differential leukocytic count

2. Case
:
• 32 years old male patient , driver , returned from al Kuwait 3 months ago
for vacation , referred from urology clinic to hematology clinic due to
persistent leukocytosis in routine CBC check up before stone extraction
procedure , the patient was given repeated courses of antibiotics without
any improvement of the leukocytosis .

3. • By examination : the patient is generally well and fit, BP 120/80 mmHg ,
pulse 95 , with no pallor , cyanosis or change in complexion .
• Cardiac auscultation revealed pansystolic murmur over the apex propagated
to axilla and with ejection systolic murmur over the pulmonary area .
• lung field examination was free .
• Abdominal examination revealed mild hepatosplenomegaly which
confirmed by abdominal US.
• Lymph node examination was normal .

4. • The patient had past medical history of infrequent attacks of bronchial
asthma for which he had no chronic medication , and infrequent recurrent
abscesses at different sites of his body
• He is non smoker, non alcoholic and had no chronic drug use
• The patient underwent lab investigations shows the following :

5. :
result test
26 ×109/L WBCs
3.6×109/L neutrophils
3.9 ×109/L lymphocytes
1.4 ×109/L monocytes
9.4×109/L eosinophiles
0 ×109/L basophils
12.5 g/dl HGB
202×109/L platelet
2% Reticulocytes count
90.3 FL MCV
38.2 l/l HCT
2.4 mg/dl Serum creatinine
1st
hour 22 mm/hr ESR
5 % hgA1C

6. • What are the differential diagnosis for this
condition ?
• What are the other investigations needed
to establish the diagnosis ?
Qs:

7. Differential leukocytic
count
By teaching assistant
:
Yasmeen Mohamed Mohamed Al-anwer 

8. White blood cells ( leukocytes)

9. WBCs : are cells of the immune system that are involved in protecting the body
against both infectious disease and foreign invaders
.
Normal Leukocytic count : 4000-11000 per microliter
(
4.5
to 11.0 × 109/L
)
Relative count : relative numbers of each type of WBC in relationship to the
total WBC. It can be expressed as a percentage
Absolute count : the actual number of each cell type (percentage x total
WBC)
.
Ex: if TLC is 4000 with relative neutrophile count 20%
Absolute count will be = (4000 × 20 ) /100 = 800 cells

11. Differential leukocytic count
Granulocytes : that characterized by
presence of cytoplasmic granules
.
1
-
neutrophiles (polymorphonuclear
leukocytes (PMN) : 50-70%
=
2000-7000
per microliter
2
-
eosinophiles : 1-3%
=
100
-
300
per microliter
3
-
Basophiles : 0.1-1%
=
10-100
per microliter
•
Agranulocyte : lakes of cytoplasmic
granules
.
1
-
lymphocytes : 20-40%
=
1500
-
4000
per microliter
2
-
monocytes : 2%-10%
=
200
-
1000
per microliter

12. Disorders of Leukocytes

13. 1neutrophilia
:
• Normal maturation stages of neutrophils :
Neutrophilia refers to number of
neutrophils that’s higher than normal
on a CBC with differential
.
(
absolute neutrophil count
7500
> /μ L in adults
)
-
Neutrophilia may result from a
shift of cells from the marginal to
the circulating pool (shift
neutrophilia) without an increase in
the total blood granulocyte pool
(TBGP)
-
or from a true increase in TBGP
size (true neutrophilia)
.

15. Approach to diagnosis of
neutrophilia

18. • 2-Lymphocytosis:
- is an increase in the number or
proportion of lymphocytes in the blood.
- Lymphocytes normally represent 20% to
40% of circulating white blood cells.
When the percentage of lymphocytes
exceeds 40%, it is recognized as relative
lymphocytosis
- absolute lymphocytosis is present when
the lymphocyte count is greater than
5000 per microliter (5.0 x 109/L) in
adult.

19. Types of lymphocytes
:
B lymphocytes make antibodies, which help a person’s
immune system fight pathogens such as bacteria and
viruses
.
T lymphocytes help destroy tumor cells and cells that
are infected with pathogens. They also control the body’s
immune responses
.
Atypical lymphocytes are lymphocytes that activate as
part of the body’s response to infections. They are larger
than normal lymphocytes, with varying sizes and shapes
.
atypical lymphocytes sometimes called “variant
lymphocytes” or “reactive lymphocytes
”.

