Validation of Thermal Imaging and the ALT-70 Prediction Model to Differentiate Cellulitis From Pseudocellulitis.

Importance: Cellulitis is misdiagnosed in up to 30% of cases due to mimic conditions termed pseudocellulitis. The resulting overuse of antibiotics is a threat to patient safety and public health. Surface thermal imaging and the ALT-70 (asymmetry, leukocytosis, tachycardia, and age ≥70 years) prediction model have been proposed as tools to help differentiate cellulitis from pseudocellulitis. Objectives: To validate differences in skin surface temperatures between patients with cellulitis and patients with pseudocellulitis, assess the optimal temperature measure and cut point for differentiating cellulitis from pseudocellulitis, and compare the performance of skin surface temperature and the ALT-70 prediction model in differentiating cellulitis from pseudocellulitis. Design, Setting, and Participants: This prospective diagnostic validation study was conducted among patients who presented to the emergency department with acute dermatologic lower extremity symptoms from October 11, 2018, through March 11, 2020. Statistical analysis was performed from July 2020 to March 2021 with additional work conducted in September 2023. Main Outcomes and Measures: Temperature measures for affected and unaffected skin were obtained. Cellulitis vs pseudocellulitis was assessed by a 6-physician, independent consensus review. Differences in temperature measures were compared using the t test. Logistic regression was used to identify the temperature measure and associated cut point with the optimal performance for discriminating between cellulitis and pseudocellulitis. Diagnostic performance characteristics for the ALT-70 prediction model, surface skin temperature, and both combined were also assessed. Results: The final sample included 204 participants (mean [SD] age, 56.6 [16.5] years; 121 men [59.3%]), 92 (45.1%) of whom had a consensus diagnosis of cellulitis. There were statistically significant differences in all skin surface temperature measures (mean temperature, maximum temperature, and gradients) between cellulitis and pseudocellulitis. The maximum temperature of the affected limb for patients with cellulitis was 33.2 °C compared with 31.2 °C for those with pseudocellulitis (difference, 2.0 °C [95% CI, 1.3-2.7 °C]; P < .001). The maximum temperature was the optimal temperature measure with a cut point of 31.2 °C in the affected skin, yielding a mean (SD) negative predictive value of 93.5% (4.7%) and a sensitivity of 96.8% (2.3%). The sensitivity of all 3 measures remained above 90%, while specificity varied considerably (ALT-70, 22.0% [95% CI, 15.8%-28.1%]; maximum temperature of the affected limb, 38.4% [95% CI, 31.7%-45.1%]; combination measure, 53.9% [95% CI, 46.5%-61.2%]). Conclusions and Relevance: In this large diagnostic validation study, significant differences in skin surface temperature measures were observed between cases of cellulitis and cases of pseudocellulitis. Thermal imaging and the ALT-70 both demonstrated high sensitivity, but specificity was improved by combining the 2 measures. These findings support the potential of thermal imaging, alone or in combination with the ALT-70 prediction model, as a diagnostic adjunct that may reduce overdiagnosis of cellulitis.

Characterization and diagnosis spectrum of patients with cerebrospinal fluid pleocytosis.

