Can a mildly elevated white blood cell count with normal C-reactive protein (CRP) level be attributed to a stress response after a recent minor podiatry procedure, including debridement and 4th metatarsal osteotomy/head resection, in a patient recovering from toe gangrene and receiving broad-coverage antibiotics?

From the Guidelines

The mild elevation in white blood cell count to 12.7 can be attributed to a stress response after the recent podiatry procedure, given the absence of symptoms and a normal CRP level. When evaluating a patient with a diabetic foot infection, as outlined in the 2012 Infectious Diseases Society of America clinical practice guideline 1, it's crucial to consider the whole patient, the affected limb, and the wound itself. The guideline recommends diagnosing infection based on symptoms or signs of inflammation, and in this case, the lack of such symptoms alongside a normal CRP suggests that the elevated white blood cell count might not indicate a worsening infection. The patient's recent history of toe gangrene and multiple debridements, including the latest procedure with 4th metatarsal osteotomy/head resection, could contribute to an elevated white blood cell count as a response to surgical stress. Key points to consider in managing this patient include:

• Monitoring for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site.
• Continuing the current antibiotic regimen as prescribed, given the patient's history and the potential for underlying infection.
• Reassessing the white blood cell count in 24-48 hours to determine if the elevation is transient or if it persists, indicating a possible need for further evaluation. Given the information provided and the guidelines for managing diabetic foot infections 1, the current approach should focus on close monitoring and maintaining the current treatment plan, unless signs of infection or other complications arise.

From the Research

Leukocytosis After Surgery

• The patient's mildly elevated white blood cell count (12.7) after a minor podiatry procedure could be a stress response, as stated in 2 and 3, which mention that stressors such as surgery, exercise, trauma, and emotional stress can cause an acute leukocytosis.
• The normal CRP level and lack of symptoms suggest that the leukocytosis may not be due to an infection, which is a common cause of elevated white blood cell counts 2, 3.
• The patient's recent history of multiple debridements and broad-coverage antibiotics may also be contributing factors to the leukocytosis, as seen in patients with prolonged hospitalization and extensive use of empiric broad-spectrum antibiotics 4.

Differential Diagnosis

• Other nonmalignant etiologies of leukocytosis, such as certain medications, asplenia, smoking, obesity, and chronic inflammatory conditions, should be considered 2.
• Primary bone marrow disorders, such as acute or chronic leukemias, are less likely but should be suspected in patients with extremely elevated white blood cell counts or concurrent abnormalities in red blood cell or platelet counts 3.
• The patient's white blood cell count is not extremely elevated, and there is no mention of other abnormal blood cell counts, making a primary bone marrow disorder less likely.

Management

• A repeat complete blood count with peripheral smear may provide helpful information, such as types and maturity of white blood cells, uniformity of white blood cells, and toxic granulations 2.
• The patient's clinical course and symptoms should be closely monitored, and the leukocytosis should be re-evaluated in the context of the patient's overall condition 5.