Why is my WBC count persistently borderline high?

Hello,

Welcome to icliniq.com.

I have gone through the attachments (attachment removed to protect patient identity).

Probable cause is cholecystitis.

After reviewing your records, it is noticeable that there is persistent leukocytosis with prevailing neutrophilia and a slight microcytosis that is low MCV (mean corpuscular volume) and hypochromia that is low MCH (mean corpuscular hemoglobin) of RBC (red blood cells).

Since your ferritin level is normal and no abnormal hemoglobin was detected, it is safe to rule out the presence of both iron deficiency anemia and thalassemia, which makes the aforementioned constellation indicative of a chronic infection, which may cause an impaired iron turnover as evident from the persistently low MCV and MCH.

Now, your primary complaint is abdominal pain, which obviously is a chronic one since it spans around two years. Yet, you do not state whether it is in the left or right abdominal half. The presence of gallbladder stones can cause chronic inflammation of the gallbladder, and that condition can cause all related lab abnormalities.

You have elevated cholesterol levels and TGL (triglycerides), as well as a BMI (body mass index) that is considered obese. It is highly probable that the reason for these gallstones is the increased concentration of cholesterol in bile. It is advisable to repeat the USG (ultrasound) of gallstones that might have increased.

You should be offered a treatment regimen to "dissolve" the gallstones, starting with the diet, such as low-fat/cholesterol food, intake of more vegetables and vegetable oil, and increased physical activity; secondarily, if necessary, drug treatment or surgery. USG will also yield information regarding your liver and spleen, which is important if one is to suspect a hematologic disorder.

In my opinion, there is less reason to suspect a hematological disorder in your case. If such is to be considered, then given the protracted course of two years, this should be either chronic myeloproliferative disorder (such as chronic myeloid leukemia or myelofibrosis) or lymphoproliferative disorder (such as chronic lymphocytic leukemia).

Both are diseases of the elderly, so splenomegaly should usually be present. And you should have other symptoms such as night sweats, weight loss of more than 10% for less than six months, malaise, and fever.

A simple differential blood count could reveal whether that neutrophilia is due to the presence of segmented cells only, meaning infection, or due to the presence of an expanded WBC formula that could prompt further testing. As for the lymphocytes, yes, they are elevated, but their number is fluctuating, paralleling an inflammatory state.

In case there is spleen enlargement on USG, and you have enlarged lymph nodes, then further testing may be necessary to rule out chronic lymphocytic leukemia.

It is okay to be seen by a hematologist, who can review the differential manually and examine for the presence of enlarged spleen or liver, and then consider whether further and more sophisticated testing is warranted. But most probably your complaints are due to the presence of chronic gallbladder inflammation.

As for the H. pylori (Helicobacter pylori), a more informative test is the stool antigen test. Serology for H. pylori is often falsely positive, but the antigen test before and after the double antibiotic course is much more informative.

I would advise you to follow up with a gastroenterologist once again, and if alkaline phosphatase is elevated, to monitor WBC parameters and their resolution with appropriate treatment.

Investigations to be done include abdominal ultrasound, GGT (gamma-glutamyl transferase), and ALP (alkaline phosphatase).

I hope it helped.

Please let me know if I can assist you further.

Thank you.

Hello,

Welcome back to icliniq.com.

This is exactly what I meant. It is uncommon for hematological diseases to go without accompanying biological features like those mentioned. Therefore, the lack of those symptoms makes diagnosing CML (chronic myelocytic leukemia) or CLL (chronic lymphocytic leukemia) less suspicious.

Of course, a diagnosis is neither confirmed by the presence of those symptoms nor ruled out, but it certainly helps to look for another probable cause. For example, you describe a pain typical of pancreatic or gastric problems in the upper central area and radiating to the back.

If you had an enlarged spleen, you would have had left upper abdominal pain and early satiety. However, if it were related to the liver or gallbladder, it would have been on the right side, even though gallbladder pain can also irradiate the back.

ALP means alkaline phosphatase, which, in your case, is normal. It is a measure of bile excretion and is elevated in cases of blocked bile excretion, like in the case of gallstones. You should still perform an imaging study, such as an abdominal ultrasound.

It is very informative for the state of the gallbladder; it can confirm or rule out cholecystitis, and there is no radiation. However, it can yield less objective information about the state of the pancreas, but if there is a gross finding, USG (ultrasound) will detect it.

Otherwise, a CT (computed tomography) scan would be best to rule out a pancreatic problem. Laboratory tests indicative of pancreatic function are amylase and lipase. But imaging is crucial. Then again, since your complaints are GIT (gastrointestinal tract) related, an endoscopy is advisable because there is no other way to look for the presence of an ulcer, especially if your pain is provoked by food or gastric ulcer or starts 30 minutes after food intake, it may be a duodenal ulcer.

To summarize, I would suggest an approach involving imaging studies:

1. Ultrasound of the abdomen.
2. Endoscopy (by a biopsy of the stomach mucosa, an H. pylori (Helicobacter pylori) infection can be proven.
3. CT (computed tomography) scan of the abdomen if the previous two tests do not yield sufficient information. I hope that will be helpful.

Otherwise, looking for CML requires molecular testing for BCR-ABL (breakpoint cluster region-Abelson murine leukemia) fusion protein, and looking for CLL requires flow cytometry.

Both are highly specialized tests that would be recommended in case of heightened suspicion, which may not be advisable at this current level of information.

