What is the management approach for a patient with leukocytosis (high White Blood Cell (WBC) count), neutrophilia (high neutrophil absolute count), and Human Immunodeficiency Virus (HIV) infection?

From the Guidelines

The management of a patient with leukocytosis, neutrophilia, and HIV infection should prioritize the identification and treatment of underlying infections, optimization of antiretroviral therapy (ART), and careful monitoring of blood counts and immune status, as outlined in the NCCN guidelines 1. The first step in managing such a patient is to evaluate for opportunistic infections that can trigger neutrophilia, given the increased susceptibility of HIV patients to these infections 1.

• Empiric broad-spectrum antibiotics, such as piperacillin-tazobactam 4.5g IV every 6 hours or cefepime 2g IV every 8 hours, should be initiated if bacterial infection is suspected, with adjustments based on culture results.
• Simultaneously, ART should be optimized or initiated if the patient is not already on treatment, typically with an integrase inhibitor-based regimen such as bictegravir/emtricitabine/tenofovir alafenamide, considering the potential for drug interactions and the need for consultation with an HIV specialist or pharmacist 1.
• Complete blood counts should be monitored regularly, along with CD4 counts and HIV viral load, to assess the response to treatment and guide further management decisions. Other potential causes of leukocytosis in HIV patients include medication effects, malignancies (particularly lymphomas), and immune reconstitution inflammatory syndrome (IRIS) 1.
• If leukocytosis persists despite treating infections and optimizing ART, further investigations including bone marrow examination may be necessary to rule out hematologic malignancies. The management approach must be individualized based on the patient's CD4 count, viral load, medication history, and clinical presentation, as the differential diagnosis and treatment priorities will vary accordingly 1.

From the Research

Management Approach for Leukocytosis, Neutrophilia, and HIV Infection

• The management of a patient with high White Blood Cell (WBC) count, high neutrophil absolute count, and Human Immunodeficiency Virus (HIV) infection involves the use of antiretroviral therapy (ART) to suppress HIV replication and restore immunity 2.
• ART has been shown to decrease the expression of neutrophil CD64, a marker of systemic inflammation associated with HIV infection 3, 4.
• The choice of ART regimen is important, with considerations including ease of use, tolerability, and efficacy in patients with elevated HIV-RNA and/or low CD4 counts 2.
• Trimethoprim-sulfamethoxazole is an important antibiotic in the treatment and prevention of opportunistic infections (OI) in HIV-infected patients, and has a broad spectrum of activity against Pneumocystis jiroveci, toxoplasmosis, and bacterial infections 5.
• Neutrophil activation and dysfunction have been observed in HIV-infected individuals, even in the presence of virally-suppressive treatment, and may contribute to persistent immune activation and an inflammatory vascular environment 6.

Monitoring and Treatment

• Monitoring of neutrophil count and function, as well as CD4+ T cell count and HIV viral load, is important in the management of HIV-infected patients with leukocytosis and neutrophilia 3, 4, 6.
• Treatment of opportunistic infections and other comorbidities is also crucial in the management of these patients 5, 2.
• The use of protease inhibitors and integrase strand transfer inhibitors, in particular, may have effects on neutrophil function that deserve further study 6.