REVIEW
Leukocytosis
D. S. CHABOT-RICHARDS, T. I. GEORGE
Department of Pathology,
University of New Mexico,
Albuquerque, NM, USA
Correspondence:
Devon Chabot-Richards, Tricore
Reference Laboratories, Department of Hematopathology, 1001
Woodward Pl NE, Albuquerque,
NM 87102, USA.
Tel.: +1 505 938-8456;
Fax: +1 505 938-8414;
E-mail: dchabot-richards@salud.
unm.edu
doi:10.1111/ijlh.12212
S U M M A RY
Keywords
Leukocytosis, lymphocytosis,
neutrophilia, morphology,
lymphoma
INTRODUCTION
Leukocytosis, defined as an increase in white blood
cell (WBC) count, is a common finding with a broad
differential diagnosis, encompassing both benign and
malignant entities. Careful evaluation of complete
blood cell count (CBC) data and morphologic features
are key steps necessary to characterize the nature of
the process and guide further workup.
Reference intervals for WBC counts and relative
percentages and absolute cell counts vary by patient
age and hospital population. Each hospital laboratory
must determine reference ranges during the validation
process of their hematology analyzers [1]. Total WBC
counts are higher in infants, with newborns having
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E X A M I N AT I O N O F T H E P E R I P H E R A L B L O O D
SMEAR
When appropriate CBC criteria are met, a peripheral
blood smear should be examined. Slides may be prepared using anticoagulated blood or fresh specimen.
The smear may be made by an instrument or manually
by placing a drop of blood at one end of a slide and then
smearing it over the surface of the slide with a second
slide or a coverslip. After air drying, the slide is typically
stained with a Romanowsky stain [6]. The smear
should first be examined at low power to identify overall cellularity and types of cells. The findings should be
correlated with the automated CBC report. Large cells
or aggregates of cells or platelets are often deposited at
the edges of the smear. Assessment of WBC morphology is most commonly carried out in the thin areas of
the slide, where cell crowding and over staining do not
interfere. Cells should be examined to determine the
appropriate classification, the level of maturity, the
morphology, and the presence of inclusions [7].
PRESENCE OF BLASTS
The leading differential in a peripheral blood smear
with blasts is acute leukemia; however, other conditions may be associated with circulating blasts. While
blast counts of >20% are diagnostic for acute leukemia, a lower blast count in the peripheral blood does
not exclude acute leukemia [8]. Acute leukemias are
often associated with bone marrow failure and are
accompanied by anemia, neutropenia, and thrombocytopenia, in addition to leukocytosis with circulating
blasts. Clinical history is important to evaluate for
progression of a previously diagnosed chronic disorder
such as chronic myelogenous leukemia.
The first step in evaluating blast cells is to examine
for lineage-specific features. It is important to realize
that there is considerable morphologic overlap
between lymphoblasts and myeloblasts and that morphology alone may not be definitive. Lymphoblasts
show a range of appearances, from small- to intermediate-sized cells with scant cytoplasm and condensed
nuclear chromatin to larger cells with moderate blue
or blue gray cytoplasm and dispersed chromatin with
prominent nucleoli. The nuclei may be smooth and
round or irregular and convoluted. There may be
cytoplasmic vacuoles or, rarely, granules. Although
there is a considerable range of morphology, myeloblasts tend to be larger, with more abundant cytoplasm. Blasts with minimal differentiation may have a
similar appearance to lymphoblasts. The presence of
Auer rods and cytoplasmic granules strongly suggests
myeloid differentiation; however, lymphoblasts may
occasionally contain azurophilic granules [9]. Cytochemical stains can be helpful to confirm lineage,
with myeloperoxidase staining granules in myeloblasts
and nonspecific esterase staining cells with monocytic
differentiation. Subtypes of acute myeloid leukemia
are associated with specific morphologic findings.
Most importantly, acute promyelocytic leukemia with
t(15;17) (APL) is associated with hypergranular cells
with coalescing granules and Auer rods, with cells
containing multiple Auer rods highly specific for APL.
The nuclei are often folded, bilobed, or kidneyshaped. The hypogranular variant shows similar
nuclear features with agranular cytoplasm. APL may
be associated with schistocytes due to disseminated
intravascular coagulation (Figure 1).
