Elevated White Cell Count Research Articles

Missile injury of the pelvis

A 12-year-old male presented to the Emergency Department with an accidental missile injury in the right lower quadrant. At the time of his admission, the boy was conscious, cooperating, and was not in any acute distress. On physical examination, vital signs were stable and cardiovascular and respiratory examinations were normal. A penetrating wound was found in the right lower quadrant of the abdomen, just above the inguinal canal. A similar but smaller hole was noticed on the left backside of the patient where the left gluteus met the posterior thigh. The abdominal hole represented the inlet and the gluteal-thigh hole was the outlet of the bullet that gave the impression of an oblique superficial injury. The hematologic profile was within normal limits except for an elevated white cell count of 20,600; a biochemistry panel was unremarkable. Urine analysis demonstrated marked hematuria. Abdominal x-ray obtained in erect posture showed a crescent shaped metallic opacity superimposed on the symphysis pubis (Figure 1), and this was thought to represent a fragment of the bullet. The patient was then evaluated by abdominal computed tomography (CT) scan (Figure 2). On the CT scan, the bullet fragment was found to be inside of the urinary bladder. The change in the position of the fragment when compared to the abdominal X-ray showed that it was freely moving in the bladder. On the right anterior margin of the bladder, a hematoma of the wall was noticed with air bubbles indicating the inlet of the bullet into the bladder. In the midline of the posterior wall of the bladder, a similar hematoma was noticed. The left perirectal fat and gluteal fat tissue planes were found to be inhomogenous, demonstrating the course of the broken bullet. The detection

Meconium aspiration injury: Uncoupling between the in vivo physiologic and in vitro inflammatory responses.

OBJECTIVE: To correlate the in vivo physiologic changes that occur with meconium aspiration injury to an associated in vitro cellular response to meconium. DESIGN: Experimental, prospective, randomized, controlled study. SETTING: University research laboratory. SUBJECTS: Eighteen adult Sprague-Dawley rats with meconium aspiration injury. INTERVENTIONS: Rats were given 3 mL/kg of a 25% meconium solution and were treated with conventional gas ventilation; nine rats were given exogenous surfactant therapy (Survanta, 4 mL/kg), and nine rats were not treated (control). Bronchoalveolar lavages were collected for total cell counts. Histologic samples also were taken for analysis. In addition, the in vitro effect of meconium on granulocytic elastase release from human neutrophils was determined. MEASUREMENTS AND MAIN RESULTS: Meconium caused significant morbidity in vivo, including poor oxygenation, elevated Paco(2), diminished compliance, and elevated white cell count in the bronchial lavages. Lung white cell count was significantly less in the surfactant group (p <.01). Meconium did not cause elastase release from human neutrophils in vitro. CONCLUSIONS: This study demonstrated uncoupling between in vivo physiologic responses to meconium injury in rats and the in vitro effect of meconium on human neutrophils. Surfactant therapy alleviated some of the perturbations associated with meconium injury, including a reduction in the inflammatory cell count in lung lavages. The absence of direct neutrophil activation by meconium suggests the requirement of an intermediary in the pathogenesis of meconium aspiration injury.

Chronic myelogenous leukaemia with p185(BCR/ABL) expression: characteristics and clinical significance.

