Buku Medicine

High haemoglobin

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Low haemoglobin

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High MCV

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Low MCV

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High B12

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High platelets

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Low platelets

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High white cell count

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High neutrophils

Quick Tip; Neutrophilia is only very rarely is caused by a malignant problem

Almost all cases of neutrophilia are due to an acute insult, and reactive counts of over 50x109/L can sometimes be seen

Common causes;

  • Bacterial infection
  • Corticosteroid use
  • Smoking
  • Chronic myelomonocytic leukaemia (associated with monocytosis and dysplastic features on blood film)
  • Chronic myeloid leukaemia
  • Chronic neutrophilic leukaemia (very rare)

Workup;

  • History and examination
  • Medication review
  • Full blood count and blood film
  • CRP

Review of trend is the most important feature in assessing neutrophilia. 

These are some features to help identify probable aetiology

  • Bacterial infection- Acute rise, will drop quickly after insult resolves. Can sometimes rise even above 50x109/l- no specific action needed unless the neutrophilia fails to resolve after the insult has
  • Smoking can lead to a persistent neutrophilia (see reference below about blood donors- neutrophilia seen in 22% of smokers and 2% of non-smokers)
  • CMML is a slow-growing leukaemia which usually presents as an incidental finding of chronic, slowly rising neutrophilia and monocytosis in a middle aged/older person. The blood film will show dysplastic features. It would require a non-urgent referral to haematology (although officially is a malignancy so see local protocols for referral guidance). If other counts (haemoglobin and platelets) had reduced, or there were systemic symptoms e.g splenomegaly/weight loss, urgent referral is recommended.
  • Chronic myeloid leukaemia is also slow-growing and usually associated with basophilia (fairly unique to CML in this context), thrombocytosis and splenomegaly. This would also merit a non-urgent referral to haematology (although officially is a malignancy so see local protocols for referral guidance).
  • Chronic neutrophilic leukaemia is very rare and associated with an isolated, persistent and progressive neutrophilia.

Specific references

Smoking as a Cause for Mild Chronic Neutrophilia. Stemmelin G et al. Blood 2004 104:3796.

Links:   Elsevier summary

Low neutrophils

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High lymphocytes

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Low lymphocytes

Quick tip; HIV is the most significant cause of lymphopenia, and otherwise often has little clinical significance

Lymphopenia is almost always due to reversible causes and a count of over 0.5 x 109/L is rarely of clinical significance.

Common causes

  • Bacterial infection
  • Increased age
  • HIV infection
  • Autoimmune disease e.g rheumatoid arthritis
  • Drugs; chemotherapy e.g immunosuppressants, alcohol 
  • Congenital immunodeficiency syndrome
  • Bone marrow disease e.g  lymphoma, myelodysplastic syndrome (uncommon, especially in the absence of other cytopenias)

Workup

  • History for above risk factors and examination for organomegaly or lymphadenopathy
  • Repeat full blood count in 2-3 months with blood film
  • HIV screen
  • Autoimmune screen
  • Serum immunoglobulins

If lymphopenia is mild (>1 x109/L) and remains stable over a 6-12 month period with no other indicators of underlying disease then no specialty referral is needed as there would be no treatment for it and it does not confer a clinical risk. Persistent lymphopenia of <1 x109/L would merit further investigation as above and referral to the appropriate medical specialty

Lymphopenia is incredibly common in clinical practice and haematological causes for it are rare therefore referral to haematology is only recommended if there is other evidence to support underlying haematological problems like other cytopenias (e.g suspected MDS) or symptoms or signs in keeping with lymphoma (weight loss, fevers, sweats, lymphadenopathy)

Links:   BMJ (requires subscription)  

High eosinophils

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High monocytes

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High ferritin

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Paraprotein

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Elevated light chains

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