I hope this helps.

Thank you.

Hello,

Welcome back to icliniq.com.

The elevation of C-reactive protein is caused by inflammation in the body, consistent with the mentioned suspicion and parallel WBC (white blood cell) count increase.

As for the mucus, there seems to be no specific reason for it or relation to some of your complaints. But again, the characteristics of the pain you mention, even though unspecific at first sight, pinpoint a GIT (gastrointestinal tract) problem. Ask for an endoscopic investigation of both the upper and lower gastrointestinal tract. It is indicated in your case.

Of course, it will be okay to share the results. I will do my best to help you as long as it is in my area of expertise.

Thank you.

Hello,

Welcome back to icliniq.com.

Indeed even though it is uniformly reported that the upper limit of WBC (white blood cell) is 10.5 (attachment removed to protect the patient's identity), this is a generalization representative of 90 % of the population. Still, there a 5 % of people at both ends of normality, so to say, that will be with either slightly lower or elevated levels of any lab parameter tested. But, again, this is due to normal distribution patterns.

On the other hand, WBC is a measure of an inflammatory response. They are most often elevated in case of inflammation or infection, in which case other markers of inflammation are elevated as well. On the microscopic evaluation of a blood smear, one would see mostly mature neutrophils.

In the case of a myeloproliferative disorder such as CML (chronic myelocytic leukemia), there will be distinct morphologic features even at the relatively low amount of 14 WBC for that disease. That is why I mentioned that a simple microscopic review of the smear would give useful information. And again, a change in one lab parameter usually is representative of clinical features and goes hand in hand with it.

So, complaints and findings of general examination should guide the lab parameter interpretation, not vice versa. Therefore, there is insufficient evidence to focus on looking for a hematological disorder in your case. There is interlaboratory variation in reported results. So, yes, this is what standardization means - averaging different values.

Not quite a rate. There can be huge variations between laboratories, making it crucial to guide a search for a disease based on complaints rather than the laboratory. Your lymphocytes could be elevated like in a young adult who often comes in contact with various pathogens and whose immune system is activated.

Then, a gross spleen or liver enlargement should be detected on a general examination. If they are slightly enlarged, then a USG (ultrasound) will help to assess that. In your case, the GP (general physician) did not find any clinically evident enlargement, so that a USG scan can be further informative.

I hope this helps.

Thank you.

Hello,

Welcome back to icliniq.com.

Thank you for keeping me updated on your condition.

Based on the USG (ultrasound) findings (attachment removed to protect the patient's identity), it is confirmed that you have chronic cholecystitis, which is inflammation of the gallbladder lining. And that low-grade inflammation should be the reason for the elevated WBC (white blood cell) counts in your case.

Moreover, there is no further evidence to suspect a hematological disorder based on the lack of enlarged organs. The spleen and liver are normal, and no lymph nodes are present.

Consult a gastroenterologist for further evaluation and a treatment plan that consists of complex measures such as diet, physical activity, medication, or surgery.

I hope this helps.

Thank you.

Hi,

Welcome back to icliniq.com.

I understand your concern.

I have reviewed your current and previous results.

Indeed, leukocytosis (both neutrophils and lymphocytes) is at a plateau. Microcytosis (low MCV) is persistent, and there is a slight decrease in MCH (hemoglobin concentration), serum iron is decreased, and iron saturation is approaching a lower limit.

Up to now, I have considered latent iron deficiency. Even though TIBC is normal, this would be my primary suggestion. Secondly, what makes an impression is the presence of reticulocytosis - those are young red blood cells and a very slight elevation of red blood cells, as well as elevated MPV (mean volume of platelets).

Altogether, this can point to general reactivity of the bone marrow, i.e., the bone marrow is irritated and responds with increased cellular production. This can happen in the case of iron deficiency because the marrow is "hungry" for iron and strives to compensate for its deficiency through the overproduction of cells. The fact that hemoglobin is normal and TIBC is normal speaks in favor of latency.

Iron cannot be absorbed efficiently due to altered bile excretion after gall bladder removal. Second, I suggest testing for ferritin. You had one previously done, so there is a baseline to compare to. Thirdly, after reviewing your previous results, I seem to need help finding reticulocytes, which have been done before. Is this correct?

It is important to know whether they were elevated from before. Because the presence of gall bladder stones and reticulocytosis can point to a hemolytic syndrome, like hereditary hemolytic anemia, due to a defect of the red blood cell membrane, of course, the normal results of bilirubin and LDH, to a greater extent, rule out this idea.

Your bilirubin has been consistently normal. But I would recommend a manual review of a blood smear on a glass slide with attention to red blood cell morphology. This largely excludes a condition related to RBCs being abnormal in shape.

Lastly, this problem with mucous secretion, like nasal discharge, is as persistent as leukocytosis. Suppose you have complained of heaviness in the forehead, nose, or cheekbones, sometimes headache, and episodically a feeling of a "stuffed" nose. In that case, it seems plausible to think about chronic sinusitis. Again, a chronic infection causes inflammatory distress to white blood cells (an inflammatory state to which elevated ESR also points). In conclusion, I would recommend decreasing priority testing for:

1. Ferritin.
2. H. pylori stool antigen test to look for gastritis.
3. ENT consults.
4. A manual review of RBC morphology (unless already done).

I hope this helps.

Please feel free to reach out in case of further queries.

Thank you.