We investigated the significance of p185BCR/ABL expression in patients with chronic myelogenous leukaemia (CML) in relation to disease features, therapy and outcome. Results of Western blot analysis for 1384 patients referred with a diagnosis of CML to our institution from 1989 to 1997 were reviewed. Clinical characteristics, results of cytogenetic analysis and RT-PCR for BCR rearrangement were analysed. Five patients with Ph-positive CML expressing the p185BCR/ABL hybrid protein were identified. By RT-PCR, bone marrow specimens of these patients were confirmed to have an e1a2 junction. The median age at diagnosis of these patients was 55 years (range 43-76). All had elevated white cell counts at diagnosis (median 50 x 109/l, range 11.7-163 x 109/l). Four patients had monocytosis (range 10-16%) with a low neutrophil/monocyte ratio in the peripheral blood (range 3.4-5.7). Patients presented with various stages of the disease (two in chronic-phase CP, two in accelerated-phase AP, and one in blastic-phase BP). The clinical course and therapy of the patients varied, with one patient receiving hydroxyurea only, three patients receiving hydroxyurea followed by interferon-alpha based regimens and bone marrow transplantation. The patient presenting in BP was treated with combination chemotherapy. The clinical outcome of the patients was also varied with one patient alive and in complete remission (with complete cytogenetic remission after transplant) and four patients dead after progression to more advanced stages. We conclude that patients with Ph-positive p185BCR/ABL CML frequently present with monocytosis and a low neutrophil/monocyte ratio in the peripheral blood, aiding the speculation that the presence of the p185BCR/ABL hybrid protein may contribute to a phenotype intermediate between CML and CMML. Of interest, the only other specific clinical feature identified was the absence of splenomegaly in four of five patients. There was no definite association with transformation to lymphoid blast phase.

Historical review. Inherited bone marrow failure: the men behind the empty space.

Historical review. Inherited bone marrow failure: the men behind the empty space.

Lumbar puncture in subarachnoid haemorrhage: a necessary evil?

A 70-year-old lady was admitted following the sudden onset of a severe, throbbing headache 7 days previously. The headache was occipital in location, with radiation to the back of the neck and both shoulders. The patient had vomited twice at the onset of the pain but, although initially severe, the headache had gradually resolved without further complication. The patient had a history of hypertension, controlled on bendrofluazide 2.5 mg once daily. A mastectomy had been performed in 1992 for carcinoma of the breast. Clinical examination revealed a sinus tachycardia 120 beats per minute and systolic hypertension 170/80 mmHg. Examination was otherwise unremarkable. Investigations included a normal full blood count, liver function tests, bone profile, random glucose, and electrocardiogram. Computed tomography scan of the head was normal. The only abnormality was the finding of a low sodium 132 mmol/litre, attributed to the diuretic, and serum electrolytes were otherwise unremarkable. The patient was discharged as she was asymptomatic and the sinus tachycardia had settled. Unfortunately, the patient was re-admitted the following day complaining of numbness on the right side of the face, together with low back pain. Clinical examination revealed mild cerebellar ataxia. A lumbar puncture was performed with the isolated finding of xanthochromia. A cell count was not performed on the cerebrospinal fluid (CSF). Subsequent cerebral angiography documented a right posterior communicating artery aneurysm, which was clipped 3 days later. The patient was discharged 10 days later with no neurological deficit. A 37-year-old lady was admitted following the sudden onset of a severe occipital headache 5 days previously. The headache had failed to resolve on simple analgesics. She had vomited twice and had developed mild photophobia. There were no apparent precipitants for the pain and there was no other relevant history. Clinical examination was unremarkable, except for the finding of mild neck stiffness and photophobia. The patient had an elevated white cell count (14.9 × 109/litre) but full blood count, serum electrolytes and glucose were otherwise normal. The initial report of the computed tomography scan of the head was normal, although a later review raised the possibility of hydrocephalus. A lumbar puncture was performed with the finding of xanthochromia, CSF red blood cells 25 000 and CSF white cell count 200 (90% polymorphs). No organisms were seen. CSF opening pressure was 12 cm. The patient was transferred to the tertiary centre and she underwent cerebral angiography which documented a left posterior cerebral artery aneurysm. This was embolized at surgery 5 days later. Postoperative recovery was complicated by communicating hydrocephalus with a CSF pressure of 40 cm, which responded well to lumbar puncture. The patient was discharged 10 days later with no neurological deficit. A 31-year-old lady was admitted following the sudden onset of headache 4 hours before admission. The headache was generalized, sharp in nature and associated with two episodes of vomiting. There was no neck stiffness and no photophobia. There were no other relevant features on the history. Clinical examination revealed a stable pulse rate of 72 beats per minute, blood pressure 130/76 mmHg and mild neck stiffness but no other focal deficit. The patient had an elevated white cell count (16.4 x 109/litre) but full blood count, serum electrolytes, and glucose were otherwise normal. Computed tomography scan of the head was normal. Lumbar puncture was performed, with the finding of 101 000 red cells, 125 white cells (60% polymorphonuclear leucocytes; 40% lymphocytes) but no xanthochromia. The patient was transferred to the tertiary neurosurgical centre, where she underwent cerebral angiography. This documented an aneurysm arising from the left internal carotid artery, with a proximal daughter aneurysm. These were clipped at surgery and the patient was discharged 10 days later with no neurological deficit.

