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Severe Leukemoid Reaction Secondary to Hemorrhagic Shock
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A3420 - Severe Leukemoid Reaction Secondary to Hemorrhagic Shock
Author Block: G. Samaha1, W. Mansour1, M. Chalhoub2; 1Internal Medicine, Staten Island University Hospital, Staten Island, NY, United States, 2SIPA, Staten Island, NY, United States.
Background:
Leukemoid reaction is defined as a leukocyte count greater than 50,000 cells/ul without evidence of leukemia. Despite that bleeding is a reported etiology for leukocytosis, the white blood cell (WBC) count is rarely above 50,000 cells/ul.
Case presentation:
50-year-old male, with history of hypertension, and stage IV pancreatic adenocarcinoma, presented to the emergency department for hematemesis. His vital signs on admission included a blood pressure of 116/70 mmHg, heart rate of 77/min, temperature of 96.7 F and respiratory rate of 16/min. Physical exam was significant for pallor and epigastric tenderness. Initial laboratory workup showed hemoglobin of 8.5 g/dl, WBC count of 17500, platelets count of 186000, with normal basic metabolic profile, and liver enzymes. At day 1, patient started having massive fresh blood per rectum along with hematemesis, he went into hemorrhagic shock, with undetectable blood pressure, and repeat complete blood count showed hemoglobin of 4.5 g/dl. Massive transfusion was initiated along with vasopressors. Bleeding remained uncontrolled; urgent abdominal angiography was done and showed a focal pseudo-aneurysm arising off the gastroduodenal artery on which a successful embolization was done. Patient received within 12 hours a total of 12 units of packed red blood cells, 4 units of fresh frozen plasma, and 2 units of platelets. Repeat blood work the next day showed hemoglobin of 9.9 g/dl, WBC of 6700. In the next few days, the hemoglobin level stayed in a stable range between 8 and 10 g/dl, but a steady increase in WBC started to be noticed on the third day, and peaked to 78000 on day 12. Platelets count at that time was 243000, and hemoglobin was 10.3 g/dl. No source of infection was clinically detected. Chest X-ray and CT chest were both negative for new infiltrate, and CT abdomen didn’t show any occult abscess. Blood and urine cultures were negative. Peripheral smear showed toxic granules without detection of blasts. WBC count progressively decreased without any intervention, and normalized at day 19 post bleeding. Diagnosis of leukemoid reaction post severe hypovolemic shock was made.
Conclusion:
This case represents hypovolemic shock with subsequent leukemoid reaction. Beside demargination of neutrophils, the hypoxia, stress hormones and cytokines might have stimulated the bone marrow and possibly the tumor cells to produce substances with colony-stimulating activity, leading to a multi-factorial leukemoid reaction. Recognition of this hematological condition in the context of hemorrhagic shock might help decrease unnecessary testing and exposing patients to antibiotherapy
Author Block: G. Samaha1, W. Mansour1, M. Chalhoub2; 1Internal Medicine, Staten Island University Hospital, Staten Island, NY, United States, 2SIPA, Staten Island, NY, United States.
Background:
Leukemoid reaction is defined as a leukocyte count greater than 50,000 cells/ul without evidence of leukemia. Despite that bleeding is a reported etiology for leukocytosis, the white blood cell (WBC) count is rarely above 50,000 cells/ul.
Case presentation:
50-year-old male, with history of hypertension, and stage IV pancreatic adenocarcinoma, presented to the emergency department for hematemesis. His vital signs on admission included a blood pressure of 116/70 mmHg, heart rate of 77/min, temperature of 96.7 F and respiratory rate of 16/min. Physical exam was significant for pallor and epigastric tenderness. Initial laboratory workup showed hemoglobin of 8.5 g/dl, WBC count of 17500, platelets count of 186000, with normal basic metabolic profile, and liver enzymes. At day 1, patient started having massive fresh blood per rectum along with hematemesis, he went into hemorrhagic shock, with undetectable blood pressure, and repeat complete blood count showed hemoglobin of 4.5 g/dl. Massive transfusion was initiated along with vasopressors. Bleeding remained uncontrolled; urgent abdominal angiography was done and showed a focal pseudo-aneurysm arising off the gastroduodenal artery on which a successful embolization was done. Patient received within 12 hours a total of 12 units of packed red blood cells, 4 units of fresh frozen plasma, and 2 units of platelets. Repeat blood work the next day showed hemoglobin of 9.9 g/dl, WBC of 6700. In the next few days, the hemoglobin level stayed in a stable range between 8 and 10 g/dl, but a steady increase in WBC started to be noticed on the third day, and peaked to 78000 on day 12. Platelets count at that time was 243000, and hemoglobin was 10.3 g/dl. No source of infection was clinically detected. Chest X-ray and CT chest were both negative for new infiltrate, and CT abdomen didn’t show any occult abscess. Blood and urine cultures were negative. Peripheral smear showed toxic granules without detection of blasts. WBC count progressively decreased without any intervention, and normalized at day 19 post bleeding. Diagnosis of leukemoid reaction post severe hypovolemic shock was made.
Conclusion:
This case represents hypovolemic shock with subsequent leukemoid reaction. Beside demargination of neutrophils, the hypoxia, stress hormones and cytokines might have stimulated the bone marrow and possibly the tumor cells to produce substances with colony-stimulating activity, leading to a multi-factorial leukemoid reaction. Recognition of this hematological condition in the context of hemorrhagic shock might help decrease unnecessary testing and exposing patients to antibiotherapy
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