PURPOSE: There is an overlap in the cerebrospinal fluid (CSF) characteristics of patients presenting with different etiologies of CSF pleocytosis. Here, we characterized patients with CSF pleocytosis treated in a large hospital. METHODS: A retrospective cohort study of 1150 patients with an elevated CSF leukocyte count > 5 cells/µl treated at a university hospital in Germany from January 2015 to December 2017 was performed. Information on clinical presentation, laboratory parameters, diagnosis and outcome was collected. Clinical and laboratory features were tested for their potential to differentiate between bacterial meningitis (BM) and other causes of CSF pleocytosis. RESULTS: The most common etiologies of CSF pleocytosis were CNS infections (34%: 20% with detected pathogen, 14% without), autoimmune (21%) and neoplastic diseases (16%). CSF cell count was higher in CNS infections with detected pathogen (median 82 cells/µl) compared to autoimmune (11 cells/µl, p = 0.001), neoplastic diseases (19 cells/µl, p = 0.01) and other causes (11 cells/µl, p < 0.001). The CHANCE score was developed to differentiate BM from other causes of CSF pleocytosis: Multivariate regression revealed that CSF cell count > 100 cells/µl, CSF protein > 100 mg/dl, CRP > 5 mg/dl, elevated white blood cell count, abnormal mental status and nuchal rigidity are important indicators. The CHANCE score identified patients with BM with high sensitivity (92.1%) and specificity (90.9%) (derivation cohort: AUC: 0.955, validation cohort: AUC: 0.956). CONCLUSION: Overall, the most common causes for CSF pleocytosis include infectious, neoplastic or autoimmune CNS diseases in ~ 70% of patients. The CHANCE score could be of help to identify patients with high likelihood of BM and support clinical decision making.

Hematological parameters in newly diagnosed TB patients: A systematic review and meta-analysis.

Despite all efforts, tuberculosis (TB) remains one of the 10 leading causes of death worldwide. The hematopoietic system is seriously affected by TB and there is little information about the hematological profile of patients with TB. In this regard, this systematic review and meta-analysis aimed to assess hematological parameters among newly diagnosed TB patients. Relevant papers were found by searching in the PubMed database until April 2023. Fifteen papers involving 3354 patients were included. One-sample meta-analysis revealed the low pooled mean values for Hgb of 11.679 g/dl (95 % CI: 10.982-12.377) and the increased pooled ESR of 63.569 mm/h (95 % CI: 57.834-69.304) among newly diagnosed TB patients. The pooled prevalence of anemia, leukocytosis, thrombocytosis, and lymphopenia was 61.6 % (95 % CI: 45.4-75.6 %), 45.9 % (95 % CI: 39.1-52.9 %), 31.9 % (95%CI: 15-55.3 %) and 23.1 % (95%CI: 5.4-61.5 %) between TB patients, respectively. From a two-sample meta-analysis, the RBC and HgB values for TB patients were significantly lower than that of healthy controls (p < 0.05). Awareness of common blood abnormalities like elevated ESR, leukocytosis, and anemia in newly diagnosed TB patients helps physicians in early diagnosis and better management of disease.

Too many white cells-TAM, JMML, or something else?

Leukocytosis is a common finding in pediatric patients, and the differential diagnosis can be broad, including benign reactive leukocytosis and malignant myeloproliferative disorders. Transient abnormal myelopoiesis is a myeloproliferative disorder that occurs in young infants with constitutional trisomy 21 and somatic GATA1 mutations. Most patients are observed, but outcomes span the spectrum from spontaneous resolution to life-threatening complications. Juvenile myelomonocytic leukemia is a highly aggressive myeloproliferative disorder associated with altered RAS-pathway signaling that occurs in infants and young children. Treatment typically involves hematopoietic stem cell transplantation, but certain patients can be observed. Early recognition of these and other myeloproliferative disorders is important and requires a clinician to be aware of these diagnoses and have a clear understanding of their presentations. This paper discusses the presentation and evaluation of leukocytosis when myeloproliferative disorders are part of the differential and reviews different concepts regarding treatment strategies.

Hyperleukocytosis in Acute Myeloid Leukemia: Considerations for Inpatient Diagnosis and Management.

Hyperleukocytosis, a white blood cell count greater than 100,000/mcl, can be associated with the following three primary oncologic emergencies: leukostasis, disseminated intravascular coagulation, and tumor lysis syndrome. Th.

Rapport de cas Mononuclear pleocytosis and meningoencephalitis caused by Listeria monocytogenes in an adult horse.

