Biological and Clinical Sciences Research Journal
ISSN: 2708-2261
www.bcsrj.com
DOI: https://doi.org/10.47264/bcsrj0101034
Biol. Clin.
Sci. Res. J., Volume, 2020: e034
Case Study
UNUSUAL LEUKEMOID REACTION IN A COVID-19 PATIENT: A
CASE REPORT
TABASSUM SA1, BIBI T1, TARIQ F1,
TARIQ S1, RAZA S1, HAFEEZ MM1,2,
RANA MA1*
1Department
of Internal and Critical Care Medicine, Bahria
International Hospital, Lahore, Pakistan
2Institute
of Molecular Biology and Biotechnology, The University
of Lahore, Lahore, Pakistan
Corresponding author email: drasimrana@yahoo.com
Abstract: A leukemoid
reaction is a hematological disorder in which the White Blood Cells (WBCs)
count may rise more than 50,000 per micro liter (μL)
accompanied by an increase in Neutrophil precursors.
The incidence of this reaction is uncertain. This looks like blood cancer but
it is caused by reasons outside bone marrow like severe infections, drug
reactions, intoxication, ischemia, inflammation and stress. The WBCs count
falls back to normal once this cause is eradicated so we present an unusual
case of leukemoid reaction with very high WBCs in a
COVID19 patient to create awareness among physicians dealing with such cases.
Keywords: COVID
19, Corona virus, viral pneumonia, Leukemoid
reaction, Myelodysplastic syndrome
Case report results
A
76 year old, male patient with past medical history of hypertension (HTN) and
ischemic heart disease (IHD) presented in ER with complaints of shortness of
breath which had started an hour before his arrival, he also had dry cough for
2 days and intermittent fever for 7 days. His respiratory symptoms rapidly worsened
necessitating intubation and ventilation on same day. He was escalated to ICU
for elevated level of care. Upon investigations it was found that he was
positive for novel coronavirus disease COVID-19 and
his WBC count was elevated to 76.6 x 109/L with predominant neutrophils, normal platelets count and hemoglobin of
patient (Figure 1). His WBC count progressively increased and on 5th
day of admission the count had reached to 96.6 x 109/L (Table 1).
His peripheral blood smear revealed a picture consistent with leukemoid reaction with neutrophilic
leukocytosis with left shift and presence of myelocytes and metamyelocytes. The JAK 2 mutation was tested which was negative thus
ruling out myeloproliferative disorders. His
Leukocyte Alkaline Phosphate Score (LAP) score was 380 (Figure 2). It
was further revealed from his family member, he had a normal WBC count before
contracting the infection. Unfortunately, the patient expired on 5th
day of admission because of acute respiratory distress syndrome (ARDS) and
refractory respiratory failure and hence further investigations could not be
undertaken.
Discussion
A
leukemoid reaction is a hematological disorder, in
which leukocyte count may exceed 50,000 cells/μL,
precipitated by causes outside the bone marrow (Hunter Jr, 2007; Nimieri
et al., 2003; Padmakumar et al.,
2014; Potasman
and Grupper, 2013; Sakka et al., 2006). Although it resembles leukemia,
it is not cancer and the leukocyte count often comes back to normal when the
underlying cause is treated. There is a significant increase in early mature neutrophil precursors circulating in the peripheral blood
and a differential count revealing marked left shift. A Leukemoid
Reaction can be caused by severe infections, such as colitis due to Clostridium
difficile, disseminated tuberculosis, and severe shigellosis
(ul Haque and ul Aan, 2010). Few drugs can also precipitate a leukemoid reaction e.g., corticosteroids, minocycline, recombinant hematopoietic growth factors (Ganti et al., 2003). Intoxication secondary to ethylene glycol (Mycyk et al., 2002) can also cause leukemoid
reaction rarely. Other rare causes include mesenteric inflammatory pseudo tumor,
alcoholic steatohepatitis, and retroperitoneal
hemorrhage (Kutluk et al., 2002; Marinella,
1998; Morales
et al., 2006; Spahr et al., 2008). The diagnosis of leukemoid reaction is made by: (i)
a full blood count with a peripheral blood smear that shows marked mature neutrophilia with a left shift; (ii) a high leukocyte
alkaline phosphatase (LAP) score; (iii) increased cellularity of bone marrow with orderly maturation and
morphology of all the elements; (iv) no karyotypic
abnormalities on cytogenetic analysis; (v) Immunophenotyping
of peripheral blood and bone marrow; (vi) a high serum level of hemopoietic growth factors, in the case of a cytokine-producing
tumor; and (vii) a polyclonal pattern of blood neutrophils
in clonality studies (Fauci, 2020; Sakka
et al., 2006; Schniewind et al.,
2005).
Differential
Diagnoses:
1. Chronic
Myeloid Leukemia
2. Chronic
Neutrophilic Leukemia
The
novel corona virus disease 2019 (COVID-19) caused by a pathogen named severe
acute respiratory syndrome coronavirus 2
(SARS-CoV-2), emerged in Wuhan city of China in December 2019 (Fauci, 2020). Coronavirus
disease was declared a pandemic and it has created a public health emergency in
Pakistan and many other countries. With number of cases still being reported,
its spread is expected to continue. Before this pandemic, very little was known
about SARS-CoV-2 virus and its pathogenicity among
humans. Our knowledge of this novel corona virus is limited and progressively
evolving. The spectrum of disease, clinical manifestations, and pathophysiology associated with this disease will be further
explained with the ongoing research on the virus. Our aim with this clinical case
report is to present the unusual finding of Leukemoid
reaction in this patient with COVID-19 positive PCR. With unfortunate death of
our patient, we could not ascertain if the leukemoid
reaction was secondary to the infection caused by COVID-19, as further
investigations to differentiate it from myelodysplastic
syndromes could not be carried out.
Figure
1: Peripheral blood smear Figure
2: LAP score
Table
1.The sequential complete blood count
Date and time |
WBCs count |
Neutrophils |
Lymphocytes |
Monocytes |
Eosinophils |
Platelets |
Hemoglobin |
24/07/2020 8:16PM |
76.6 X 109/ L |
72% |
07% |
20% |
01% |
156 x 109/ L |
11.3 gm% |
25/07/2020 8:52PM |
72.5 X 109/ L |
78% |
06% |
15% |
01% |
133 x 109/ L |
11.0 gm% |
26/07/2020 4:57AM |
69.5 X 109/ L |
80% |
06% |
12% |
02% |
98 x 109/ L |
10.6 gm% |
27/07/2020 6:28AM |
79.6 X 109/ L |
83% |
06% |
10% |
01% |
91 x 109/ L |
10.7 gm% |
27/07/2020 2:10PM |
96.6 X 109/ L |
83% |
09% |
07% |
01% |
78 x 109/ L |
10.1 gm% |
Conflict
of interest
The
authors showed absence of conflict of interest for manuscript publication.
References
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