regarding the delivery of preterm infants at risk of chorioamnionitis and the sequelae of this inflammatory process.

METHODS

This was a retrospective case-control study performed in a single, tertiary Maternity Hospital in Dublin. Two matched controls were identified for each case based on gestation and year of birth and data was collected on both the infants and their mothers.

RESULTS

7 extremely preterm neonates were identified as having a leukemoid reaction, defined as a total white cell count of >50,000 or in the first seven days of life. Baseline characteristics between the groups were similar. The median gestational age in the cases group was 24 + 4 weeks and in the control group was 24 + 1. The mean birthweight was 650 g in the cases group vs. 655 g in the control group. There was a higher percentage of males in the control group, 42.9% vs 28.6% in the cases. The preterm infants with leukemoid reaction had a longer duration of ventilation with a median of 18 days (7.5-23.5 days) compared to 6.5 days (2.8-24.5 days) in the control group. More infants in the leukemoid reaction group required inotropes for hypotension in the first 72 h after delivery (42.9% vs 7.1% in the controls, p value .169). Death or Bronchopulmonary dysplasia (BPD) occurred in 85.7% of the cases identified with a leukemoid reaction vs 71.4% of the controls matched. Median maternal CRP was higher in cases prior to delivery vs the controls (66 vs 18.1 mg/L, p-value = .2151). There was histological evidence of maternal inflammatory response in all cases with fetal inflammatory response in 71% of cases.

CONCLUSIONS

Leukemoid reaction in ELBW infants with evidence of maternal and fetal inflammatory response syndrome on placental histology is associated with a longer duration of initial ventilation, increased need for inotropes in the first 72 h after birth, higher rates of death, and BPD. Prospective studies are required to identify potential biomarkers such as proinflammatory cytokines, IL-6, which might aid the decision-making process in delivery.

Mycoplasma pneumonia with severe cold agglutinin hemolysis, thrombocytosis, leukemoid reaction and acute renal failure

Mycoplasma pneumoniae (M. pneumoniae) is a common cause of community acquired pneumonia and although most cases are mild, complications sometimes occur. Cold agglutinin hemolysis is a known complication of M. pneumoniae infection, and usually presents as a mild and transient hemolysis. Here we present a case of infection with M. pneumoniae in a 64-year-old male that caused life threatening hemolysis that required multiple blood transfusions. The patient also presented with acute kidney failure and a marked leukemoid reaction and thrombocytosis. This is a very rare combination of symptoms that could have led the clinicians to suspect a more virulent etiology than M. pneumoniae, thereby delaying adequate antibiotic treatment.

Moderate to severe leukocytosis with vasopressor use is associated with increased mortality in trauma patients

Background

Leukocytosis is a rise in white blood cell (WBC) count and clinical outcomes of moderate to severe leukocytosis in trauma patients have not been described. We hypothesized that trauma patients with severe leukocytosis (SL; ≥40.0 × 109 leukocytes/L) have higher rates of in-hospital complications and mortality than those with moderate leukocytosis (ML; 25.0-39 × 109 leukocytes/L).

Methods

We performed a retrospective analysis (2010-2017) on trauma patients developing ML or SL at a single Level-I trauma center. A multivariable logistic regression analysis for risk factors were performed.

Results

From 15,807 trauma admissions, 332 (2.1%) had ML or SL. Of these, 308 (92.8%) were ML and 24 (7.2%) were SL. Patients with ML and SL reached their peak WBC count in 1 and 10 days after admission respectively (p < 0.001). SL patients suffered higher rates of in-hospital complications (p < 0.05) and mortality compared to those without ML or SL (14.5% vs. 3.3%, p < 0.001). Between ML and SL, mortality rates rose with leukocytosis severity (13.3% vs. 29.2%, p = 0.03). Among all patients with ML or SL, vasopressor use was the strongest independent risk factor for mortality (OR 12.61, p < 0.001).

Conclusion

Clinicians should be weary of the increased mortality rates and in-hospital complications in SL patients. Among patients with ML or SL, vasopressor use, rather than SL, was the strongest predictor of mortality. Patients with ML had a quicker time course to peak leukocytosis compared to SL, suggesting these two entities to be distinct in etiology and outcome, warranting future research.

