Leukemoid reaction: A 21st-century cohort study.

INTRODUCTION: Leukemoid reaction (leukocyte count >50 cells ×109  L) is a rare but extremely relevant finding. Since little has been published on this condition's clinical relevance and prognosis, we investigated leukemoid reaction in patients with a white blood cell count of >50 × 109  L, including etiology and outcomes. METHODS: This retrospective cohort study included all patients at a Brazilian tertiary hospital between January 2016 and July 2018 > 18 years with a total leukocyte count >50 cells×109  L. Demographics, complete blood count, clinical features, and the exams used to diagnose and determine leukemoid reaction etiology were analyzed. A Kaplan-Meyer survival analysis was performed, and a binary logistic regression model identified variables associated with death. RESULTS: Of the 267 cases with white blood cell count of >50 × 109 , 162/267 (60%) were secondary to hematopoietic neoplasm and 105/267 (40%) presenting as a true leukemoid reaction. The primary causes of the true leukemoid reaction cases were infection (59), nonhematopoietic neoplasm (17), or other causes (29). Patient deaths (66) differed significantly between groups (P < .001, log-rank [Mantel-Cox] Test). Lower hemoglobin, older age, and increased segmented neutrophil count were associated with increased risk of death. CONCLUSIONS: This was a modern cohort analysis of leukemoid reactions, inclusive of all etiologies. The most common cause was infection, which involved several microorganisms. Paraneoplastic leukemoid reaction was also common. Both conditions have a poor prognosis with high mortality, being a major medical challenge.

A prospective study of hospitalized patients with leukemoid reaction; causes, prognosis and value of manual peripheral smear review.

INTRODUCTION: Several diagnoses have been associated with leukemoid reaction (LR). In patients with LR the diagnostic and prognostic value of detailed manual blood smear counts (such as the percentage of band cells or grading of neutrophil toxic changes) has not been studied previously. METHODS: We prospectively recorded all hospitalized adult (> 18 years old) patients with LR (≥ 30000/ul) of neutrophilic predominance, excluding patients with pre-existing leukocytosis due to hematological malignancies. We examined the diagnoses and prognosis (in-hospital mortality and post-discharge mortality up to a year after the end of the study) of these patients as well as the value of manual peripheral smear review. RESULTS: We recorded a total of 93 patients with LR from January 2017 to December 2017. Infection was the most common diagnosis (70%), followed by malignancy (7.5%) and bleeding (6.5%). In-hospital mortality (45%) and post-discharge mortality (35% of those discharged) were very high. Among blood smear findings, only neutrophil vacuolation was significantly more common in patients with infections (34%), although it was also observed in many patients without any infection (13%). Blood smear findings were not associated with prognosis. CONCLUSION: Detailed manual smear review is a labor-intensive procedure and it has limited diagnostic and prognostic value in unselected hospitalized patients with neutrophilic LR.

Low-dose cytarabine to prevent myeloid leukemia in children with Down syndrome: TMD Prevention 2007 study.

Approximately 5% to 10% of children with Down syndrome (DS) are diagnosed with transient myeloproliferative disorder (TMD). Approximately 20% of these patients die within 6 months (early death), and another 20% to 30% progress to myeloid leukemia (ML-DS) within their first 4 years of life. The aim of the multicenter, nonrandomized, historically controlled TMD Prevention 2007 trial was to evaluate the impact of low-dose cytarabine treatment on survival and prevention of ML-DS in patients with TMD. Patients received cytarabine (1.5 mg/kg for 7 days) in case of TMD-related symptoms at diagnosis (high white blood cell count, ascites, liver dysfunction, hydrops fetalis) or detection of minimal residual disease (MRD) 8 weeks after diagnosis. The 5-year probability of event-free and overall survival of 102 enrolled TMD patients was 72 ± 5% and 91 ± 3%, respectively. In patients eligible for treatment because of symptoms (n = 43), we observed a significantly lower cumulative incidence (CI) of early death as compared with symptomatic patients in the historical control (n = 45) (12 ± 5% vs 33 ± 7%, PGray = .02). None of the asymptomatic patients in the current study suffered early death. However, the treatment of symptomatic or MRD-positive patients did not result in a significantly lower CI of ML-DS (25 ± 7% [treated] vs 14 ± 7% [untreated], PGray = .34 [per protocol analysis]; historical control: 22 ± 4%, PGray = .55). Thus, low-dose cytarabine treatment helped to reduce TMD-related mortality when compared with the historical control but was insufficient to prevent progression to ML-DS. This trial was registered at EudraCT as #2006-002962-20.

Leukemoid reaction in malignant bone tumor patients - a retrospective, single-institution study.

BACKGROUND: To the Authors' knowledge, the literature regarding leukemoid reaction in patients with malignant bone tumor is sparse, and most of patients with leukemoid reaction have poor prognosis. AIM: To study the leukemoid reaction in malignant bone tumor patients. MATERIALS AND METHODS: A total of 105 consecutive malignant bone tumor patients with a white blood cell count > 50,000/microL were retrospectively identified over a 4-years period (2007-2010). Those patients without a secondary cause of their leukocytosis were defined as having a paraneoplastic leukemoid reaction. RESULTS: Three etiologies of the leukocytosis were found in those 105 patients: the major one was paraneoplastic leukemoid reaction which accounted for 56%; the second one was hematopoietic growth factors defect accounting for 30%; 14% patients were caused by infection and Tumor bone marrow involvement. The patients diagnosed with a paraneoplastic leukemoid reaction typically had neutrophil predominance (94.8%) and radiographic evidence of metastatic diseases (78%). They were clinically stable, but had a poor prognosis. 95% either died or were discharged to hospice within 12 weeks of their initial extreme leukocyte count. Both of the 2 (2%) patients who survived over 12 weeks received effective antineoplastic therapy. CONCLUSIONS: Patients with typical paraneoplastic leukemoid reaction were clinically stable despite having large tumor burdens. However, clinical outcomes were poor unless receiving an effective antineoplastic treatment.

