INTRODUCTION: Leukemoid reaction is defined by predominantly neutrophilic leukocytosis with a total leukocyte count >50,000 cells/µl, after excluding leukemia. Leukemoid reaction is seen in various conditions. It is very rare in alcoholic hepatitis (AH). Herein, we present a case of a young alcoholic male who was admitted with alcoholic hepatitis and leukemoid reaction. He underwent extensive workup to rule out other etiologies and subsequently improved after glucocorticoid therapy. CASE DESCRIPTION/METHODS: 28-year-old male with history of alcohol abuse presented with a two-week history of abdominal pain, distention, jaundice and vomiting. On exam, the patient had a fever and tachycardia. He was also found to be icteric and had ascites. Investigations revealed a bilirubin of 9.4 mg/dl. WBC of 42,000 cells/µl with a left shift. Ultrasound showed enlarged fatty liver. MDF was 61 and MELD was 37. Septic workup was negative including ascitic fluid cell count and culture. He was started on prednisolone 40 mg. Hematologic workup including peripheral smear ruled out neoplasm. Leukocyte alkaline phosphatase was elevated at 249. The patient was discharged on prednisolone and was followed as an outpatient. He improved after four weeks and his WBC count normalized. DISCUSSION: Leukemoid reaction is a very rare event in AH and is a poor prognostic marker. The pathophysiology is likely due to the increased levels of granulocyte colony stimulating factor (G-CSF) released by the damaged hepatocytes. The release of excessive amounts of tumor necrosis factor-alpha has been postulated to be instrumental in the causation of leukemoid reaction in alcoholic patients as well. However, Arguelles-Grande et al. reported a patient in which the cytokine profile did not demonstrate increased amounts of TNF-a. In their patient, levels of IL-18 and IL-1b were increased. IL-1b stimulates the proliferation and maturation of neutrophils in the bone marrow both directly by the induction of granulocyte-macrophage colony-stimulating factor and G-CSF; thus the postulated pathogenic sequence for LR: increased IL-18 produces increased IL-1b, which along with increased IL-8 produces neutrophilia. In this setting, corticosteroids may play a role by their reported inhibition of IL-1b transcription. Hematologic evaluation in these cases is necessary to rule out underlying neoplasm. If patients with severe alcoholic hepatitis are found to have leukemoid reaction, treatment with steroids should be considered after excluding sepsis and neoplasm.
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