Clinical disease caused by infection with Listeria monocytogenes is rare in adult horses, and there is a paucity of ante-mortem clinicopathologic changes for this species reported in the literature. Confirmatory diagnosis is difficult and often requires post-mortem sampling of the brainstem. This report details a case of meningoencephalitis caused by Listeria monocytogenes in an adult American quarter horse gelding presenting with central neurologic signs. Pre-mortem analysis of the cerebrospinal fluid revealed a mononuclear, primarily lymphocytic, pleocytosis, which is a reported finding in other species with listeriosis. Post-mortem histopathologic changes of the brainstem were characteristic of listeriosis, and infection was confirmed with immunohistochemical labeling and bacterial culture. Key clinical message: Listeriosis should be included as a differential diagnosis in neurologic horses with mononuclear pleocytosis identified on cerebrospinal fluid analysis.

Pléocytose mononucléaire et méningo-encéphalite causées par Listeria monocytogenes chez un cheval adulte. La maladie clinique causée par une infection à L. monocytogenes est rare chez les chevaux adultes, et il y a peu de changements clinico-pathologiques ante-mortem rapportés dans la littérature pour cette espèce. Le diagnostic de confirmation est difficile et nécessite souvent un prélèvement post-mortem du tronc cérébral. Ce rapport détaille un cas de méningo-encéphalite causée par L. monocytogenes chez un hongre quarter horse américain adulte présentant des signes neurologiques centraux. L'analyse pré-mortem du liquide céphalo-rachidien a révélé une pléocytose mononucléaire, principalement lymphocytaire, qui est une trouvaille rapportée chez d'autres espèces atteintes de listériose. Les modifications histopathologiques post-mortem du tronc cérébral étaient caractéristiques de la listériose et l'infection a été confirmée par un marquage immunohistochimique et une culture bactérienne.Message clinique clé :La listériose doit être incluse comme diagnostic différentiel chez les chevaux avec signes neurologiques présentant une pléocytose mononucléaire identifiée lors de l'analyse du liquide céphalo-rachidien.(Traduit par Dr Serge Messier).

Predictive Value of Routine WBC Count Obtained Before Discharge for Organ Space Infection in Children with Complicated Appendicitis: Results from the Eastern Pediatric Surgery Network.

BACKGROUND: The objective of this study was to evaluate the clinical utility of a routine predischarge WBC count (RPD-WBC) for predicting postdischarge organ space infection (OSI) in children with complicated appendicitis. STUDY DESIGN: This was a multicenter study using NSQIP-Pediatric data from 14 hospitals augmented with RPD-WBC data obtained through supplemental chart review. Children with fever or surgical site infection diagnosed during the index admission were excluded. The positive predictive value (PPV) for postdischarge OSI was calculated for RPD-WBC values of persistent leukocytosis (≥9.0 × 10 3 cells/µL), increasing leukocytosis (RPD-WBC > preoperative WBC), quartiles of absolute RPD-WBC, and quartiles of relative proportional change from preoperative WBC. Logistic regression was used to calculate predictive values adjusted for patient age, appendicitis severity, and use of postdischarge antibiotics. RESULTS: A total of 1,264 children were included, of which 348 (27.5%) had a RPD-WBC obtained (hospital range: 0.8 to 100%, p < 0.01). The median RPD-WBC was similar between children who did and did not develop a postdischarge OSI (9.0 vs 8.9; p = 0.57), and leukocytosis was absent in 50% of children who developed a postdischarge OSI. The PPV of RPD-WBC was poor for both persistent and increasing leukocytosis (3.9% and 9.8%, respectively) and for thresholds based on the quartiles of highest RPD-WBC values (>11.1, PPV: 6.4%) and greatest proportional change (<32% decrease from preoperative WBC; PPV: 7.8%). CONCLUSIONS: Routine predischarge WBC data have poor predictive value for identifying children at risk for postdischarge OSI after appendectomy for complicated appendicitis.

Monocytosis in primary care and risk of haematological malignancies.

