What are the next steps for a patient with neutrophilia and hyperalbuminemia?

Management of Isolated Neutrophilia with Elevated Albumin

The most critical next step is to assess for clinical signs of infection and initiate empiric broad-spectrum antibiotics immediately if any symptoms are present, as neutrophilia >75% carries a high probability of bacterial infection. 1

Immediate Clinical Assessment

Evaluate for infection symptoms systematically:

• Fever, chills, or rigors
• Localized infection signs (respiratory symptoms, urinary symptoms, abdominal pain)
• Skin lesions or rashes
• Hepatosplenomegaly or lymphadenopathy 1

The neutrophil percentage of 75.9% has significant diagnostic value—elevated neutrophil percentages >90% have a likelihood ratio of 7.5 for documented bacterial infection, and your patient's value approaches this threshold. 1

Laboratory Workup

Order the following tests immediately:

• C-reactive protein to quantify inflammatory burden 1
• Blood cultures (two sets from different sites) if any infection symptoms present 1
• Site-specific cultures based on symptoms (urine, sputum, wound) 1

Special consideration for the elevated albumin (51 g/L): The slightly elevated albumin suggests hemoconcentration/dehydration rather than a primary pathologic process. This is clinically relevant because:

• True hyperalbuminemia is rare and typically reflects volume depletion
• The combination of neutrophilia with elevated albumin may indicate dehydration in the setting of infection 1

Management Algorithm

If symptomatic (fever, signs of infection):

• Initiate broad-spectrum antibiotics immediately—do NOT wait for culture results 1
• Reassess at 48 hours: if afebrile with negative cultures, consider stopping antibiotics after 48 hours of being afebrile 1

If asymptomatic:

• Monitor clinical status closely over 48-72 hours 1
• Repeat CBC with differential in 48-72 hours to assess trend
• Maintain high index of suspicion for occult infection

Critical Pitfalls to Avoid

Do not delay antibiotic therapy in symptomatic patients while awaiting culture results—this is the most common and dangerous error. 1

Consider non-infectious causes only after excluding infection:

• Medications (corticosteroids, lithium, G-CSF)
• Stress response (surgery, trauma, myocardial infarction)
• Smoking
• Chronic inflammatory conditions 1

If patient has cirrhosis with ascites: Perform diagnostic paracentesis immediately to rule out spontaneous bacterial peritonitis (SBP), as neutrophil count >250/mm³ in ascitic fluid requires immediate antibiotic initiation. 2, 1

Follow-up Monitoring

• Reassess clinical status and repeat laboratory parameters within 48-72 hours 1
• If fever develops or clinical deterioration occurs, obtain imaging (chest CT if respiratory symptoms) and broaden antibiotic coverage 2
• Address dehydration with appropriate fluid resuscitation given the elevated albumin