What is the management approach for a patient with elevated neutrophil absolute count and white blood cell (WBC) count, who is human immunodeficiency virus (HIV) negative, as confirmed by 4th generation and qualitative RNA tests at 83 days?

From the Guidelines

For a patient with elevated neutrophil absolute count and white blood cell count who has been confirmed HIV-negative through both 4th generation and qualitative RNA testing at 83 days, the management approach should focus on identifying other potential causes of neutrophilia. Initial steps should include a comprehensive medical history, physical examination, and additional laboratory tests to determine the underlying etiology. Common causes to investigate include:

• Bacterial infections
• Inflammatory conditions
• Medications (such as corticosteroids or lithium)
• Stress responses
• Hematologic disorders
• Malignancies Specific tests to consider include:
• Complete blood count with differential
• Comprehensive metabolic panel
• C-reactive protein
• Erythrocyte sedimentation rate
• Blood cultures if infection is suspected
• Chest imaging Management will depend on the identified cause - for example, antibiotics for bacterial infections, discontinuation of offending medications, or referral to hematology if a primary hematologic disorder is suspected. No specific medications should be started until the underlying cause is determined, as suggested by guidelines for managing febrile neutropenia 1. The elevated neutrophil count itself is not a disease but rather a response to an underlying condition, and treatment should target this primary cause rather than the neutrophilia directly. Close follow-up with serial complete blood counts is recommended to monitor the response to treatment. It's also important to note that an elevated white blood cell count can be seen in various conditions, including bacterial pneumonia, as indicated by guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents 1. However, the patient's HIV-negative status, as confirmed by 4th generation and qualitative RNA tests at 83 days, helps to rule out HIV-related complications, and the focus should remain on identifying and managing the underlying cause of neutrophilia.

From the Research

Management Approach

The management approach for a patient with elevated neutrophil absolute count and white blood cell (WBC) count, who is human immunodeficiency virus (HIV) negative, as confirmed by 4th generation and qualitative RNA tests at 83 days, involves several considerations:

• Evaluating the patient's symptoms and medical history to determine the underlying cause of the elevated neutrophil and WBC counts 2
• Conducting further tests, such as blood cultures and imaging studies, to rule out bacterial infections or other conditions that may be causing the elevated counts 3
• Monitoring the patient's condition closely and adjusting the management approach as needed based on the results of further testing and the patient's response to treatment

Diagnostic Considerations

The diagnostic value of absolute neutrophil count, band count, and morphologic changes of neutrophils in predicting bacterial infections has been studied 2. The results suggest that:

• Absolute neutrophil count (ANC) and toxic granulation in neutrophils are sensitive markers for predicting bacterial infections
• Band count is less sensitive than ANC and WBC count in predicting bacterial infections, except in elderly and infant populations
• Other studies have also investigated the diagnostic value of IL-6, CRP, WBC, and absolute neutrophil count in predicting serious bacterial infections in febrile infants 3

HIV-Related Considerations

Although the patient is HIV negative, it is worth noting that:

• HIV-infected patients with pulmonary tuberculosis have been found to have increased blood neutrophil counts, which are associated with sputum mycobacterial load 4
• Neutrophil counts and phenotype have been found to correlate with TB disease severity and treatment response, irrespective of HIV co-infection 5
• The full blood count and differential parameters have been found to be significantly different in HIV-infected versus uninfected individuals, and some of these parameters correlate with markers of immune activation and disease progression in HIV infection 6