Can leukocytosis be observed in patients presenting with acute chest pain?

Can Leukocytosis Be Observed in Acute Chest Pain?

Yes, leukocytosis can be observed in patients presenting with acute chest pain, but it is typically modest and should prompt evaluation for specific underlying causes rather than being dismissed as a benign finding.

When Leukocytosis Occurs with Chest Pain

Life-Threatening Cardiac Conditions

• Acute coronary syndrome (ACS) may be accompanied by leukocytosis as part of the inflammatory response to myocardial injury, though this is not a primary diagnostic feature. 1
• Acute pericarditis can present with leukocytosis alongside sharp, positional chest pain that improves when sitting forward, with widespread ST-elevation and PR depression on ECG. 2, 3
• The presence of leukocytosis should never delay immediate ECG within 10 minutes and cardiac troponin measurement to exclude ACS. 1, 2

Pulmonary Embolism

• Modest leukocytosis (WBC >10,000/mm³) occurs in approximately 20% of patients with acute PE when other causes of leukocytosis are excluded. 4
• Importantly, no patients with PE alone had WBC counts ≥20,000/mm³ in the largest retrospective series, suggesting that marked leukocytosis should prompt investigation for alternative diagnoses. 4
• The presence of leukocytosis should not dissuade clinicians from pursuing PE diagnosis with Wells score, D-dimer, and CT pulmonary angiography when clinically indicated. 4, 2

Sickle Cell Disease and Acute Chest Syndrome

• Acute chest syndrome in sickle cell disease is a life-threatening complication characterized by new pulmonary infiltrate, chest pain, respiratory symptoms, and/or hypoxemia that requires emergency transfer to acute care. 1
• Leukocytosis may be present but is less reliable in sickle cell patients due to baseline hematologic abnormalities. 1
• These patients require aggressive treatment with oxygen, incentive spirometry, analgesics, antibiotics, and often transfusions regardless of WBC count. 1

Critical Diagnostic Pitfalls

When Leukocytosis Signals Serious Pathology

• Marked leukocytosis (>20,000/mm³) with chest pain should raise suspicion for:
  • Hematologic malignancy (acute leukemia, though WBC may be normal initially with prominent thrombocytopenia and coagulation abnormalities). 5
  • Paraneoplastic syndrome from aggressive malignancies such as anaplastic thyroid carcinoma secreting IL-6. 6
  • Extensive tissue damage or persistent inflammation-immunosuppression and catabolism syndrome (PICS) in critically ill patients. 7

Coagulation Abnormalities Trump WBC Count

• In a patient with chest pain and normal WBC but thrombocytopenia (platelets <100,000/µL), elevated PT-INR, or markedly elevated D-dimer (>70 µg/mL), consider acute leukemia even without leukocytosis. 5
• This combination warrants immediate peripheral blood smear review for blast cells and hematology consultation. 5

Algorithmic Approach to Chest Pain with Leukocytosis

Step 1: Exclude Immediate Life-Threatening Causes (First 10 Minutes)

• Obtain 12-lead ECG to identify STEMI, pericarditis patterns, or PE-related right ventricular strain. 1, 2, 3
• Measure high-sensitivity cardiac troponin immediately; this is the preferred biomarker for myocardial injury. 1, 2
• Perform chest radiograph to evaluate for pneumonia, pneumothorax, pleural effusion, or widened mediastinum. 1, 2

Step 2: Characterize the Leukocytosis

• WBC 10,000-20,000/mm³: Compatible with PE, acute chest syndrome, pericarditis, or inflammatory response to myocardial injury. 4, 1
• WBC >20,000/mm³: Suggests infection (pneumonia), hematologic malignancy, or paraneoplastic syndrome—requires expanded workup. 6, 7
• Normal WBC with thrombocytopenia and coagulopathy: Consider acute leukemia; obtain peripheral smear urgently. 5

Step 3: Risk Stratify for Pulmonary Embolism

• Apply Wells score or Geneva score for PE pretest probability. 2, 8
• Use age-adjusted D-dimer cutoff (age × 10 ng/mL for patients >50 years) if low-to-intermediate probability. 2, 3
• Proceed directly to CT pulmonary angiography if Wells score is high or D-dimer is elevated. 2, 3

Step 4: Special Population Considerations

• Sickle cell disease patients with chest pain: Emergency transfer by EMS is mandatory; exclude acute chest syndrome with chest X-ray and pulse oximetry. 1
• Immunocompromised patients: Leukocytosis may be blunted or absent despite serious infection; contrast-enhanced CT is the most reliable diagnostic modality. 1
• Women with autoimmune disease (SLE): Use sex-specific troponin thresholds (>16 ng/L for women); they present with atypical ACS symptoms (jaw pain, nausea) more frequently. 3

Common Clinical Pitfalls to Avoid

• Do not assume leukocytosis excludes cardiac causes: 7% of patients with reproducible chest wall tenderness still have ACS. 2, 3
• Do not delay imaging or treatment based on "modest" leukocytosis—it provides minimal diagnostic specificity. 4
• Do not overlook coagulation studies: In chest pain with leukocytosis, check platelet count, PT-INR, APTT, and D-dimer to identify occult hematologic disorders. 5
• Do not attribute leukocytosis solely to stress or steroids in hospitalized patients with persistent elevation—consider PICS and avoid prolonged empiric antibiotics without clear infection. 7