Lower circulating blast counts may be seen in
chronic myeloid neoplasms, including myelodysplastic
syndromes (MDS), myeloproliferative neoplasms
(MPN), and overlap MDS/MPN. MDS with excess
blasts may have up to 19% circulating blasts. The
blasts in MDS are associated with cytopenias and dysplasia; blasts in MDS may be smaller in size with less
differentiation compared with typical myeloblasts.
Patients with MPN generally have <10% blasts and
increased cell counts in one or more myeloid lineage.
Ten to nineteen percent blasts are seen in the accelerated phase of MPNs. Patients with MDS/MPN syndromes have dysplasia and a combination of increased
and decreased cell counts in different lineages.
Circulating blasts can be seen in the absence of hematologic malignancy. Iatrogenic or endogenous excess
granulocyte colony-stimulating factor (G-CSF) stimulation can cause a left shift of the myeloid lineage to the
blast stage [10]. Bone marrow damage or infiltration
by fibrosis, malignancy, or infection can be associated
with circulating immature cells (leukoerythroblastosis),
including blasts and nucleated red blood cells.
LY M P H O C Y TO S I S
In the patient with an increased lymphocyte count,
the differential diagnosis depends on patient age,
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(a)
(b)
(c)
(d)
(e)
(f)
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Lymphocytosis
Monomorphic
Pleomorphic
Suspect Reactive
Suspect Neoplastic
Dierenal Diagnosis
Convoluted nuclei
Villous cytoplasm
Plasmacytoid
Granules
Prominent nucleoli
Large cells
Ancillary Tests
CLL
MBL
PBL
Burkitt
MCL
T-PLL
FL
MCL
Atypical CLL
Flow cytometry
T-cell
FISH CCND1, BCL2
Pertussis*
Tissue biopsy
Sezary syndrome
Adult T-cell leukemia
HCL
SMZL
HCLV
T-PLL
LPL
Flow cytometry
FISH
Flow cytometry
T-cell clonality
Flow cytometry
LPL
Plasma cell myeloma
Plasma cell leukemia
Flow cytometry
SPEP/UPEP
T-LGL
NK cell leukemia
Flow cytometry
T-cell clonality
KIR profile
T-PLL
B-PLL
HCLV
MCL
Burkitt Leukemia
DLBCL
MCL
ALCL
Flow cytometry
Cytogenetics
Flow cytometry
FISH MYC
LY M P H O C Y TO S I S W I T H P L E O M O R P H I C
MORPHOLOGY
Pleomorphic lymphocytosis is most commonly associated with a reactive process. Reactive lymphocytoses
rarely exceed 30 9 109/L and show a range of lymphocyte size and shapes, often best appreciated at low
power [12]. The nuclei show mature chromatin and
inconspicuous nucleoli. Many cells are large with abundant clear to light blue cytoplasm with a basophilic rim.
The cytoplasm may partially wrap around adjacent red
blood cells. There may be large granular lymphocytes
(LGLs) with azurophilic cytoplasmic granules. Immunoblasts and plasma cells may also be present. These
cells are large with deeply basophilic cytoplasm, and
round to oval nuclei, and prominent nucleoli.
Pleomorphic lymphocytosis with activated morphology is most commonly associated with viral infection.
EpsteinBarr virus, or infectious mononucleosis, is the
classic example, but other causes include CMV, influenza, adenovirus, and HIV. Some bacterial or parasitic
infections may be associated with pleomorphic lymphocytosis. Noninfectious causes include medication, stress,
trauma, vaccination, postsplenectomy, hypersensitivity
reaction, smoking, and autoimmune disease [6].
LY M P H O C Y TO S I S W I T H M O N O M O R P H I C
MORPHOLOGY
Monomorphic lymphocytoses are much more concerning for lymphoproliferative neoplasm; however,
there are some reactive processes associated with a
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Bordetella pertussis is an important exception. Bordetella infection is associated with severe, paroxysmal
coughing, or whooping cough, most often seen in
children. The bacteria produce a toxin which results
in a characteristic severe, monomorphic lymphocytosis
characterized by small, mature cells with deeply
cleaved nuclei [14]. Patient age and clinical presentation are important in making this diagnosis.
Another benign cause of lymphocytosis with deeply
cleaved or binucleated cells is polyclonal B-lymphocytosis. This is a benign condition seen in young to
middle-aged female smokers and associated with HLADR7 [15]. The lymphocytosis is typically moderate
with approximately 10% binucleated forms [16].