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.

Use of Tocilizumab in Management of Post-Operative Myelomonocytic Leukemoid Reaction

Interleukin 6 receptor (IL6R) inhibitor, tocilizumab, has been effectively used in the treatment of cytokine release syndrome in patients receiving chimeric antigen receptor T-cell therapy. Here we present a patient with chronic myelomonocytic leukemia (CMML) who developed a steroid refractory, post-operative myelomonocytic leukemoid reaction (PO-MMLR), effectively treated with tocilizumab. Although, further studies are needed to validate the effectiveness of tocilizumab in management of PO-MMLR, this case serves to provide a new management approach in treatment of this rare but lethal syndrome with no standardized treatment options.

Spontaneous remission of acute myeloid leukemia with NF1 alteration

Acute myeloid leukemia (AML) is defined by the presence of ≥ 20% myeloblasts in the blood or bone marrow. Spontaneous remission (SR) of AML is a rare event, with few cases described in the literature. SR is generally associated with recovery from an infectious or immunologic process, and more recently possibly with clonal hematopoiesis. We review the literature and assess the trends associated with SR, and report a new case of a 58-year-old man with a morphologic diagnosis of AML associated with a severe gastrointestinal (GI) tract infection. The patient had an NF1 variant that was previously unreported in AML as the only clonal abnormality.  After treatment of the infection, the increased blast population subsided with no leukemia-directed therapy, and the patient has remained in a continuous, spontaneous complete remission for > 2 years.

Eosinophilic Leukemoid Reaction with Eosinophilic Tumor Tissue Infiltration as an Extermely Poor Prognostic Factor in Urinary Bladder Cancer- a Known Entity Revisited

Eosinophilia can be a manifestation of a variety of causes such as infections, allergic reactions and autoimmune processes. Also, it is described in various solid malignancies in the presence of tumour eosinophilic infiltration. We report a patient of high-grade urinary bladder cancer with eosinophilic leukemoid reaction and tumour histopathology demonstrated diffuse infiltration of eosinophils. Though the entity is described to carry a good prognosis in literature, our experience is totally different as the patient deteriorated rapidly in a matter of days, was deemed inoperable in view of worsening performance status and was referred for palliative management.

Survival from Clostridium toxic shock syndrome: Case report and review of the literature

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This case is a rare presentation of C. sordellii toxic shock syndrome resulting from a Caesarian section.

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This is the only obstetric case of C. sordellii to have survived.

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Extreme levels of a leukocytosis and hypotension without fevers raises suspiscion for this severe infection.

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Broad spectrum antibiotics, including coverage for anaerobic organisms, and surgical intervention is the standard of care.

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At the moment, no early detection or antitoxins are commercially available.

Introduction

Clostridial toxic shock is a rare syndrome traditionally described in case studies and reviews as a uniformly fatal condition associated with post-partum and post-abortion. Clostridium sordellii was first mentioned in scientific literature as a human pathogen in 1922 when Argentinian microbiologist Alfredo Sordellii identified the organism in gangrenous wounds. Over the past century, there has been infrequent discussion and little awareness surrounding this serious condition. Information about patients who survived C. sordellii toxic shock is essentially nonexistent.

Presentation of case

A 31-year old post-partum female who underwent caesarian section 17 days prior, presented with abdominal pain and septic features. She underwent six operations/procedures over the next 17 days and was hospitalized for 25 days before discharge to her home with a successful outcome.

Discussion

This case provides insight on the process of identifying and managing complications associated with clostridial toxic shock syndrome. Out of now, 16 reported cases of C sordellii gynecologic infections in the world literature, our patient is the second patient to survive infection by this organism. More research is needed to provide clinicians with evidence-based approaches for managing these unique cases.

Conclusion

We present a case report of a rare toxic shock syndrome in a post-partum female caused by Clostridium sordellii. Her survival is notable among 16 patients with whom this infection now has a documented 87.5% mortality rate. Aggressive surgical measures and optimized intensive care management may have contributed to this patient’s survival.