The relationship between leukemoid reaction and perinatal morbidity, mortality, and chorioamnionitis in low birth weight infants.

OBJECTIVES: Neonatal leukemoid reaction (NLR) is relatively rare and considered as a white blood cell (WBC) count ≥50×10(9)/l . The aim of this study was to investigate the association of NLR with neonatal morbidity and mortality and maternal chorioamnionitis in low birth weight infants. METHODS: In this case-controlled retrospective study, the medical records of 1200 newborn infants with a birth weight <2500g admitted to the neonatal unit over a period of 5 years were reviewed. The infants who developed features of NLR (n=17, 1.4%) formed the study group, while the remainder without NLR, matched for gestational age and birth weight (n=123), formed the control group. A chart review was performed and salient demographic, clinical, and laboratory data abstracted. A statistical analysis was subsequently performed on this data. RESULTS: The mean WBC and absolute neutrophil counts of infants with NLR were significantly higher than those in the control group. The peak time of NLR was at 7.9±3.6 (interquartile range (IQR) 1-30) days and on average it improved within 4.1±1.95 (IQR 2-9) days. It was noted that those infants with NLR were mostly born by vaginal delivery and their mothers had a higher rate of early rupture of the membranes and chorioamnionitis. NLR was associated with a 4-fold increase in sepsis, 20-fold increase in intraventricular hemorrhage, 54-fold increase in bronchopulmonary dysplasia, and 6-fold increase in mortality. In the study group, those infants whose mothers had chorioamnionitis had a higher rate of early rupture of the membranes and they developed sepsis and intraventricular hemorrhage more often than those whose mothers did not have clinical chorioamnionitis. CONCLUSIONS: In low birth weight newborn infants, NLR is significantly associated with sepsis, intraventricular hemorrhage, bronchopulmonary dysplasia, and a high mortality rate. Also, those infants with NLR are more likely to be born to mothers with chorioamnionitis and they face sepsis and intraventricular hemorrhage more often.

White cell count and intensive care unit outcome.

A high white cell count on admission to the intensive care unit (ICU) is generally perceived to be associated with severe illness and poor outcome, but the implications of a low white cell count are less well recognised. We retrospectively analysed data on 4,165 patients. The white cell count on admission was split into four categories, leucopenic (< 4.0 x 10(9).l(-1)), normal (4.001-10.0 x 10(9).l(-1)), leucemoid (10.001-25.0 x 10(9).l(-1)) and an exaggerated leucemoid response (> 25.001 x 10(9).l(-1)). The mortality of patients with leucopenia on admission to the intensive care unit was higher than those with normal or moderately raised white cell count (37.5% vs. 18.9% and 23.9%, respectively). A leucopenic response, as well as an exaggerated leucemoid response, is associated with an increased mortality.

[The clinicoimmunological characteristics of blast transformation in lymphosarcomas]. / Kliniko-immunologicheskaia kharakteristika blastnoi transformatsii limfosarkom.

The authors studied a blast cell immunological phenotype in 50 adults with lymphosarcoma undergoing leukemization following the pattern of acute leukemia. Among the patients there were 12 females and 38 males aged 14-61. Immunological phenotyping of tumor cells was performed using a panel of monoclonal antibodies to T- and B-lymphocyte antigens, to myelomonocytic cells, some nonlinear and activation antigens. T, B and zero variants of blast cells were identified. Occasionally, blast cells carried nonlymphoid antigens and those corresponding to the common lymphosarcoma subvariant. Leukemization in the direction of lymphoblastic leukemia is associated with greater frequency of lymphosarcoma T subvariant (46%). B-cell and zero subvariants occurred in 28% and 20% of the patients, respectively. The number of complete remissions in the group of patients with T-cell subvariant was greater than in the group with B-cell subvariant. The survival in these two groups, however, was almost similar (median up to 8-12 months). Further studies into lymphoblastic leukemization immunophenotyping can help design programs of differentiated polychemotherapy.

High mortality among patients with the leukemoid reaction and alcoholic hepatitis.

We describe a patient with severe alcoholic hepatitis, markedly elevated white blood cell count, and high fever. After review of the English literature, we discovered reports of other cases similar to our case. The striking feature in all of these cases was a high short-term mortality rate, despite predictions of a favorable outcome. We therefore believe these patients represent a subgroup of patients with alcoholic hepatitis and that the leukemoid reaction is a poor prognostic sign in this disease.

Myeloid leukaemoid reactions in South African Blacks.

Myeloid leukaemoid reactions were observed in 18 Black adults and 20 Black children at Baragwanath Hospital, Johannesburg, during a 10-month period. This represented an incidence of 1,3/1 000 adult medical admissions and 3,7/1 000 paediatric medical admissions. During the same period the incidence of myeloid leukaemoid reactions in White children in Johannesburg and in Black and White children in Buffalo, NY, was less than 1/1 000 admissions. The reactions were associated with bacterial infections, neoplasms, hepatorenal failure, acute metabolic disorders and non-malignant blood dyscrasias. The mortality in adults was 55,6% and in children 35%. Sixty-five per cent of all deaths occurred within 24--48 hours of admission. Residual morbidity in survivors was common. The pattern of acute leukaemia in the same hospital population is predominantly myelocytic in both adults and children.