The Internist Approach to Lymphocytosis Approach to Lymphocytosis No anaemia Significant Anaemia...
Transcript of The Internist Approach to Lymphocytosis Approach to Lymphocytosis No anaemia Significant Anaemia...
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The Internist Approach to Lymphocytosis
Clin Assoc Prof P KuperanFRCP, FRCPA, FRCPath
Head & Senior ConsultantDept of Haematology
Tan Tock Seng Hospital
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Lymphocytes in the Blood
B cells
10 – 20%
NK cells
5 – 10%
T cells
60 – 80%
HelperT cells
60 – 70%
SuppressorT cells
30 – 40%
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Lymphocytes in the Blood
98%
2%
Blood Lymphoid TissueBoneMarrow
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Approach to Lymphocytosis
? Is there a lymphocytosis
RelativeLymphocytosis
AbsoluteLymphocytosis
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Total WBC/ l 8000 4000 10,000
% neutrophils 60% 20% 30%
% lymphocytes 30% 80% 70%
Absolute neutrophils l 4800 800 3000
Absolute lymphocytes l 2400 3200 7000
Case IICase INormalWBC
NeutropeniaBut No
Lymphocytosis
No NeutropeniaBut
Lymphocytosis
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Approach to Lymphocytosis
Absolute Lymphocytosis Present
Transient<24 hours
Acute Stress• Cardiac emergencies• Trauma• Status epilepticus• Stroke
Transient Lymphocytosisor
Sustained Lymphocytosis
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Approach to Lymphocytosis
Sustained Lymphocytosis
Benign Malignant
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Approach to Lymphocytosis
Benign Lymphocytosis
Infectious MononucleosisSyndrome
• Drug allergy• Serum sickness
InfectionOthersHypersensitivity
Syndrome
Primary EBV infection • Phenytoin• Allopurinol• Carbamezapine• Dapsone
Primary CMV infectionToxoplasma
Viral Hepatitis
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Approach to Lymphocytosis
60 years old male
WBC 9000/l
Neutrophils 2000/l
Lymphocytes 6000/l
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Cause for Lymphocytosis
Benign
Post splenectomy
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Approach to Lymphocytosis
History
Phsyical examination
LFT
LDH
WBCHBPlateletsDifferential
FBC
Examination of the Peripheral Blood Film
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Typical Infectious Mononucleosis
20 years old male
Fever, sore throat, malaise
Posterior cervical lymphadenopathy
Mild splenomegaly
WBC 18 x 109/L ALT 150 (15 – 41)HB 13.0 gm/dL AST 140 (17 – 63)Platelets 140 x 109/L Bilirubin 38 (7 – 31)Neutrophils 30% LDH 1500 (250 – 580)Lymphocytes 60%
PBF – Reactive lymphocytes present (>10%)
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Typical Infectious Mononucleosis
Leave him alone
Monitor for any complications
Monitor FBC/ LFT
May take 1 – 2 months to normalise
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Approach to Lymphocytosis
Malignant Lymphocytosis
Aggressive Indolent
Urgent Referral Non-urgent Referral
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Typical Chronic Lymphocytic Leukaemia
60 years old man
Admitted for routine surgery
WBC 60 x 109/L
HB 13 gm/dL
Platelets 230 x 109/L
Neutrophils 10%
Lymphocytes 80%
PBF – Typical Mature B cells
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Typical CLL
Not symptomatic
Non-urgent referral to haematologist
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Approach to Lymphocytosis
? InfectiousMononucleosis
Syndrome
? Malignant
• Age• Constitutional symptoms• Extent & size of lymphadenopathy/ hepatosplenomegaly• FBC• LFT / LDH• Peripheral blood film
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Approach to Lymphocytosis
15 – 30 years old
> 30 years old
Generalised lymphadenopathy
Posterior cervical lymphadenopathy
Mild splenomegaly
> Mild splenomegaly
Significant constitutionalsymptoms
Fever / malaise
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Approach to Lymphocytosis
No anaemia
Significant Anaemia
Lymphocytes > 20,000
Lymphocytes < 20,000
Leucoerythroblastic picture
No early cells
Moderate to severe thrombocytopenia
Mild thrombocytopenia
LDH
(mild)
ALT/ AST
(mild to moderate
LDH > 3000
ALT/ AST markedly increased
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Approach to Lymphocytosis
Only Mild Lymphocytosis
Benign Aggressive Lymphoma
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Not Typical Infectious Mononucleosis
EBV - IgM VCA / IgG VCA
CMV - IgM CMV
HIV - Anti HIV
Hepatitis
HBsAg
Anti HCV
Anti HAV
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Malignant Lymphocytosis
Aggressive Indolent
• Acute Lymphoid Leukaemia• Aggressive Lymphoma
• Chronic Lymphocytic Leukaemia
• Other Chronic Lymphoproliferative Disorder
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Malignant Lymphocytosis
Aggressive Indolent
Significant constitutional syndrome
Significant organomegaly
Anaemia/ thrombocytopenia/ neutropenia
LDH – markedly increased
No significant constitutional symptoms
WBC 9 x 109/L
80 x 109/L
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Approach to Lymphocytosis
Examination of the peripheral blood film by experienced staff
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Lymphocytosis
ClinicallyInfectiousMononucleosis
Syndrome
ClinicallyMalignant Lymphocytosis
Lymphocyte Subsets
Most of the lymphocytes are T-cell suppressor cells
(CD8+)
B cell malignant (common)CD19+)
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Lymphocytes in the Blood
B cells
10 – 20%
NK cells
5 – 10%
T cells
60 – 80%
HelperT cells
60 – 70%
SuppressorT cells
30 – 40%
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Lymphocytosis
Total WBC Absolute Lymphocytes
CD3 CD4 CD8 CD19
4000 – 10,000 1000 – 3500 600 – 2500 280 – 1430 165 – 1045 65 – 620
Norm
alCase I
19410,00099312,23013,40018,700 19410,00099312,23013,40018,700
52,8008001400220055,00060,000 52,8008001400220055,00060,000
Case II
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Approach to Lymphocytosis
Examination of the peripheral blood film
Immunophenotyping of lymphocytes
If Malignant Lymphocytosis is more likely
Morphology MolecularGenetics
FlowCytometry
Cytogenetics
Bone Marrow
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Approach to Lymphocytosis
When to refer to haematologists?
Not sure whether IMS?
? Malignant Lymphocytosis
Urgent Non-urgent
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Approach to Lymphocytosis
Is there absolute lymphocytosis?
Detailed history/ examination to exclude hypersensitivity syndrome/ post-spenectomy
? Infectious mononucleosis syndrome
EBV/ CMV/ HIV/ Hepatitis/ Toxoplasma
FBC/ LFT/ LDH/ PBF
Monitor clinical features
Monitor FBC/ LFT/ LDH
Summary
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Approach to Lymphocytosis
Summary
? Malignant Lymphocytosis
Haematologist is always there to help you!!
Aggressive Indolent
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Thank You
For Your
Kind Attention