What is the appropriate management for a 32-year-old male with leukocytosis and neutrophilia found on a routine CBC, without signs of illness?

Management of Leukocytosis and Neutrophilia in an Asymptomatic 32-Year-Old Male

For an asymptomatic 32-year-old male with leukocytosis (WBC 17.37) and neutrophilia (absolute neutrophil count 13.2) found on routine CBC, a watchful waiting approach with repeat CBC in 4-6 weeks is recommended, as this is likely a benign reactive process in the absence of symptoms. 1

Initial Assessment

• The patient presents with:
  • WBC: 17.37 (elevated)
  • Neutrophils: 76% (elevated)
  • Absolute neutrophil count: 13.2 (elevated)
  • Lymphocytes: 15% (relatively low)
  • Monocytes absolute: 1.3
  • Basophils: 0.10
  • No clinical symptoms or signs of illness

Diagnostic Considerations

Benign Causes (Most Likely)

• Stress-induced leukocytosis (physiologic)
• Recent exercise
• Smoking
• Medications (corticosteroids, epinephrine, lithium)
• Obesity
• Recent trauma or surgery
• Emotional stress
• Infection (subclinical)

Malignant Causes (Less Likely in Asymptomatic Patient)

• Myeloproliferative disorders
• Chronic neutrophilic leukemia
• Chronic myeloid leukemia

Management Algorithm

1. Confirm CBC Results

   • Examine peripheral blood smear to evaluate cell morphology and exclude immature forms 2
   • Look for toxic granulations, Döhle bodies, or other signs of reactive neutrophilia

2. Focused History and Examination

   • Recent infections or inflammatory conditions
   • Medication use (particularly corticosteroids)
   • Smoking status
   • Recent strenuous exercise
   • Check for fever, lymphadenopathy, hepatosplenomegaly

3. Initial Management Plan

   • In an asymptomatic patient with moderate leukocytosis and no concerning features:
     • Repeat CBC with differential in 4-6 weeks 1, 3
     • If persistent or worsening, proceed to further workup

4. Further Workup (if leukocytosis persists or worsens)

   • Basic metabolic panel
   • Liver function tests
   • C-reactive protein and ESR
   • Consider blood cultures if fever develops
   • Consider bone marrow examination if persistent unexplained leukocytosis

Key Considerations

• The absence of symptoms significantly decreases the likelihood of a serious underlying condition 3
• A single elevated WBC count without other abnormalities rarely indicates malignancy in an otherwise healthy young adult 2
• Neutrophilia with a normal peripheral smear morphology is most commonly due to benign causes 3

Common Pitfalls to Avoid

• Overinvestigation of asymptomatic leukocytosis can lead to unnecessary testing and patient anxiety
• Failure to recognize that transient leukocytosis is common and often resolves spontaneously
• Missing subtle signs of infection that may require treatment
• Attributing leukocytosis to infection without appropriate evaluation for non-infectious causes 1

When to Consider Referral to Hematology

• Persistent unexplained leukocytosis after 4-6 weeks
• Development of symptoms (fever, weight loss, night sweats)
• Presence of immature cells in peripheral blood
• Progressive increase in WBC count
• Development of other cytopenias
• Presence of hepatosplenomegaly or lymphadenopathy

The most important aspect of management is recognizing that in an asymptomatic young adult, isolated moderate leukocytosis with neutrophilia is most commonly a benign, self-limited finding that warrants observation rather than extensive immediate workup.