Although follicular lymphoma only rarely involves
the peripheral blood, it is associated with a characteristic appearance with small to intermediate cells with
folded, convoluted nuclei and scant cytoplasm.
Occasional large cells may be present [17]. The neoplastic cells are monoclonal B-cells, which often
express CD10. FISH analysis showing rearrangement
of BCL2 can be helpful.
Although mantle cell lymphoma is primarily lymph
node based, it involves the peripheral blood in almost
50% of cases [18]. Circulating MCL cells often vary in
size and shape, but the typical cell is large with a folded
or indented nucleus and variably prominent nucleolus.
Blastic variants are large with fine chromatin and prominent nucleoli; however, they also often have indented
nuclei. Flow cytometry reveals a monoclonal B-cell population with expression of CD5. FISH analysis demonstrating IGH-CCND1 can help confirm the diagnosis.
Atypical CLL may show predominantly cleaved
cells and must be distinguished from MCL when a
CD5+ monoclonal B-cell population is identified in
the peripheral blood. T-cell prolymphocytic leukemia
can occasionally show nuclear irregularity, but the
prolymphocytic form usually predominates.
Circulating mature T-cell leukemias and lymphomas often show irregular nuclei; however, they are
more typically highly convoluted or cerebriform in
appearance.
Monomorphic lymphocytosis with highly convoluted or
cerebriform nuclei
Highly convoluted or cerebriform nuclei are most
commonly associated with mature T-cell leukemias.
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Peripheral blood involvement by mycosis fungoides (MF) or Sezary syndrome (SS) features medium
to large lymphocytes with characteristic dark, cerebriform nuclei. The neoplastic cells are most often
CD4-positive T-cells with loss of CD7. T-cell clonality
studies can be helpful. While the peripheral blood
features overlap, the distinction between MF and
SS is made based on the clinical course. In SS,
erythroderma and lymphadenopathy with blood
involvement are present at diagnosis, while MF does
not exhibit peripheral blood involvement at presentation [19].
Adult T-cell leukemia is an aggressive disease
caused by chronic infection with human T-cell leukemia virus (HTLV)-1. Only a small percentage of those
infected with the virus develop leukemia. Patients
often show systemic manifestations, including skin
rash, hypercalcemia, and lytic bone lesions. The
peripheral blood smear shows a severe lymphocytosis
with highly irregular nuclei. Cytopenias are common;
however, there may be eosinophilia. The neoplastic
cells are typically CD4-positive T-cells with expression
of CD25 and loss of CD7.
Monomorphic lymphocytosis with villous cytoplasm
Hairy cell leukemia (HCL) and splenic marginal zone
lymphoma (SMZL) often show peripheral blood
involvement with villous lymphocytes with associated
splenomegaly. In HCL, there is typically pancytopenia
with monocytopenia. The lymphocyte count may be
low or normal, and circulating neoplastic hairy cells
are rare. These cells show abundant cytoplasm with
circumferential spiky projections. The nuclei are
round or kidney-bean-shaped. Flow cytometry in classic HCL shows a monoclonal B-cell population with
bright CD20, CD11c, CD22, CD25, and CD103.
In contrast, in SMZL, the lymphocytes show bipolar projections, and the nuclei are usually round.
CD25 may be positive, but CD103 is typically negative
and CD22 is usually dim. Hairy cell leukemia variant
(HCLV) is an uncommon entity with neoplastic cells
appearing similar to HCL; however, the lymphocyte
count is usually much higher, and cells may be larger
with prominent nucleoli. HCLV is positive for CD103,
and only rare cases are positive for CD25.
Rarely, the neoplastic lymphocytes in T-PLL and
plasma cell leukemia may show cytoplasmic projec-
M Y E L O I D L E U KO C Y TO S I S
Myeloid leukocytoses are elevations of neutrophils, eosinophils, basophils, or monocytes. Causes vary by the
type of cell increased, but include infection, medication, autoimmune disorders, metabolic disorders, and
other reactive states as well as clonal myeloid neo 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279288
285
plasms. Patient history and clinical findings are necessary to ensure appropriate classification (Figure 3).
Neutrophilia
Neutrophils are the most abundant leukocyte and play
a key role in immune defense from bacterial infections. These cells are short-lived, and the bone marrow production rate is astronomical, with an
additional reserve pool of cells available. Typically,
only the mature, polymorphonuclear forms are present in the peripheral blood, with 510% band forms.