21. Neoplastic Lymphocytosis
Lymphoproliferative disorders.
Chronic Lymphocytic Leukemia (CLL)
Chronic myeloid leukemia (CML)
acute lymphoblastic leukemia (ALL)
and lymphoma (Hodgkin and Non Hodgkin ) with circulating neoplastic
cells (stage V lymphoma)

22. Approach to diagnosis of
lymphocytosis

23. Careful history
taking
.
Clinical examination for
:
-
lymph node enlargement
-
Hepatosplenomegaly
-
Skin rash , vasculitis or
Other cutaneous signs
.

24. CBC with peripheral blood film

25. Flow cytometry (FC) : Is a technique used to detect and measure the physical
and chemical characteristics of a population of cells or particles
Uses for flow cytometry include in diagnosis of lymphocytosis :
Accurate Cell counting
Cell sorting to identify the type of lymphocyte.
Determining cell characteristics and function
Detecting microorganisms
Biomarker detection on the cell surface
Protein engineering detection
Diagnosis of health disorders such as blood cancers
Measuring genome size

26.  Imaging :
abdominal and neck ultrasound
CT or MRI
Invasive definitive investigations :
Bone marrow Aspirate and biopsy
Lymph node biopsy if accessible .
Investigations for underlying causes:
Autoimmune workup
CRP and PCR for possible infections
Hormonal assessment for possible
Endocrine causes

28. 3
-
eosinophilia
:
- Increase levels of
eosinophilic leukocytes
in the blood more than
500 / μL.
- Hypereosinophilia is
generally defined as
a peripheral blood
eosinophil count
greater than 1500/μL

30. Approach to Diagnosis of
eosinophilia

31. Careful history taking :
- drug intake
-allergic diseases : asthma or allergic rhinitis and sinusitis
- travel history
Clinical examination for:
-chest disease .
-Cardiac assessment .
-Abdominal examination for organomegaly .
-Skin lesions or change of color .

32. • Lab investigation:
Stool analysis : for parasitic investgaions
CBC with differential leukocytic count
LFT and serum creatinine
Urine analysis for hematuria and urinary eosinophile as; in Churg Strauss and
Wegener's granulomatosis.
• Imaging :
CT chest and abdomen.
Echocardiography.

33. Bone marrow aspirate :
if persistent eosinophilia more than 3 months
If absolute eosinophilic count more than 1500 per microliter
If no detected secondary cause.
Cytogenetic test :
FISH (fluorescent in situ hybridization) or RT- PCR for detection of
PDGFRA (platelet derived growth factor receptor alpha) mutation

35. 4
-
monocytosis
Monocytosis is an increase in
the number of monocytes
circulating in the blood.
sustained rise in monocyte counts
greater than to 1000/mm3

37. Approach to Diagnosis of
monocytosis

39. 5
-
basophilia
Basophilia is the
condition of having
greater than 200
basophils/μL in the
blood

40. causes
Infection
:
1
-
TB
.
2
-
influenza
.
allergy
Inflammation
:
1
-
autoimmune
diseases
2
-
IBD
-
Myeloproliferative
disorders
1
-
CML
2
-
Essential
thrombocytosis (ET)
3
-
primary
myelofibrosis
4
-
polycythemia
Rupar vera
-
Myelodysplastic
syndrome

41. Approach to diagnosis of
basophilia

42.  Careful history taking
 Clinical examination
 Lab investigation
 Imaging
CT or chest and abdomen.
 Flowcytometry .
 Invasive definitive
investigations :
Bone marrow Aspirate and
biopsy

43. Case answer

44. •Q:other investigations include
• 1- stool analysis for parasitic infection ……. Was positive for entamoeba
histolytica and patient received treatment
• 2-Anti bilharzial antibodies …. negative
• 3- live function tests …… was normal
• 4- ANA, p ANCA and c ANCA for exclusion of Wagener granulomatosis and
Churg Strauss …… was negative.
• 5- Serum immunoglobulins to exclude hyper IgE syndrome : showing mild
elevation of serum IgE (253) , with normal IgG.. IgA and IgM levels

45. Imaging :
 CT chest…………. cardiomegaly
 Echocardiography : sever MR,
dilated LA,
dilated RT side ,
sever TR , PASP= 75 mmHg ,
EF= 60% with minimal
pericardial effusion
 CT abdomen : hepatosplenomegaly
dilated stomach with irregular out lines

46. • Bone marrow aspirate :

47. Cytogenetic test :

48. Diagnosis

49. Hyper Eosinophilic syndrome