What is the significance of lymphocytosis (elevated lymphocytes), neutrophilia (elevated neutrophils), and monocytosis (elevated monocytes) in a patient with a known autoimmune disease on immunosuppression (immunosuppressive therapy) with previously normal laboratory results?

From the Guidelines

This patient with an autoimmune disease on immunosuppression, presenting with leukopenia (lymphocytes 800, neutrophils 1100, monocytes 400), should continue their current immunosuppressive medication with close monitoring of complete blood counts weekly until stabilization, as the benefits of controlling the autoimmune disease outweigh the risks of potential infections, as suggested by 1. The patient's laboratory results indicate a low absolute neutrophil count and lymphopenia, which are likely side effects of the immunosuppressive therapy.

• The neutrophil count is above the threshold for severe neutropenia (<500 cells/mm³) as indicated in 1, which suggests that the patient is not at high risk for severe infections at this time.
• The lymphocyte count is also low, but not severely low, which may increase the risk of infections, and therefore, close monitoring is necessary.
• The monocyte count is at the lower end of normal, which further suggests that the immunosuppressive medication is affecting the patient's bone marrow function. Given the patient's condition, it is recommended to continue the current immunosuppressive medication, but with close monitoring of complete blood counts and adjustment of the medication dose as needed to balance the risks and benefits, as suggested by 1. If the neutrophil count drops below 1000/μL, consideration should be given to reducing the immunosuppressant dose by 25-50% in consultation with the specialist managing the autoimmune condition. For severe neutropenia (below 500/μL), temporary discontinuation of the medication may be necessary, and supportive measures such as infection prevention and prompt evaluation of fever or signs of infection should be implemented, as indicated in 1. Filgrastim (G-CSF) at 5μg/kg subcutaneously daily for 1-3 days could be considered for severe neutropenia, but only after specialist consultation, as suggested by the general principles of managing neutropenia. These recommendations are based on the balance between controlling the autoimmune disease and preventing serious infections, and are in line with the guidelines for monitoring patients with systemic lupus erythematosus, as indicated in 1.

From the Research

Immunosuppression and Blood Cell Counts

• The patient has a known autoimmune disease and is on immunosuppression, with labs previously being normal 2, 3, 4.
• The current blood cell counts are: lymphocytes 800, neutrophils 1100, monocytes 400.
• Immunosuppressive therapy can affect blood cell counts, with some agents causing more suppression of certain cell types than others 5, 6.

Effects of Immunosuppressive Agents on Blood Cell Counts

• Azathioprine, an antimetabolite, can inhibit lymphocyte production and also cause toxicity to bone marrow, gastrointestinal tract, and liver 2.
• Mycophenolate mofetil (MMF), another antimetabolite, inhibits only the de novo purine synthesis pathway and can cause less toxicity than azathioprine 2, 6.
• Corticosteroids can cause immunosuppression by sequestrating CD4+ T-lymphocytes and inhibiting cytokine transcription, but can also have adverse effects on various systems in the body 2, 3.
• Calcineurin inhibitors, such as cyclosporine and tacrolimus, can prevent transcription and secretion of IL-2, but can also cause nephrotoxicity, neurotoxicity, and glucose intolerance 2, 3, 5.

Clinical Implications

• The patient's current blood cell counts should be monitored and adjusted accordingly to minimize the risk of adverse effects from immunosuppressive therapy 4, 5, 6.
• The choice of immunosuppressive agent and dosage should be individualized based on the patient's specific needs and medical history 3, 4, 6.