What is the appropriate management for a patient with leukocytosis and neutrophilia without any symptoms for 2 weeks?

Management of Leukocytosis and Neutrophilia Without Symptoms for 2 Weeks

For a patient with leukocytosis and neutrophilia without symptoms for 2 weeks, observation and further diagnostic workup are recommended rather than immediate antibiotic therapy, as this likely represents a reactive process rather than infection requiring treatment.

Laboratory Findings Assessment

• The patient has leukocytosis (WBC 11.5 × 10³/μL) with neutrophilia (absolute neutrophil count 8.0 × 10³/μL) 1
• Other cell lines are normal, including hemoglobin (16.3 g/dL), hematocrit (49.7%), and platelets (240 × 10³/μL) 2
• The absence of immature cells in the differential suggests a non-malignant process 3

Diagnostic Approach

• Leukocytosis with neutrophilia is commonly a reactive response to various stimuli rather than indicating infection, especially when the patient is asymptomatic 2, 4
• Leucocytosis and neutrophilia are common findings (45% and 60% respectively) following trauma or stress and may be a reactive response rather than indicative of infection 2
• A repeat complete blood count with peripheral smear is recommended to evaluate the types and maturity of white blood cells and to look for toxic granulations 4

Potential Etiologies

• Common non-infectious causes of persistent neutrophilic leukocytosis include:
  • Medications (corticosteroids, lithium, beta-agonists) 4
  • Chronic inflammatory conditions 4
  • Smoking 4
  • Obesity 4
  • Stress response (physical or emotional) 4, 3
  • Thrombotic events (even without obvious symptoms) 5

Management Recommendations

• For asymptomatic patients with leukocytosis and neutrophilia without evidence of infection, observation is appropriate 1
• Empiric antibiotic therapy is not recommended in the absence of fever or other signs of infection 2
• According to the Infectious Diseases Society of America, antibiotic therapy should be reserved for patients with neutropenic fever (neutrophil count ≤0.5 × 10⁹/L) or clear signs of infection 2
• The patient should be evaluated for potential underlying causes:
  • Medication review 4
  • Assessment for occult inflammatory conditions 4, 3
  • Evaluation for possible thrombotic events 5

Follow-up Recommendations

• Repeat CBC in 1-2 weeks to monitor trends 4
• If leukocytosis persists beyond 4 weeks without a clear etiology, consider:
  • Additional diagnostic workup including C-reactive protein and ESR 1
  • Imaging studies if clinically indicated 1
  • Hematology consultation if persistent without explanation or if concerning features develop 3

When to Consider More Aggressive Evaluation

• Development of fever, weight loss, night sweats, or other B symptoms 3
• Appearance of immature cells or blasts in the peripheral blood 3
• Progressive increase in WBC count 3
• Development of anemia or thrombocytopenia 3

Caution

• Leukocytosis with neutrophilia can occasionally be an early sign of a hematologic malignancy, but this is less likely with normal red blood cell and platelet parameters and absence of immature cells 3, 6
• The absence of symptoms for 2 weeks makes an acute infectious process less likely, but does not completely exclude chronic or indolent infections 2