Heightened suspicion and rapid evaluation with CT for early diagnosis of partial renal infarction.

Although renal infarction has been well studied and clearly defined, it remains greatly underdiagnosed, resulting in significant morbidity. Acute segmental renal infarction is a diagnosis even more problematic, as the problem can appear insidiously and masquerade as other entities including stone, infection, and even tumor. The clinical manifestations and evaluation of partial renal infarction in our patients were reviewed. Seven patients presenting to the emergency department who were subsequently found to have partial renal infarction were identified from the 5-year records of a single institution. Patients were evaluated for presenting complaints, physical findings, temperature, and blood pressure. Laboratory analysis consisted of a complete blood count (CBC); measurements of creatinine, lactate dehydrogenase (LDH), aspartate transaminase/alanine transaminase (AST/ALT), and alkaline phosphatase; and urinalysis. The sequence of the work-up was recorded, as well as time to diagnosis. The etiology of infarction was identified for all patients. All seven patients were eventually discovered to have partial renal infarction as a result of dysrhythmia (N = 4), mural thrombus (N = 2), or septic emboli (N = 1). The average time to diagnosis was 65.2 hours with a range of 9.5 to 168 hours. The chief complaint was flank pain (N = 3), nonspecific abdominal pain (N = 2), left lower-quadrant pain (N = 1), and mental status change (N = 1). The presenting signs and symptoms included abdominal tenderness (N = 4), nausea and vomiting (N = 4), temperature >100.5 degrees F (N = 3), and hypertension (N = 3). Laboratory studies revealed a white cell count >11,000/microL in six, microhematuria in four, proteinuria in four, elevated LDH in all patients, elevated AST/ALT in two, and elevated alkaline phosphatase in one. The work-up varied by presentation, but definitive diagnosis was made by CT in all five patients scanned and by angiography in two. Angiography confirmed the CT findings in four of the five patients. In evaluating partial renal infarction, a strong clinical suspicion is necessary. We found a history of dysrhythmia or other cardiac disease, the presence of abdominal or flank pain, fever with an elevated white cell count, and an elevated LDH to be clinically significant, and their presence should alert the clinician to the possibility of renal infarction. Once a degree of suspicion exists, early evaluation with CT should speed the diagnosis and effect decreased morbidity.

Causes, clinical features and non-operative management of bile leaks.

This paper evaluates the management of 31 patients with bile leaks identified over a 7-year period. Leaks complicated cholecystectomy in 19 patients (11 laparoscopic, 8 open), interventional procedures in 10 (including surgery in 1), trauma in one and was spontaneous in one case. Confirmation of the diagnosis typically lagged behind the onset of symptoms (mean for the group 4.2 days), indicating that a high index of suspicion is required in at-risk patients with typical symptoms. These include abdominal pain or distension, fever, bile leaking along a drain, jaundice, abnormal liver function tests and elevated white cell count. Two post-surgical bile leaks required surgical drainage of abdominal cellections. The remainder were successfully managed by non-operative methods including percutaneous drainage, endoscopic retrograde cholangiography with or without sphincterotomy or stent placement and percutaneous stenting. The spontaneous leak and all bile leaks complicating interventional procedures were managed non-operatively, although six patients in this group died due to the underlying malignant pathology. Only the patient with self-inflicted transection of the bile duct died directly from the complications of the bile leak. Although this is a varied, small series, we conclude that the majority of bile leaks can be managed by non-operative techniques. Whilst endoscopy is the primary modality for treatment, percutaneous techniques are crucially important for the management of complex cases and endoscopic failure.

