Can a lymphocyte count of 800, neutrophil count of 1100, and monocyte count of 400 represent an autoimmune disease flare in a patient with a known autoimmune disease on immunosuppression, with previously normal laboratory results and no medication changes in the past 6 months?

From the Guidelines

Yes, these lab values could represent a flare of the autoimmune disease, given the patient's history of autoimmune disease and current immunosuppression regimen. The total white blood cell count is within a relatively normal range, but the distribution of lymphocytes, neutrophils, and monocytes may indicate a shift in immune response. According to the study by Kostine et al. 1, patients with pre-existing autoimmune diseases are at risk of experiencing a flare of their underlying condition while on immunosuppressive therapy. The study suggests that many patients may have a flare of the underlying condition and/or immune-related adverse events, requiring the use of glucocorticoids and/or DMARDs.

Key Considerations

• The patient's labs were previously normal, and there have been no medication changes in 6 months, which suggests a change in disease status rather than a medication side effect.
• The study by Kostine et al. 1 highlights the importance of monitoring patients with pre-existing autoimmune diseases for signs of flare or immune-related adverse events.
• The EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitors 1 recommend a shared decision-making process between patients, oncologists, and rheumatologists.

Recommendations

• Contact your rheumatologist promptly to report these findings, as they may indicate the need for adjustment of your immunosuppressive regimen.
• Do not stop your current medications without medical advice.
• Additional testing may be needed, including inflammatory markers (ESR, CRP), complement levels, and specific autoantibody titers to assess disease activity.
• Watch for symptoms like increased fatigue, joint pain, rash, or fever that might accompany a flare.

From the Research

Laboratory Results and Autoimmune Disease

• Lymphocytes: 800
• Neutrophils: 1100
• Monocytes: 400
• Known autoimmune disease on immunosuppression
• Labs previously normal

Potential for Disease Flare

• A flare is defined as a measurable increase in disease activity in one or more organ systems involving new or worse clinical signs and symptoms and/or laboratory measurements 2
• The current laboratory results may indicate a potential flare, but it is essential to consider the clinical significance of these results and whether they represent a significant change from previous values
• The definition of a flare proposed by the Lupus Foundation of America emphasizes the importance of considering the clinical significance of changes in disease activity 2

Impact of Immunosuppressive Therapy

• Immunosuppressive therapies, such as DMARDs and biologic agents, are commonly used to reduce disease activity and induce remission in autoimmune conditions 3
• However, these therapies can also increase the risk of infections and other complications, highlighting the need for careful monitoring and management 3, 4
• The use of immunosuppressive therapies may affect the interpretation of laboratory results and the assessment of disease activity 4, 5

Monitoring and Management

• Regular monitoring of laboratory results and clinical symptoms is crucial for detecting potential flares and adjusting treatment as needed 3, 6
• The use of novel biomarkers and proactive approaches to clinical disease management may help predict changes in disease activity and prevent organ damage 6