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Leukocytosis

Article in International journal of laboratory hematology · June 2014

DOI: 10.1111/ijlh.12212

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 International Journal of Laboratory Hematology
The Official journal of the International Society for Laboratory Hematology

REVIEW INTERNAT IONAL JOURNAL OF LABORATO RY HEMATO LOGY

Leukocytosis
D. S. CHABOT-RICHARDS, T. I. GEORGE

Department of Pathology,
University of New Mexico,
Albuquerque, NM, USA
Correspondence:
Devon Chabot-Richards, Tricore
Reference Laboratories, Depart-
ment of Hematopathology, 1001
Woodward Pl NE, Albuquerque,
NM 87102, USA.
Tel.: +1 505 938-8456;
Fax: +1 505 938-8414;
E-mail: dchabot-richards@salud.
unm.edu
doi:10.1111/ijlh.12212
Received 17 January 2014;
accepted for publication 5 Feb-
ruary 2014
S U M M A RY
An increased white blood cell count, or leukocytosis, is a common
laboratory finding. Appropriate specimen evaluation depends on
which lineages are increased and the morphologic findings on
peripheral blood smear review to guide further testing. The pres-
ence of blasts is concerning for acute leukemia and may require
bone marrow biopsy. Lymphocytosis may be morphologically
divided into polymorphic and monomorphic populations. Polymor-
phic lymphocytosis is most consistent with a reactive process, while
monomorphic populations are concerning for lymphoproliferative
neoplasm. The differential can be further narrowed based on mor-
phologic findings. Myeloid leukocytosis can occur in a number of
reactive conditions as well as myeloid malignancies. The types of
cells present and morphology can help to guide additional workup.
This study provides guidance for the appropriate evaluation and
further workup of leukocytosis.

Keywords
Leukocytosis, lymphocytosis,
neutrophilia, morphology,
lymphoma

the highest WBC count and absolute neutrophil count

INTRODUCTION
Leukocytosis, defined as an increase in white blood
cell (WBC) count, is a common finding with a broad
differential diagnosis, encompassing both benign and
malignant entities. Careful evaluation of complete
blood cell count (CBC) data and morphologic features
are key steps necessary to characterize the nature of
the process and guide further workup.
Reference intervals for WBC counts and relative
percentages and absolute cell counts vary by patient
age and hospital population. Each hospital laboratory
must determine reference ranges during the validation
process of their hematology analyzers [1]. Total WBC
counts are higher in infants, with newborns having
of any age [2]. By 1–2 weeks of age through early
adolescence, lymphocytes become the predominant
WBC. This gradually shifts and neutrophils are the
predominant WBC in teenagers and adults [3]. Race is
also associated with differences in total WBC count
and differential, with individuals of black African des-
cent having lower absolute neutrophil counts [4].
Laboratories should determine automated CBC criteria
that trigger a peripheral blood smear review [5]. Com-
mon WBC flags include numeric flags such as overall
leukopenia or leukocytosis or abnormalities of the dif-
ferential counts, as well as morphologic criteria such
as immature granulocytes, atypical or variant lympho-
cytes, or blasts [5].

© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288 279
280 D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS
E X A M I N AT I O N O F T H E P E R I P H E R A L B L O O D
SMEAR
When appropriate CBC criteria are met, a peripheral
blood smear should be examined. Slides may be pre-
pared using anticoagulated blood or fresh specimen.
The smear may be made by an instrument or manually
by placing a drop of blood at one end of a slide and then
smearing it over the surface of the slide with a second
slide or a coverslip. After air drying, the slide is typically
stained with a Romanowsky stain [6]. The smear
should first be examined at low power to identify over-
all cellularity and types of cells. The findings should be
correlated with the automated CBC report. Large cells
or aggregates of cells or platelets are often deposited at
the edges of the smear. Assessment of WBC morphol-
ogy is most commonly carried out in the thin areas of
the slide, where cell crowding and over staining do not
interfere. Cells should be examined to determine the
appropriate classification, the level of maturity, the
morphology, and the presence of inclusions [7].
PRESENCE OF BLASTS
The leading differential in a peripheral blood smear
with blasts is acute leukemia; however, other condi-
tions may be associated with circulating blasts. While
blast counts of >20% are diagnostic for acute leuke-
mia, a lower blast count in the peripheral blood does
not exclude acute leukemia [8]. Acute leukemias are
often associated with bone marrow failure and are
accompanied by anemia, neutropenia, and thrombo-
cytopenia, in addition to leukocytosis with circulating
blasts. Clinical history is important to evaluate for
progression of a previously diagnosed chronic disorder
such as chronic myelogenous leukemia.
The first step in evaluating blast cells is to examine
for lineage-specific features. It is important to realize
that there is considerable morphologic overlap
between lymphoblasts and myeloblasts and that mor-
phology alone may not be definitive. Lymphoblasts
show a range of appearances, from small- to interme-
diate-sized cells with scant cytoplasm and condensed
nuclear chromatin to larger cells with moderate blue
or blue gray cytoplasm and dispersed chromatin with
prominent nucleoli. The nuclei may be smooth and
round or irregular and convoluted. There may be
cytoplasmic vacuoles or, rarely, granules. Although
there is a considerable range of morphology, myelo-
blasts tend to be larger, with more abundant cyto-
plasm. Blasts with minimal differentiation may have a
similar appearance to lymphoblasts. The presence of
Auer rods and cytoplasmic granules strongly suggests
myeloid differentiation; however, lymphoblasts may
occasionally contain azurophilic granules [9]. Cyto-
chemical stains can be helpful to confirm lineage,
with myeloperoxidase staining granules in myeloblasts
and nonspecific esterase staining cells with monocytic
differentiation. Subtypes of acute myeloid leukemia
are associated with specific morphologic findings.
Most importantly, acute promyelocytic leukemia with
t(15;17) (APL) is associated with hypergranular cells
with coalescing granules and Auer rods, with cells
containing multiple Auer rods highly specific for APL.
The nuclei are often folded, bilobed, or kidney-
shaped. The hypogranular variant shows similar
nuclear features with agranular cytoplasm. APL may
be associated with schistocytes due to disseminated
intravascular coagulation (Figure 1).
Lower circulating blast counts may be seen in
chronic myeloid neoplasms, including myelodysplastic
syndromes (MDS), myeloproliferative neoplasms
(MPN), and overlap MDS/MPN. MDS with excess
blasts may have up to 19% circulating blasts. The
blasts in MDS are associated with cytopenias and dys-
plasia; blasts in MDS may be smaller in size with less
differentiation compared with typical myeloblasts.
Patients with MPN generally have <10% blasts and
increased cell counts in one or more myeloid lineage.
Ten to nineteen percent blasts are seen in the acceler-
ated phase of MPNs. Patients with MDS/MPN syn-
dromes have dysplasia and a combination of increased
and decreased cell counts in different lineages.
Circulating blasts can be seen in the absence of he-
matologic malignancy. Iatrogenic or endogenous excess
granulocyte colony-stimulating factor (G-CSF) stimula-
tion can cause a left shift of the myeloid lineage to the
blast stage [10]. Bone marrow damage or infiltration
by fibrosis, malignancy, or infection can be associated
with circulating immature cells (leukoerythroblastosis),
including blasts and nucleated red blood cells.
LY M P H O C Y TO S I S
In the patient with an increased lymphocyte count,
the differential diagnosis depends on patient age,
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288
 D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS 281

(a) (b)

(c) (d)

(e) (f)
Figure 1. Myeloblasts. (a) Large
blasts with irregular nuclei,
prominent nucleoli, and
moderate cytoplasm. (b)
Myeloblast with cytoplasmic
Auer rod. (c) Monoblasts with
abundant blue cytoplasm. (d)
Cytoplasmic nonspecific esterase
positivity in monoblasts. (e)
Acute promyelocytic leukemia
(APL) showing multiple Auer
rods. (f) Bright myeloperoxidase
staining in APL.

clinical history, and morphologic findings. Absolute
lymphocyte counts are higher in children, and pedi-
atric lymphocytosis is most commonly benign.
Benign causes of lymphocytosis commonly include
infection, particularly viral, autoimmune disorders,
transient stress, and polyclonal B-cell lymphocytosis.
Lymphocytosis in adults requires a diligent workup
to exclude a neoplastic process. Lymphocytes are
fragile, and both clonal and reactive lymphocytes
may appear as smudge cells on peripheral blood
smear. Albumin preparations preserve lymphocytes
to allow morphologic examination when many
smudge cells are present in the initial blood smear
[11] (Figure 2).

© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288
282 D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS

Lymphocytosis
Monomorphic Pleomorphic

Suspect Neoplastic Suspect Reactive

Differenal Diagnosis Ancillary Tests

PBL
CLL Flow cytometry
Burkitt
Small, round nuclei MBL MCL FISH
T-PLL

FL Flow cytometry
T-cell
MCL FISH CCND1, BCL2
Folded or cleaved nuclei Pertussis*
Atypical CLL Tissue biopsy

Sezary syndrome Flow cytometry

Convoluted nuclei Adult T-cell leukemia T-cell clonality
Figure 2. Diagnostic algorithm for
HCL
T-PLL the workup of lymphocytosis.
SMZL Flow cytometry
Villous cytoplasm
HCLV
LPL Pleomorphic lymphocytosis
favors a reactive etiology.
LPL Correlation with clinical and
Flow cytometry
Plasmacytoid Plasma cell myeloma laboratory testing is required.
SPEP/UPEP
Plasma cell leukemia
Monomorphic lymphocytes are
Flow cytometry concerning for a neoplastic
T-LGL
Granules
NK cell leukemia
T-cell clonality process, and further workup
KIR profile
including flow cytometric
T-PLL immunophenotyping and
B-PLL Flow cytometry appropriate ancillary testing is
Prominent nucleoli
HCLV Cytogenetics
MCL required. *Pertussis infection is a
Burkitt Leukemia reactive cause of monomorphic
Large cells DLBCL Flow cytometry lymphocytosis, most often seen
MCL FISH MYC
in pediatric populations.
ALCL

Pleomorphic lymphocytosis with activated morphol-

LY M P H O C Y TO S I S W I T H P L E O M O R P H I C
MORPHOLOGY
Pleomorphic lymphocytosis is most commonly associ-
ated with a reactive process. Reactive lymphocytoses
rarely exceed 30 9 109/L and show a range of lympho-
cyte size and shapes, often best appreciated at low
power [12]. The nuclei show mature chromatin and
inconspicuous nucleoli. Many cells are large with abun-
dant clear to light blue cytoplasm with a basophilic rim.
The cytoplasm may partially wrap around adjacent red
blood cells. There may be large granular lymphocytes
(LGLs) with azurophilic cytoplasmic granules. Immu-
noblasts and plasma cells may also be present. These
cells are large with deeply basophilic cytoplasm, and
round to oval nuclei, and prominent nucleoli.
ogy is most commonly associated with viral infection.
Epstein–Barr virus, or infectious mononucleosis, is the
classic example, but other causes include CMV, influ-
enza, adenovirus, and HIV. Some bacterial or parasitic
infections may be associated with pleomorphic lympho-
cytosis. Noninfectious causes include medication, stress,
trauma, vaccination, postsplenectomy, hypersensitivity
reaction, smoking, and autoimmune disease [6].
LY M P H O C Y TO S I S W I T H M O N O M O R P H I C
MORPHOLOGY
Monomorphic lymphocytoses are much more con-
cerning for lymphoproliferative neoplasm; however,
there are some reactive processes associated with a

© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288

homogenous appearance. It is important to distinguish
a monomorphic population of neoplastic lymphocytes
in a background of normal lymphocytes from a
polymorphic lymphocytosis.
Monomorphic lymphocytosis with small cells with small,
round nuclei
Chronic lymphocytic leukemia (CLL) is the most com-
mon leukemia in adults. The incidence increases with
age, and it is important to consider the diagnosis
when evaluating lymphocytosis in an older adult.
Flow cytometric analysis shows B-lymphocytes with
aberrant expression of CD5 and weak surface immu-
noglobulin. Typical lymphocytes in CLL are round
and small, with condensed, clumped nuclear chroma-
tin and scant cytoplasm. Nucleoli are inconspicuous.
Cases with atypical morphology can show a range of
morphology including cleaved nuclei and larger cells,
with up to 55% prolymphocytes. Prolymphocytes are
large cells with abundant cytoplasm and a round, cen-
tral nucleus with a single prominent nucleolus. The
diagnosis of CLL can only be made when ≥5 9 109/L
monoclonal lymphocytes are present. Lower numbers
of neoplastic cells should be diagnosed as monoclonal
B-lymphocytosis, a proliferation of clonal B-lym-
phocytes found in 7% of healthy subjects that may
progress to CLL in a small fraction of patients [13].
Other disorders can occasionally present with lym-
phocytosis with small cells with round nuclei. Poly-
clonal B-lymphocytosis may present in this fashion;
however, it is more typically associated with nuclear
irregularities and binucleated forms. Burkitt cells are
more often moderate or large in size and have moderate,
deeply basophilic cytoplasm with small vacuoles. Man-
tle cell lymphoma (MCL) cells usually have irregular or
folded nuclei and may include large cells with blastic
features. The neoplastic cells in T-prolymphocytic leu-
kemia (T-PLL) are usually larger prolymphocytes; how-
ever, small cells with condensed chromatin can be seen.
Monomorphic lymphocytosis with folded or cleaved
nuclei
There are a number of benign and malignant causes
of lymphocytosis with folded or cleaved nuclei.
Although infectious causes of lymphocytosis are most
commonly associated with a polymorphic appearance,
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288
D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS 283
Bordetella pertussis is an important exception. Bordetel-
la infection is associated with severe, paroxysmal
coughing, or whooping cough, most often seen in
children. The bacteria produce a toxin which results
in a characteristic severe, monomorphic lymphocytosis
characterized by small, mature cells with deeply
cleaved nuclei [14]. Patient age and clinical presenta-
tion are important in making this diagnosis.
Another benign cause of lymphocytosis with deeply
cleaved or binucleated cells is polyclonal B-lymphocy-
tosis. This is a benign condition seen in young to
middle-aged female smokers and associated with HLA-
DR7 [15]. The lymphocytosis is typically moderate
with approximately 10% binucleated forms [16].
Although follicular lymphoma only rarely involves
the peripheral blood, it is associated with a characteris-
tic appearance with small to intermediate cells with
folded, convoluted nuclei and scant cytoplasm.
Occasional large cells may be present [17]. The neo-
plastic cells are monoclonal B-cells, which often
express CD10. FISH analysis showing rearrangement
of BCL2 can be helpful.
Although mantle cell lymphoma is primarily lymph
node based, it involves the peripheral blood in almost
50% of cases [18]. Circulating MCL cells often vary in
size and shape, but the typical cell is large with a folded
or indented nucleus and variably prominent nucleolus.
Blastic variants are large with fine chromatin and promi-
nent nucleoli; however, they also often have indented
nuclei. Flow cytometry reveals a monoclonal B-cell pop-
ulation with expression of CD5. FISH analysis demon-
strating IGH-CCND1 can help confirm the diagnosis.
Atypical CLL may show predominantly cleaved
cells and must be distinguished from MCL when a
CD5+ monoclonal B-cell population is identified in
the peripheral blood. T-cell prolymphocytic leukemia
can occasionally show nuclear irregularity, but the
prolymphocytic form usually predominates.
Circulating mature T-cell leukemias and lympho-
mas often show irregular nuclei; however, they are
more typically highly convoluted or cerebriform in
appearance.
Monomorphic lymphocytosis with highly convoluted or
cerebriform nuclei
Highly convoluted or cerebriform nuclei are most
commonly associated with mature T-cell leukemias.
284 D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS
Peripheral blood involvement by mycosis fungo-
ides (MF) or Sezary syndrome (SS) features medium
to large lymphocytes with characteristic dark, cere-
briform nuclei. The neoplastic cells are most often