APPENDICITIS IN HIV‐POSITIVE PATIENTS

The aim of the present study was to review the experience of appendicitis in human immunodeficiency virus (HIV)-positive patients. A retrospective analysis of all HIV-positive patients operated on for suspected acute appendicitis during a 10-year period at St Vincent's Hospital was performed. These patients were compared to a group of 60 age- and sex-matched patients with no HIV risk factors who were operated on during the same time period. On presentation the clinical findings were similar in both groups, with two notable exceptions. No HIV-positive patient had an elevated white cell count. The present study demonstrated a significant delay in presentation of the HIV-positive group to the Emergency Department, possibly explaining the higher appendiceal perforation rate in this group. There were no cases of HIV-related diseases mimicking acute appendicitis. There was no mortality, and morbidity was higher in the seropositive group. HIV-positive patients with a history suggestive of acute appendicitis should not be treated differently from the normal population. Morbidity and mortality can be minimized by prompt surgical treatment.

Diagnosis of neurosyphilis: appraisal of clinical caseload.

OBJECTIVES: To review the management of a cohort of patients with positive treponemal serology and psychiatric and/or neurological disorders. METHODS: A retrospective case note review of 172 patients with positive...

Circulating soluble adhesion molecules E-cadherin, E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in patients with gastric cancer.

The concentrations of the soluble adhesion molecules E-cadherin, E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were investigated in 45 patients with gastric cancer before treatment and their correlation with clinical, histological and routine laboratory parameters was examined. Data were collected on tumour stage at presentation, presence and sites of metastatic disease, tumour pathology, survival and results of routine laboratory tests. Serum concentrations of ICAM-1 and VCAM-1 were significantly elevated in the patients with gastric cancer in comparison with the group of healthy subjects (P < 0.00001 and P < 0.0001 respectively). Increased serum concentrations of VCAM-1 were associated with locally advanced and metastatic disease whereas ICAM-1 was significantly elevated both in local and in advanced/metastatic disease. Soluble E-cadherin and E-selectin concentrations did not show any significant elevation in gastric cancer patients. Concentrations of soluble adhesion molecules showed significant correlation with each other (except E-selectin and VCAM-1) and with alkaline phosphatase. Soluble ICAM-1 and VCAM-1 were significantly associated with an elevated total white cell count. Patients with elevated VCAM-1 had significantly poorer survival in comparison with patients with normal serum levels (P = 0.0361).

Bacterial meningitis in cirrhosis: review of 16 cases

Background: Although bacterial infections are frequent in patients with liver cirrhosis, only isolated cases of bacterial meningitis have been reported. Methods: We have reviewed a series of 16 cases of bacterial meningitis in patients with cirrhosis, diagnosed in a single hospital over a 30-year period. Results: Thirteen patients had alcoholic cirrhosis. On presentation, all patients had fever and most of them had an abnormal mental status (coma in 11 cases), but neck stiffness was not present or was delayed for more than 24 h in seven (43.7%) patients. The cerebrospinal fluid white cell count was always elevated, higher than 1000/μl in ten cases. The cerebrospinal fluid culture was positive in 14 (87.5%) patients. Gram-negative bacilli (mainly E. coli) and L. monocytogenes were the most frequent pathogens, accounting for nine cases. In contrast, S. pneumoniae and N. meningitidis were found in only four cases. Concurrent bacteremia was present in 12 (75%) cases. Ten patients (62.5%) died. Death was meningitis-related in seven patients and due to decompensated liver cirrhosis after clinical recovery from meningitis in the three other patients. Child-Pugh class C was associated with a higher mortality rate (80%, versus 33% for Child-Pugh class A–B), although the difference did not reach statistical significance. Conclusions: Bacterial meningitis should be suspected in every patient with cirrhosis presenting with a febrile coma. If lumbar puncture must be delayed, or if no causative agent can be identified on cerebrospinal Gram stain despite elevated cerebrospinal fluid white cell count, empirical antimicrobial therapy should be started straightaway with ampicillin plus a third-generation cephalosporin in sufficient doses.