Leukemoid reaction in the pediatric population: etiologies, outcome, and implications

Leukemoid reaction (WBC > 30,000/μL) may indicate significant medical conditions, mostly infectious. Prompted by the lack of population-based data on the presentation, characteristics, and necessary workup in children with leukemoid reaction, we searched the database of a tertiary pediatric medical center for all children presented with at least one WBC count of ≥ 30,000/μL in 2009-2014. Demographic, clinical, and laboratory parameters were recorded. Children admitted with WBC < 30,000/μL served as controls. Pneumonia was the most common diagnosis in the leukemoid reaction group, with a 5.5-fold higher prevalence of pleuropneumonia than in the control group. The leukemoid group had a longer average hospital stay (7.5 vs. 5.5 days). Patients with WBC ≥ 50,000/μL had a sixfold higher rate of leukemia than patients with a lower count. There was a significant association of leukemia with low platelet count, low levels of C-reactive protein, and high levels of uric acid and lactate dehydrogenase.

CONCLUSION

Children presented with a leukemoid reaction are at high risk of pneumonia, especially pleuropneumonia, and a long hospital stay. Those with WBC ≥ 50,000/μL have a sixfold higher risk of leukemia. For prompt diagnosis, clinicians should be aware of the variables associated with leukemia. What is Known: • Leukemoid reaction has been associated with infectious diseases. • Leukemoid reaction at presentation in adults is correlated with high morbidity and mortality. What is New: • Children with leukemoid reaction are at high risk of pleuropneumonia. • We did not observe increased mortality in children with a leukemoid reaction.

Esophagogastric variceal bleeding with leukemoid reaction: A case report

Leukemoid reaction is a defense reaction to severe bacterial or viral infection, tumor metastasis, massive hemorrhage, acute hemolysis, and some drugs. The mechanism of leukemoid reaction is still unclear. The majority of published cases of leukemoid reaction are related to infection or malignant tumor, and leukemoid reaction resulting from hemorrhage is rarely reported. Here we report a case of leukemoid reaction in a patient with esophageal variceal bleeding and decompensated liver cirrhosis. After hemorrhage was controlled, the patient's leukocyte count gradually returned to the normal level.

A novel murine model of Clostridium sordellii myonecrosis: Insights into the pathogenesis of disease

Clostridium sordellii infections have been reported in women following natural childbirth and spontaneous or medically-induced abortion, injection drug users and patients with trauma. Death is rapid and mortality ranges from 70 to 100%. Clinical features include an extreme leukemoid reaction, the absence of fever, and only minimal pain or erythema at the infected site. In the current study, we developed a murine model of C. sordellii soft tissue infection to elucidate the pathogenic mechanisms. Mice received 0.5, 1.0 or 2.0 × 10(6) CFU C. sordellii (ATCC 9714 type strain) in the right thigh muscle. All doses caused fatal infection characterized by intense swelling of the infected limb but no erythema or visible perfusion deficits. Survival rates and time to death were inoculum dose-dependent. Mice developed a granulocytic leukocytosis with left shift, the onset of which directly correlated with disease severity. Histopathology of infected tissue showed widespread edema, moderate muscle damage and minimal neutrophil infiltration. Circulating levels of granulocyte colony-stimulating factor (G-CSF), soluble tumor necrosis factor receptor I (sTNF-RI) and interlukin-6 (IL-6) were significantly increased in infected animals, while TNF-α, and IL-1β levels were only mildly elevated, suggesting these host factors likely mediate the leukocytosis and innate immune dysfunction characteristic of this infection. Thus, this model mimics many of the salient features of this infection in humans and has allowed us to identify novel targets for intervention.

Paraneoplastic leukemoid reaction in pancreatic cancer: A case report

Paraneoplastic leukemoid reaction is a rare syndrome defined by a leukocyte count exceeding 50 Giga/Liter (G/L), mostly described with progressive lung or renal carcinoma. We report a case of a 68-year-old man with recurrent pancreatic carcinoma presenting a leukemoid reaction with a white blood cell count of 63.87 G/L without identified infectious, iatrogenic or hematologic causes. His overall condition quickly degraded and he died three weeks after the discovery of the leukemoid reaction. This is the first case in French literature of leukemoid reaction in a patient with pancreatic carcinoma with poor prognostic value.