Monocytosis (≥0.5 × 109 /L in peripheral blood) is the hallmark of chronic myelomonocytic leukaemia (CMML) but may be present in a spectrum of diseases including other haematological malignancies. In the primary care sector, monocytosis is a relatively common finding, but its predictive value for haematological malignancy is unknown. We included 663 184 adult primary care patients from the greater Copenhagen area with one or more differential cell counts registered between 2000 and 2016 and followed them in the extensive nationwide Danish health data registers for 3 years after blood sampling. We used logistic regression to model the risk of haematological malignancy and death following monocytosis. Monocytosis was associated with an increased risk of all types of haematological malignancy with the greatest relative risk increase observed in CMML with an OR of 105.22 (95% confidence interval: 38.27-289.30). Sustained monocytosis (at least two requisitions in 3 months) further increased CMML risk, although the diagnosis was still very rare, that is, observed in only 0.1% of these individuals. Outside the haematological setting, the absolute risk of haematological malignancy associated with monocytosis is low and haematological malignancy should mainly be suspected when monocytosis is sustained or the clinical presentation raises suspicion of malignancy.

Probable paraneoplastic leukocytosis in a dog with a gastrointestinal stromal tumor.

A 9-year-old female spayed Boston Terrier presented for diagnostic investigation of lethargy, poor appetite, weight loss, and a marked leukocytosis. Significant muscle wasting and a palpable abdominal mass were present on physical examination. Abdominal imaging revealed the mass to be of small intestinal origin; consequently, an intestinal resection and anastomosis were performed without complication. The histopathologic diagnosis was a gastrointestinal stromal tumor, verified by immunohistochemical positivity to CD117 (KIT). Two weeks after discharge, the leukocytosis had resolved. Though the exact molecular mediator of the severe leukocytosis was undetermined, resolution following tumor removal suggests a paraneoplastic cause. To the authors' knowledge, this is the first reported case of probable paraneoplastic leukocytosis secondary to a gastrointestinal stromal tumor in the dog. Gastrointestinal tract imaging should be performed when this uncommon hematologic abnormality is present.

Haematological changes in sailors who had COVID-19.

BACKGROUND: Follow-up of patients who had coronavirus disease 2019 (COVID-19) proves that clinical symptoms persist for months after recovery. A complex of such persistent manifestations is defined as the post-COVID-19 syndrome. One of the criteria for post-COVID-19 syndrome may be typical changes in white blood cell count and white blood cell (WBC) differential. The aim of the work is to study the frequency of haematological changes in sailors who had the acute coronavirus infection. MATERIALS AND METHODS: The retrospective study covered 30 candidate sailors aged 21 to 60 years with a history of COVID-19 and persistent changes in the WBC count and WBC differential and who did not have haematological abnormalities during the previous medical examinations. RESULTS: Analysis of WBC and WBC count at the long-term period after COVID-19 confirmed persistent changes in the form of neutrophilia, lymphopenia, changes in the neutrophils and lymphocytes ratio. The revealed changes in the WBC count were typical and fit into several patterns: A. Absolute leukocytosis, absolute and relative neutrophilia, relative lymphopenia; B. Relative and absolute lymphopenia, relative neutrophilia; C. Relative and absolute lymphocytosis, relative neutropenia; D. Relative lymphopenia, without other changes in WBC differential. CONCLUSIONS: The most typical laboratory change in WBC count in patients with the past COVID-19 is relative or absolute leukopenia. Persistent changes in WBC count are not always outside of the reference range for absolute values and should be assessed by a complex of typical changes. The presence of typical changes in WBC count in a patient with the past COVID-19 requires a profound examination for the post-COVID-19 syndrome.

Differential diagnosis of leukocytosis and leukopenia.

