What is the management plan for a patient with low Mean Corpuscular Hemoglobin Concentration (MCHC) and elevated absolute polys count?

Management of Low MCHC with Elevated Absolute Neutrophil Count

The management of a patient with low Mean Corpuscular Hemoglobin Concentration (MCHC) and elevated absolute neutrophil count should focus on treating the underlying infection while addressing the potential iron deficiency.

Assessment of Laboratory Findings

The patient's CBC shows:

• Low MCHC (31.1 g/dL, below reference range of 31.7-35.3 g/dL)
• Elevated absolute neutrophil count (7.35 x10³/uL, above reference range of 1.30-7.00 x10³/uL)
• Elevated immature granulocyte absolute count (0.11 x10³/uL, above reference range of 0.00-0.09 x10³/uL)
• Other parameters within normal limits

Interpretation

1. The low MCHC indicates hypochromia, which is most commonly associated with iron deficiency
2. The elevated neutrophil count (neutrophilia) with increased immature granulocytes suggests an active inflammatory or infectious process

Management Algorithm

Step 1: Address the Infectious Process

• Evaluate for signs and symptoms of infection (fever, localized symptoms)
• Consider empiric antibiotic therapy if clinically indicated for severe infection 1
• For neutrophilic patients with fever, immediate broad-spectrum antibiotics may be necessary, especially if immunocompromised 2

Step 2: Investigate Iron Status

• Order iron studies including:
  • Serum ferritin
  • Transferrin saturation
  • Serum iron
  • Total iron binding capacity 2
• Consider evaluation for sources of blood loss if iron deficiency is confirmed, particularly gastrointestinal bleeding in non-menstruating patients 2

Step 3: Evaluate for Other Causes of Hypochromia and Neutrophilia

• Review medication history for drugs that may cause neutrophilia
• Consider chronic inflammatory conditions that can affect both parameters
• Assess for hematologic malignancies if other abnormalities are present in the CBC 1

Step 4: Treatment Approach

For confirmed iron deficiency:

• Initiate oral iron supplementation (ferrous sulfate 325 mg 1-3 times daily)
• Monitor hemoglobin and MCHC response after 4-6 weeks
• Continue iron therapy for 3-6 months after normalization of hemoglobin to replenish stores 2

For infection:

• Targeted antimicrobial therapy based on identified source
• Follow-up CBC to monitor resolution of neutrophilia
• Consider discontinuation of antibiotics when clinically improved and neutrophil count normalizes 2

Special Considerations

Monitoring

• Weekly CBC during initial treatment phase to assess response 1
• Repeat iron studies after 2-3 months of iron therapy
• Monitor for side effects of iron therapy (constipation, nausea, abdominal discomfort)

Cautions

• Avoid iron supplementation without documented iron deficiency as it may worsen outcomes in some conditions 1
• Be aware that chronic inflammatory conditions can cause functional iron deficiency with normal or elevated ferritin levels 2
• Consider hematology consultation if:
  • No improvement with initial therapy
  • Multiple cell lines are affected
  • Suspicion of primary bone marrow disorder 1

Pitfalls to Avoid

1. Attributing low MCHC solely to iron deficiency without proper investigation
2. Overlooking serious underlying causes of neutrophilia such as leukemia or severe infection
3. Failing to investigate sources of blood loss in iron-deficient patients
4. Delaying antimicrobial therapy in neutropenic patients with fever 2
5. Missing concomitant vitamin B12 or folate deficiency that may be masked by iron deficiency 3

By following this systematic approach, clinicians can effectively manage patients with low MCHC and elevated neutrophil count while addressing both the immediate infectious concern and the underlying hematologic abnormality.