A Case of Leukemoid Reaction in Pancreatic Ductal Adenocarcinoma

Leukemoid reaction is defined as leukocytosis exceeding 50,000 cells/mm(3). When it occurs in a patient with a malignancy, secondary causes such as infections, drugs, hematologic diseases and hemorrhage need to be ruled out. After excluding such causes, paraneoplastic leukemoid reaction can be considered as a diagnosis of exclusion. Paraneoplastic leukemoid reactions have been described in association with lung, gastrointestinal, genitourinary and head and neck cancers. However, pancreatic cancer with leukemoid reaction has been rarely reported. We diagnosed a case of a 55-year-old Korean woman with extreme leukocytosis associated with advanced pancreatic cancer.

Leukemoid reaction to Clostridium difficile infection

Clostridium difficile infections (CDI) are increasing in incidence and severity. Leukemoid reaction is rarely seen with CDI, and indicates severe disease with grave prognosis. We present an elderly female who developed leukemoid reaction in response to CDI. The patient died despite early antibiotic therapy with surgical evaluation.

Acute adult-onset still's disease presenting as pulmonary hemorrhage, urticaria, angioedema and leukemoid reaction: a case report and literature review

INTRODUCTION

Adult-onset Still's disease is a rare systemic inflammatory disorder of unknown aetiology characterized by the classic triad of persistent high spiking fevers, joint pain and a distinctive salmon-colored bumpy rash however, the multiorgan involvement can be present.

CASE DESCRIPTION

A 40-year-old woman previously healthy was referred to our hospital with 7 days of high fever and generalized arthralgia, The physical exam revealed angioneurotic edema detected on soles, palms and tongue and widespread red, urticated plaques in a symmetrical distribution affecting the arms, dorsal hands, upper and lower chest and back. Followed 5 days later by fever, the patient presented dyspnea, cough and hypoxemia, the imaging studies showed unilateral consolidation and pleural effusion. The bronchoscopy with bronchoalveolar lavage and skin biopsy were consistent with neutrophilic urticarial. The hematological disorders, infections and other autoimmune diseases were excluded.

DISCUSSION AND EVALUATION

The diagnosis of adult-onset Still's disease can be very difficult. There are no specific tests and reliance is usually placed on a symptom complex and the well described typical rash seen in most patients. In recent years, however, other cutaneous manifestations of Adult-onset Still's disease have been reported but these are not so well known.

CONCLUSIONS

The evidence of rare manifestations is growing and the early clinical presentation of Adult-onset Still's is extremely variable, making diagnosis difficult. For this reason, data on early clinical presentation of the disease are of interest. We reported the first case of acute Adult-onset Still's disease with the association of pulmonary hemorrhage, urticaria and angioedema including a rare systemic manifestation as leukemoid reaction.

Chronic neutrophilic leukemia: a rare case report

Chronic neutrophilic leukemia (CNL) is a rare chronic myeloproliferative disorder characterized by splenomegaly, sustained neutrophilic leukocytosis, raised serum vitamin B12 level and absence of the Philadelphia chromosome and BCR/ABL1 fusion gene. CNL can be distinguished from chronic myelogenous leukemia, leukemoid reaction and myelodysplastic syndrome. We report a case of 45 year old male patient with CNL.

Leukemoid reaction associated with pediatric nasopharyngeal carcinoma: An unusual presentation

Nasopharyngeal carcinoma is a tumor originating from the surface epithelial cells of nasopharynx. It is rare in children and adolescents. Most common physical finding is a neck mass. Most children with nasopharyngeal carcinoma present with advanced stage disease. The presentation with hematological abnormalities in patients without systemic metastasis is extremely rare. We reported a 14-year-old boy presenting with a mass at the right side of the pharynx and leukemoid reaction. To our knowledge, this is the first report of leukemoid reaction associated with pediatric nasopharyngeal carcinoma in English literature.

Fulminant leukemoid reaction due to postpartum Clostridium sordellii infection

Clostridium sordellii is gram positive anaerobic spore forming rod and it has been demonstrated to cause gas gangrene, refractory shock, leukemoid reaction, and pleuroperitoneal effusion due to capillary leak. We report here a case of postpartum female who presented with leukemoid reaction, ascites, pleural effusion, and shock without fever 7 days after normal vaginal home delivery.