The blood cell count is often examined in routine clinical praxis. Physiologic leucocyte count is in range 4-10 × 109 in liter of blood. Abnormal values of leukocytes and subtypes of leukocytes in differential count are often present. Changes in leukocytes counts are caused by variety of benignant or malignant conditions. It is important in clinical praxis to interpret changes in blood cell count correctly and choose adequate approach in investigation process. In general, leukocytosis and leukocytopenia may present in primary hematologic disorder or secondary/reactive states, caused by reaction of hematopoiesis to underlying condition. This article review common causes of leukocytosis or leucopenia and give basic advice how to investigate patients with changes in leukocytes count.

Association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes.

BACKGROUND: Chorioamnionitis is a risk factor for fetal and neonatal outcomes. Therefore, predicting histological chorioamnionitis (HCA) and neonatal outcomes using clinical parameters could be helpful in management and preventing morbidities. OBJECTIVE: To determine if parameters of clinical chorioamnionitis (CCA) would be associated with HCA and neonatal outcomes. STUDY DESIGN: In this cohort study using a retrospective design, we analyzed the performance of signs of CCA in predicting HCA, and neonatal outcomes. Data were extracted from the electronic health record for all neonates with documented CCA delivered at our institution from 2011 to 2016. We compared our findings based on the old ACOG definition of CCA and the new definition released in 2017 - maternal fever plus any of fetal tachycardia, maternal leukocytosis, and purulent vaginal discharge. Maternal tachycardia and uterine tenderness were removed from the new criteria. Neonatal laboratory samples on admission, 12 h and 24 h were used to define the three time points of neonatal suspected sepsis. RESULTS: There were 530 mothers-infant dyads with chorioamnionitis. Seventy-three were preterm, and 457 were term. Eighty-eight percent of the preterm mothers had CCA, and HCA was present in 62.5% of 72 preterm placentas. Preterm infants with placental HCA significantly had lower birth weight, gestational age, placental weight, and more infants with lower 5-minute Apgar scores, compared to those with no HCA. In preterm infants, maternal urinary tract infection was significantly associated with decreased odds for HCA (OR 0.22, CI 0.10 - 0.71). More preterm babies with suspected sepsis criteria at the 3 time points had HCA (all p ≤ .01). In the term cohort, 95.4% and 65.6% had CCA and HCA, respectively. In term infants (n = 457), maternal leukocytosis (p = .002) and prolonged rupture of membranes (PROM; p = 002) were associated with HCA. Suspected sepsis was associated with PROM (p = .04), HCA (p = .0001), and maternal leukocytosis (p ≤ .05) in at least 1 of the 3 time points. CONCLUSION: Though maternal leukocytosis was significantly associated with the presence of HCA in the term cohort, there were no CCA criteria that accurately predicted presence of HCA in either the preterm or the term infants.

[Paraneoplastic hyperleukocytosis in lung cancer]. / Paraneoplastische Hyperleukozytose bei Lungenkarzinom.

Paraneoplastic leukocytosis in solid tumors is associated with poor prognosis. While mild leukocytosis is common, paraneoplastic hyperleukocytosis is extremely rare. The case of a 73-year-old male diagnosed with an adenocarcinoma of the lung and a peak white blood cell count of 178,000/µl is reported. The patient succumbed to the disease after two cycles of immunochemotherapy only 2 months after first hospital admission. Specific treatment options are still under investigation and have not been reported in clinical use.

Interpretation of white blood cell counts in the cerebrospinal fluid of neonates with traumatic lumbar puncture: a retrospective cohort study.