Ventricular fluid pleocytosis in children with ventriculoperitoneal shunts.

Ventricular fluid pleocytosis in children with ventriculoperitoneal shunts.

Clinical and laboratory findings in acute appendicitis in the elderly.

Early diagnosis and surgery are important factors by which the morbidity and mortality of acute appendicitis in elderly patients can be lowered. This study was conducted to determine clinical and laboratory results that are commonly associated with acute appendicitis in elderly patients. A retrospective chart review was conducted of patients aged 60 years or older who underwent appendectomy or laparotomy for suspected acute appendicitis during a 5-year period in a metropolitan county. Acute appendicitis was confirmed by the pathology report. Elevated band cells and right lower quadrant pain were predictors of acute appendicitis in clinically suspected cases. Band cells greater than 6 percent had an excellent positive predictive value, as all patients with elevated band cells had acute appendicitis. With increasing white cell count and temperature, specificity increased, sensitivity decreased, and the positive predictive value remained high. It is essential to have a high degree of suspicion to recognize acute appendicitis in an afebrile elderly patient who has abdominal pain, a mildly elevated white cell count, and band cells in the upper limits of normal.

Hypoxaemia in patients with hyperleukocytosis: True or spurious, and clinical implications

It has been suggested that in asymptomatic patients with leukaemias and very high white blood cell counts, the apparent hypoxaemia found using routine blood gas analysis is spurious, the result of excessive O 2 metabolism by leukocytes. Pulse oximetry has been suggested as a means of overcoming the shortcomings of blood gas analysis in the assessment of these patients. We present the findings of two patients with extremely high white cell counts, which show that the hypoxaemia found is in fact true hypoxaemia, even in asymptomatic patients, and that met-haemoglobinaemia may be at least in part responsible for the low P aO 2. We also showed that pulse oximetry was completely unreliable in our patients due to the elevated met-haemoglobin levels. We recommend that all patients with markedly elevated white cell counts should undergo blood gas analysis with no delay between sampling and processing and that patients with low P aO 2 should undergo urgent cytoreduction.

Spontaneous Bacterial Peritonitis in a Hemodialysis Patient with Systemic Lupus erythematosus

Spontaneous bacterial peritonitis (SBP) is defined as infection of preexisting ascites without evidence for any intraabdominal source for secondary infection. SBP is now recognized with rising frequency and has mainly been reported in patients with alcohol-induced cirrhosis of the liver. We report SBP in a female dialysis patient whose ascites was not due to liver disease, but was possibly due to lupus erythematosus or represented 'nephrogenic ascites'. The patient had severe abdominal pain and a positive rebound phenomenon, fever and an elevated peripheral white cell count of 21,000 cells/microliters. Ascitic fluid analysis revealed an exudate with a protein concentration of 5.2 g/dl, 13,000 white cells/microliters with 94% neutrophils and positive cultures for Streptococcus morbillorum. Because of the dramatic clinical features the patient underwent laparotomy which did not reveal a source for secondary infection and in retrospect was unnecessary. The patient responded well to antibiotic therapy. This case report draws attention to SBP as a cause of acute abdomen in patients on chronic hemodialysis.

Diagnosis of Trypanosoma brucei gambiense sleeping sickness using an antigen detection enzyme-linked immunosorbent assay