Immature granulocytes or left-shifted forms can be
seen in both reactive and neoplastic conditions. It
should be noted that the band count is not reproducible and its use is not recommended [22].
Reactive neutrophilias can be seen with infection,
particularly bacterial, inflammation, drugs (particularly
steroids, epinephrine, and lithium), colony-stimulating
factors such as G-CSF, metabolic disorders, trauma,
stress, pregnancy, other malignancy, and smoking [17].
Reactive neutrophilias are associated with activated
changes, including toxic granulation, vacuoles, and Dohle bodies. The other lineages are generally unremarkable; however, monocytes may also show toxic changes.
There can be significant morphologic overlap
between reactive neutrophilias and MPN and MDS/
MPN. Chronic myelogenous leukemia (CML) is often
associated with a very high WBC count. There is generally a pronounced left shift with increased myelocytes. Toxic changes are typically absent. An associated
basophilia and eosinophilia are usually present.
Definitive diagnosis of CML requires demonstration of
the BCR-ABL1 translocation by cytogenetics, FISH, or
molecular genetic methods. Chronic neutrophilic leukemia (CNL) is a myeloproliferative neoplasm characterized by a mature neutrophilia accounting for >80%
of WBC with limited left shift. Definitive diagnosis can
be difficult, as a reactive process must be excluded.
Recent identification of an oncogenic mutation in
CSF3R in CNL may aid in diagnosis [23]. Other MPNs
may show neutrophilia, particularly as a part of a leukoerythroblastic picture due to underlying bone marrow fibrosis. Dacrocytes (tear-drop shaped red blood
cells) may be present in this case. Atypical chronic
myeloid leukemia (aCML) is a MDS/MPN with neutrophilia and left shift. There are prominent dysplastic
changes with nuclear hypolobation or bizarrely
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Myeloid Leukocytosis
Neutrophilia
Features supporting reactive
WBC >50 x 10 /L
Pronounced left shift
Basophilia or Eosinophilia
Dacrocytes
Dysplasia
WBC <50 x 10 /L
Predominantly mature
Toxic granulation and vacuoles
Dhle bodies
Thrombocytosis
Monocytosis
Features supporting neoplastic
Persistent
Promonocytes and blasts
Dysplasia
Transient
Predominantly mature
Reactive changes
Eosinophilia
Features supporting neoplastic
Persistent
Immature cells present
Cytopenias and dysplasia in other lineages
Transient
Clinical presence of drugs, allergy or infection
Basophilia
Features supporting reactive
Rare
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tive monocytosis, flow cytometric identification of aberrant expression of two or more antigens on monocytes
is correlated with CMML [27]. Identification of a clonal
abnormality is helpful to confirm the diagnosis. Bone
marrow evaluation should be performed as AMML may
present with mature monocytosis in the peripheral
blood while immature forms predominate in the marrow. JMML is a rare disease seen in children with persistent monocytosis with marked hepatosplenomegaly and
increased hemoglobin F. There is often left shift of the
granulocytes, and dysplasia is minimal.
CONCLUSION
Basophilia
Isolated basophilia is extremely uncommon. Reactive
basophilia has been linked to hypersensitivity disorders, iron deficiency, chronic inflammation, and rarely
infection, including influenza and chicken pox [26].
As reactive causes are rare, a finding of basophilia
should prompt further workup to exclude a myeloproliferative neoplasm such as CML.
Monocytosis
Reactive monocytosis is associated with chronic infection, autoimmune disease, splenectomy, and a range
of malignancies, including carcinoma, lymphoma, and
plasma cell myeloma. It can also be seen with neutropenia and in regenerating bone marrow following
bone marrow transplant or chemotherapy. If monocytosis is persistent and reactive causes are excluded,
the differential diagnosis includes chronic myelomonocytic leukemia (CMML), acute myelomonocytic leukemia (AMML), CML, juvenile myelomonocytic
leukemia (JMML), atypical CML, and MDS/MPNunclassifiable.
Chronic myelomonocytic leukemia is most commonly seen in older adults and is associated with a persistent monocytosis with dysplasia in one or more
myeloid lineage. There may be increased blasts, with
promonocytes counted as blast equivalents. Although
immunophenotypic abnormalities may be seen in reac-
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