BACKGROUND: Difficulty in interpreting white blood cell (WBC) counts in cerebrospinal fluid (CSF) complicates the diagnosis of neonatal meningitis in traumatic lumbar punctures (LP). The aim of our study was to determine the correction factor for WBC counts in traumatic LP that offers the greatest diagnostic efficacy in meningitis. METHODS: We conducted a retrospective observational study of LP in neonates between January 2014 and December 2020. Traumatic LP was defined as a red blood cell (RBC) count ≥ 1,000 cells/mm3 CSF and pleocytosis as WBCs ≥ 20 cells/mm3 CSF. The CSF RBC:WBC ratio was analyzed by linear regression to determine a new correction factor. Cell count adjustments were also studied using the 500:1, the 1,000:1 ratio method, and the peripheral blood RBC:WBC ratio, using ROC curves and studies of accuracy (sensitivity and specificity). RESULTS: Overall, 41.0% of the 1,053 LPs included in the study were traumatic. The best results for effective WBC correction were the method based on the peripheral blood ratio (sensitivity = 1.0 and specificity = 0.9 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.9 for viral meningitis) and the 400:1 ratio (sensitivity = 1.0 and specificity = 0.8 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.8 for viral meningitis) obtained from linear regression (95% CI 381.7-427.4; R2 = 0.7). CONCLUSION: Both the peripheral blood correction and the 400:1 correction reduce the number of neonates classified with pleocytosis who were not eventually diagnosed with meningitis. Both methods might be a useful tool to clarify the neonatal meningitis diagnosis, offering neonatologists the possibility to assess the WBC count in traumatic LP.

Retrospective Evaluation of Various Serological Assays and Multiple Parameters for Optimal Diagnosis of Lyme Neuroborreliosis in a Routine Clinical Setting.

Laboratory diagnosis of Lyme neuroborreliosis (LNB) is challenging, and validated diagnostic algorithms are lacking. Therefore, this retrospective cross-sectional study aimed to compare the diagnostic performance of seven commercial antibody assays for LNB diagnosis. Random forest (RF) modeling was conducted to investigate whether the diagnostic performance using the antibody assays could be improved by including several routine cerebrospinal fluid (CSF) parameters (i.e., leukocyte count, total protein, blood-CSF barrier functionality, and intrathecal total antibody synthesis), two-tier serology on serum, the CSF level of the B-cell chemokine (C-X-C motif) ligand 13 (CXCL13), and a Borrelia species PCR on CSF. In total, 156 patients were included who were classified as definite LNB (n = 10), possible LNB (n = 7), or non-LNB patient (n = 139) according to the criteria of the European Federation of Neurological Societies using a consensus strategy for intrathecal Borrelia-specific antibody synthesis. The seven antibody assays showed sensitivities ranging from 47.1% to 100% and specificities ranging from 95.7% to 100%. RF modeling demonstrated that the sensitivities of most antibody assays could be improved by including other parameters to the diagnostic repertoire for diagnosing LNB (range: 94.1% to 100%), although with slightly lower specificities (range: 92.8% to 96.4%). The most important parameters for LNB diagnosis are the detection of intrathecally produced Borrelia-specific antibodies, two-tier serology on serum, CSF-CXCL13, Reibergram classification, and pleocytosis. In conclusion, this study shows that LNB diagnosis is best supported using multiparameter analysis. Furthermore, a collaborative prospective study is proposed to investigate if a standardized diagnostic algorithm can be developed for improved LNB diagnosis. IMPORTANCE The diagnosis of LNB is established by clinical symptoms, pleocytosis, and proof of intrathecal synthesis of Borrelia-specific antibodies. Laboratory diagnosis of LNB is challenging, and validated diagnostic algorithms are lacking. Therefore, this retrospective cross-sectional study aimed to compare the diagnostic performance of seven commercial antibody assays for LNB diagnosis. Multiparameter analysis was conducted to investigate whether the diagnostic performance using the antibody assays could be improved by including several routine (CSF) parameters. The results of this study show that LNB diagnosis is best supported using the detection of intrathecally produced Borrelia-specific antibodies, two-tier serology on serum, CSF-CXCL13, Reibergram classification, and pleocytosis. Furthermore, we propose a collaborative prospective study to investigate the potential role of constructing a diagnostic algorithm using multiparameter analysis for improved LNB diagnosis.

Hyperleukocytosis and leukostasis in acute and chronic leukemias.

