What is the clinical significance and appropriate management of a patient with leukocytosis, mild anemia, and thrombocytosis, along with morphological changes in red and white blood cells?

Translation of Hematology Results from German to American Units

The blood test results show leukocytosis, mild anemia, and thrombocytosis with morphological changes in blood cells, which is most consistent with a myelodysplastic/myeloproliferative neoplasm that requires hematology consultation and further diagnostic workup.

Complete Blood Count Translation

White Blood Cell Parameters

• White Blood Cell Count: 12.0 × 10³/μL (Reference: 4.0-10.0 × 10³/μL) - ELEVATED
• Neutrophils: 7.33 × 10³/μL (61.0%) (Reference: 1.80-7.50 × 10³/μL, 45.0-75.0%)
• Band Neutrophils: 0.6 × 10³/μL (5.0%) (Reference: 0.0-1.6 × 10³/μL, 0.0-15.0%)
• Segmented Neutrophils: 6.7 × 10³/μL (56.0%) (Reference: 1.7-7.2 × 10³/μL, 40.0-70.0%)
• Eosinophils: 0.16 × 10³/μL (1.3%) (Reference: 0.02-0.40 × 10³/μL, 0.1-5.0%)
• Basophils: 0.10 × 10³/μL (0.8%) (Reference: 0.00-0.20 × 10³/μL, 0.0-2.0%)
• Immature Granulocytes: 0.04 × 10³/μL (0.3%) (Reference: <1.0%)
• Monocytes: 0.74 × 10³/μL (6.2%) (Reference: 0.10-1.00 × 10³/μL, 2.0-10.0%)
• Lymphocytes: 3.69 × 10³/μL (30.7%) (Reference: 1.00-4.50 × 10³/μL, 25.0-45.0%)

Red Blood Cell Parameters

• Red Blood Cell Count: 4.03 × 10⁶/μL (Reference: 4.40-5.60 × 10⁶/μL) - LOW
• Hemoglobin: 13.3 g/dL (Reference: 13.5-16.9 g/dL) - SLIGHTLY LOW
• Hematocrit: 37% (Reference: 40-49%) - LOW
• MCV: 92 fL (Reference: 82-98 fL)
• MCHC: 35.9 g/dL (Reference: 32.0-36.0 g/dL)
• MCH: 33 pg (Reference: 26-34 pg)
• RDW: 14% (Reference: 12-15%)
• Reticulocytes: 3.8% (Reference: 0.8-1.4%) - ELEVATED
• Reticulocytes (absolute): 155 × 10³/μL (Reference: 43-85 × 10³/μL) - ELEVATED
• Corrected Reticulocytes: 3.1% - ELEVATED

Platelet Parameters

• Platelet Count: 513 × 10³/μL (Reference: 150-400 × 10³/μL) - ELEVATED
• Mean Platelet Volume: 11.2 fL (Reference: 9.0-12.0 fL)

Morphological Findings

Red Blood Cell Morphology

• Anisocytosis: Present (+)
• Megalocytes: Present (+)
• Poikilocytosis: Present (+)
• Polychromasia: Present (+)
• Echinocytes: Present (+)
• Acanthocytes: Present (+)
• Target cells: Present (+)
• Howell-Jolly bodies: Present (+)
• Rouleaux formation: Present (+)

White Blood Cell Morphology

• Toxic granulation: Present (+)
• Medium-coarse granules

Platelet Morphology

• Platelet anisocytosis: Present (+)
• Giant platelets: Present (+)

Comment

• Lymphocytes occasionally show reactive changes

Clinical Interpretation

This blood count shows several significant abnormalities 1:

1. Leukocytosis (12.0 × 10³/μL) with normal differential
2. Mild anemia with hemoglobin of 13.3 g/dL and hematocrit of 37%
3. Marked thrombocytosis (513 × 10³/μL)
4. Elevated reticulocyte count (3.8%)
5. Multiple RBC morphological abnormalities including anisocytosis, poikilocytosis, and presence of Howell-Jolly bodies
6. Platelet abnormalities including giant platelets

These findings suggest a myelodysplastic/myeloproliferative neoplasm (MDS/MPN), particularly MDS/MPN with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T) given the combination of dysplastic features and elevated platelets 1, 2.

Recommended Next Steps

1. Bone marrow aspiration and biopsy to assess:

   • Cellularity
   • Ring sideroblasts (≥15% of erythroid precursors)
   • Dysplastic features in multiple cell lines
   • Blast percentage
   • Megakaryocyte morphology

2. Cytogenetic analysis to identify chromosomal abnormalities 1

3. Molecular testing for:

   • JAK2 V617F mutation
   • SF3B1 mutation
   • CALR and MPL mutations
   • BCR-ABL1 to rule out chronic myeloid leukemia 1, 2

4. Iron studies to evaluate for iron deficiency as a potential contributor to thrombocytosis 3, 4

5. Serum ferritin measurement to assess iron stores and inflammation

Differential Diagnosis

1. MDS/MPN with ring sideroblasts and thrombocytosis - most likely given the combination of dysplastic features and thrombocytosis 2

2. Essential thrombocythemia - but the presence of multiple dysplastic features makes this less likely 1

3. Chronic myeloid leukemia - needs to be ruled out with BCR-ABL1 testing 1, 5

4. Reactive thrombocytosis and leukocytosis - possibly due to iron deficiency, but the multiple dysplastic features suggest a primary bone marrow disorder 4

5. Adult-onset Still's disease - can present with leukocytosis, anemia, and thrombocytosis, but typically has more pronounced clinical symptoms 1

Management Considerations

• Hematology consultation is mandatory for suspected primary bone marrow disorders 3

• Cytoreductive therapy may be needed if thrombocytosis is symptomatic or presents thrombotic risk 3, 2

• Monitor for complications of thrombocytosis and leukocytosis, including thrombotic events 3, 6

• Avoid iron supplementation without confirmed iron deficiency, as it may worsen outcomes in myeloproliferative disorders 3

• Regular monitoring of blood counts is essential during and after treatment 3