What is the appropriate management for a patient with anemia and elevated WBC count?

Management of Anemia with Elevated WBC Count

The appropriate management for this patient with anemia and elevated WBC count should focus on identifying and treating the underlying cause of the neutrophilic leukocytosis while addressing the chronic anemia.

Assessment of Laboratory Findings

The patient's laboratory results show:

• Elevated WBC (11.8 K/mcL) with neutrophilia (absolute neutrophil count 8.93 K/mcL)
• Chronic anemia (hemoglobin 12.7-13.2 g/dL, below reference range of 13.5-17.5 g/dL)
• Low RBC count (4.26-4.29 M/mcL, below reference range of 4.30-5.70 M/mcL)
• Normal MCV, MCH, MCHC, and RDW (normocytic, normochromic anemia)
• Normal platelet count

Diagnostic Approach

1. Evaluate for Causes of Neutrophilia

• Acute infection or inflammation
• Medication effect
• Stress response
• Hematologic malignancy
• Chronic inflammatory condition

2. Investigate Anemia Etiology

Based on guidelines 1, the following investigations are recommended:

• Complete blood count (already available)
• Absolute reticulocyte count
• Serum ferritin level
• Transferrin saturation (TSAT)
• Serum vitamin B12 and folate levels
• Renal function tests
• Inflammatory markers (CRP, ESR)
• Stool for occult blood

Management Algorithm

Step 1: Address Acute Neutrophilia

• If signs of infection are present, identify source and treat with appropriate antibiotics
• If medication-induced, consider modification of therapy
• If no obvious cause, monitor WBC with repeat CBC in 1-2 weeks

Step 2: Manage Anemia Based on Etiology

If Iron Deficiency Identified:

• For confirmed absolute iron deficiency (ferritin <30 ng/mL and TSAT <15%), administer intravenous iron according to approved formulations 1
• Investigate source of blood loss with upper and lower GI endoscopy in men and post-menopausal women 1

If B12 or Folate Deficiency:

• For B12 deficiency, administer 100 mcg vitamin B12 IM daily for 6-7 days, then alternate days for 7 doses, then every 3-4 days for 2-3 weeks, followed by monthly maintenance 2
• For folate deficiency, supplement with oral folate

If Anemia of Chronic Disease/Inflammation:

• Treat underlying inflammatory condition
• Consider erythropoiesis-stimulating agents (ESAs) if hemoglobin <10 g/dL and patient is symptomatic 1

If Myelodysplastic Syndrome Suspected:

• Refer to hematology for bone marrow evaluation
• For low-risk MDS with symptomatic anemia, ESAs may be considered if serum erythropoietin <500 IU/L 1

Step 3: Blood Transfusion Decision

• Reserve RBC transfusions primarily for patients with severe anemia symptoms or hemoglobin <7-8 g/dL requiring rapid improvement 1
• This patient's hemoglobin (12.7-13.2 g/dL) does not warrant transfusion

Special Considerations

• The combination of anemia with elevated WBC count warrants consideration of hematologic disorders, including early myelodysplastic syndrome with transformation 3
• Elevated WBC counts in patients with anemia have been associated with increased healthcare utilization 4, suggesting more aggressive management may be beneficial
• Monitor hemoglobin levels regularly, as patients in facilities with higher prevalence of hemoglobin <10 g/dL have approximately 30% elevated risk of requiring transfusions 5

Follow-up Recommendations

• Repeat CBC in 1-2 weeks to monitor WBC count and anemia
• If neutrophilia persists without identified cause, consider hematology consultation
• Once underlying cause is identified, tailor follow-up based on specific diagnosis
• For chronic anemia, monitor hemoglobin every 1-3 months depending on severity and treatment response

The key to successful management is identifying the underlying cause of both the anemia and leukocytosis rather than treating them as separate entities, as they may represent manifestations of a single underlying disorder.