Leukostasis is a life-threatening complication of high concentrations of circulating leukemic cells, most often myeloblasts. Effective care of patients with leukostasis involves early recognition and treatment, and aggressive management of concurrent complications of the underlying leukemia. The relatively poor prognosis in patients with leukostasis underscores the importance of the timely and effective care of this hematologic emergency. While cytoreductive measures such as hydroxyurea, corticosteroids, intravenous chemotherapy, and leukapheresis are available to urgently reduce high cell counts, characterization of the leukemia and initiation of tailored, definitive treatment is a parallel priority. However, data supporting any specific cytoreductive approach are limited, making clinical practice guided primarily by expert opinion. In this review, we discuss the pathophysiology, clinical manifestations, diagnosis, and management of leukemic hyperleukocytosis and leukostasis, with an emphasis on how to acutely manage this oncologic emergency in patients with acute myeloid leukemia, which is the most common cause of symptomatic leukostasis.

Asymptomatic Preoperative Leukocytosis Before Carotid Endarterectomy is Associated With Increased Risk of Stroke: A Study From NSQIP Database.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard operation for treating carotid artery stenosis in patients with symptomatic carotid stenosis of more than 50% and asymptomatic carotid stenosis of more than 80%. Asymptomatic leukocytosis before CEA represents a clinical dilemma for surgeons about the management options. The objectives of this study are to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in patients undergoing CEA and to assess the relationship between asymptomatic preoperative leukocytosis and postoperative complications in the cohort of patients with symptomatic carotid stenosis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database for the years 2011-2019 was utilized for this analysis. Patients with preoperative sepsis, septic shock, pneumonia, wound infections, disseminated cancer, renal failure, and history of chronic steroid use were excluded. The remaining patients were sub-grouped based on white blood cell (WBC) count: Normal WBC (<11k/µL) and High WBC (≥11k/µL). Bivariate analysis between the patient characteristics and preoperative WBC levels was performed following simple and multiple regression analysis. A P-value of <0.05 was set as significant. RESULTS: Of the 26,332 patients in the study cohort, 7.4% (n =1,946) had preoperative leukocytosis. Patients with preoperative leukocytosis were relatively younger (mean age: 41.5 +/- 9.7 vs 44.3 +/- 9.1; P< 0.001) and more likely to be females (43% vs. 38.5; P< 0.001) than patients with normal WBC count. Patients with preoperative leukocytosis were also more likely to have DM, COPD, a bleeding disorder, be smokers, and be functionally dependent. The analysis revealed that patients with preoperative leukocytosis had a significantly higher rate of stroke, length of stay (LOS)>1- week, acute occlusion or revision, acute renal failure, and return to OR when compared to patients with normal WBC count. Furthermore, patients with high WBC count also experienced higher occurrences of infectious complications, such as wound dehiscence, wound infections, pneumonia, and sepsis. However, there was no difference in the overall 30-day mortality. Multivariate regression analysis showed patients with preoperative leukocytosis had anincreased risk of stroke (AOR 1.5, CI: 1.1-1.9, P = 0.009), LOS>1 week (AOR 1.3, CI: 1.1-1.5, P = 0.003), and return to OR (AOR 1.3, CI: 1.0-1.8, P = 0.030). The increased LOS was especially more pronounced in symptomatic carotid stenosis patients with preoperative leukocytosis. The occurrence of LOS>1 week was 4.91% in asymptomatic stenosis patients with high WBC count compared to 21.5% in symptomatic stenosis patients with high WBC count (P< 0.001). CONCLUSIONS: Patients with asymptomatic preoperative leukocytosis undergoing CEA have a significantly higher risk of stroke and infectious complications in the postoperative period. Furthermore, patients with symptomatic carotid disease are especially at an increased risk of prolonged LOS. A routine preoperative hematological evaluation may be recommended as a risk assessment tool for patients undergoing CEA, and postponing the elective operation in patients with asymptomatic CEA may be advised unless a thorough preoperative infectious workup is completed.