A monoclonal antibody-based enzyme-linked immunosorbent assay (antigen elisa) developed for detection of trypanosome antigens in the serum and cerebrospinal fluid (CSF) of patients as a means for diagnosis of Trypanosoma brucei gambiense sleeping sickness was evaluated at the Bureau Central de la Trypanosomiase, Kinshasa, Zaire. Sixty-nine (89·6%) of 77 parasitologically confirmed cases examined at the Daloa clinic had antigens in serum; 35 (45·5%) had antigens in CSF and, in 4 of these, the antigens were detected in CSF only. Taking the serum and CSF results together, 73 (94·8%) of the 77 patients were positive in the assay. In the Kinshasa series, 168 (89·4%) of 188 parasitologically confirmed cases were positive by antigen elisa. The controls, who included 165 blood donors and 40 patients with malaria, 2 with hydatidosis and 12 with leishmaniasis, were negative by antigen elisa. Analysis of CSF results for 35 patients who had antigens in CSF revealed that 34 (97·1%) had elevated CSF white cell counts, 29 (82·9%) had elevated protein levels, and 23 (65·7%) had trypanosomes in their CSF. Moreover, analysis of results for 34 patients whose CSF had been shown to harbour trypanosomes by the double centrifugation technique showed that 24 (70·6%) had antigens in CSF, 28 (82·6%) had elevated protein levels, and 33 (97·1%) had elevated CSF white cell counts. Antigens were rapidly cleared from peripheral circulation following institution of treatment. Antigen clearance was accompanied by a rapid fall in CSF protein levels and white cell counts. These results demonstrate the potential of antigen elisa, not only as a tool for diagnosis, but also for clinical staging and treatment follow-up of patients with T. b. gambiense sleeping sickness.

Unusual gastrointestinal complications in neurosurgery.

Nine neurosurgical patients with unusual gastrointestinal complications are presented. Their diagnostic clinical features, as well as pitfalls in their diagnosis are highlighted. A high index of clinical suspicion of these unusual complications is important as patients' decreased level of consciousness and concomitant steroid therapy often complicates the clinical presentation. Progressive abdominal distension and absent or sluggish bowel sounds were the most consistent clinical features in comatose patients with peritonitis, whereas, high fever and markedly elevated white cell counts were often absent.

Fungal infection: a common, unrecognised complication of acute liver failure

The true incidence and clinical relevance of fungal infection was ascertained in a prospective study of 50 consecutive patients with acute liver failure. Fungal infection was present in 16 (32%) patients (15 Candida, one aspergillus) and in seven was considered the major cause of death. All six untreated died, while five of ten patients treated with anti-fungal therapy survived. The diagrusis was made on positive cultures from at least one significant site or on histological evidence of tissue invasion. All 16 hed concomitant bacterial infection and shared features suggestive of a clinical syndrome: deterioration in coma grade after initial improvement; pyrexia unresponsive to antibiotics; established renal failure; and a markedly elevated white cell count. Fungal infection is a common, serious complication of acute liver failure and therapy is indicated for those with positive cultures. A prophylactic trial would be justified in those surviving 5 days, especially, with established renal failure.

A diaphragmatic nick

A 27-year-old man was admitted with acute onset of severe, constant epigastric pain and vomiting associated with lifting at work. There were no other symptoms. Four years previously he had attended the Casualty Department with a knife wound to the left chest which had been sutured. Examination revealed only generalized abdominal tenderness. Haematological and biochemical investigations showed a mildly elevated white cell count (16.1 × 109/L). Abdominal radiographs were unremarkable. Forty-eight hours after admission he deteriorated rapidly with increasing abdominal pain, hypotension and tachycardia.

A Case Control Study of Some Hematological and Biochemical Variables in Acute Stroke and Their Prognostic Value

Hematocrit, total white cell and platelet counts, plasma urea and creatinine concentrations were estimated in 291 patients (mean age 70 +/- 12 years) admitted consecutively over a 6-month period to a district general hospital with acute stroke. Urinary albumin/creatinine ratio was also determined in a subgroup of patients during a follow-up visit 3 months after ictus. Results were compared with those from age- and sex-matched community controls. Total white cell count was elevated in all types of stroke compared with values from control subjects. Platelet count, plasma urea and creatinine concentrations were higher and the plasma albumin/globulin ratio was lower among patients with ischemic stroke. Elevated total white cell count, urea and creatinine, which were of prognostic significance, were found to be associated with the severity of stroke as indicated by the Glasgow coma score, and did not have any independent prognostic value. Elevated hematocrit was not shown to be a risk factor and did not have any prognostic significance. A low plasma albumin/globulin ratio, an index of plasma viscosity, was a possible risk factor for ischemic strokes. Urinary albumin/creatinine ratios in the highest quintile increased the risk of stroke 13-fold.