CD4-positive T-cells with loss of CD7. T-cell clonality
studies can be helpful. While the peripheral blood
features overlap, the distinction between MF and
SS is made based on the clinical course. In SS,
erythroderma and lymphadenopathy with blood
involvement are present at diagnosis, while MF does
not exhibit peripheral blood involvement at presen-
tation [19].
Adult T-cell leukemia is an aggressive disease
caused by chronic infection with human T-cell leuke-
mia virus (HTLV)-1. Only a small percentage of those
infected with the virus develop leukemia. Patients
often show systemic manifestations, including skin
rash, hypercalcemia, and lytic bone lesions. The
peripheral blood smear shows a severe lymphocytosis
with highly irregular nuclei. Cytopenias are common;
however, there may be eosinophilia. The neoplastic
cells are typically CD4-positive T-cells with expression
of CD25 and loss of CD7.
Monomorphic lymphocytosis with villous cytoplasm
Hairy cell leukemia (HCL) and splenic marginal zone
lymphoma (SMZL) often show peripheral blood
involvement with villous lymphocytes with associated
splenomegaly. In HCL, there is typically pancytopenia
with monocytopenia. The lymphocyte count may be
low or normal, and circulating neoplastic ‘hairy cells’
are rare. These cells show abundant cytoplasm with
circumferential spiky projections. The nuclei are
round or kidney-bean-shaped. Flow cytometry in clas-
sic HCL shows a monoclonal B-cell population with
bright CD20, CD11c, CD22, CD25, and CD103.
In contrast, in SMZL, the lymphocytes show bipo-
lar projections, and the nuclei are usually round.
CD25 may be positive, but CD103 is typically negative
and CD22 is usually dim. Hairy cell leukemia variant
(HCLV) is an uncommon entity with neoplastic cells
appearing similar to HCL; however, the lymphocyte
count is usually much higher, and cells may be larger
with prominent nucleoli. HCLV is positive for CD103,
and only rare cases are positive for CD25.
Rarely, the neoplastic lymphocytes in T-PLL and
plasma cell leukemia may show cytoplasmic projec-
tions or cytoplasmic blebbing; however, the more
typical forms usually predominate.
Monomorphic lymphocytosis with plasmacytoid
lymphocytes or plasma cells
Lymphoplasmacytic lymphoma is typically a tissue-
based disease; however, in 10% of cases, it may
involve the peripheral blood with circulating plasma-
cytoid lymphocytes and occasional plasma cells [18].
The red blood cells may show rouleaux formation.
Flow cytometry shows a CD5-negative, CD10-negative
monoclonal B-cell and plasma cell populations.
Small numbers of circulating plasma cells can
rarely be seen with plasma cell myeloma. If plasma
cells account for >20% of WBCs, a diagnosis of plasma
cell leukemia should be made. The circulating
plasma cells in plasma cell leukemia may be smaller
with less cytoplasm and may be difficult to distinguish
from plasmacytoid lymphocytes.
Monomorphic lymphocytosis with large granular
lymphocytes
Large granular lymphocytes are a subset of T-cells
expressing CD3, CD8, and CD57. Natural killer (NK)
cells can also have a similar appearance. These cells are
surface CD3 negative and express cytoplasmic CD3,
weak CD56, CD2, TIA-1, and granzyme. Lymphocytosis
with a dominant population of LGLs can be seen in
reactive disorders, most commonly autoimmune dis-
ease, viral infection, other malignancy, chemotherapy,
and following bone marrow transplantation [20]. It can
be difficult to distinguish these reactive processes from
T-cell large granular lymphocytic leukemia or chronic
lymphoproliferative neoplasm of NK cells. Clinical and
laboratory workup is necessary to exclude infection
and autoimmune disease. A positive T-cell receptor
gene rearrangement test can be helpful; however, some
reactive processes will show a pseudo clone. Demon-
stration of a clonal NK population requires demonstra-
tion of a restricted KIR expression profile [21].
Monomorphic lymphocytosis with prominent nucleoli
Both B-Cell Prolymphocytic Leukemia (B-PLL) and T-
PLL present with a rapidly increasing, striking lympho-
cytosis primarily composed of large cells with a central
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288

round nucleus, abundant blue cytoplasm, and a single
prominent nucleolus. The morphologic appearance of
T-PLL is more variable than B-PLL. T-PLL is an aggres-
sive disease. Patients often present with systemic symp-
toms, including abdominal distention, skin rash,
organomegaly, and lymphadenopathy. The neoplastic
cells can show a range of morphology including small
cells with condensed chromatin and cells with cyto-
plasmic projections.
B-Cell Prolymphocytic Leukemia is a very rare dis-
ease which should only be diagnosed when a prol-
ymphocytic transformation of CLL can be excluded.
The clinical course is generally extremely aggressive.
B-PLL requires >55% prolymphocytes at diagnosis. If
the percentage is lower and typical CLL cells are pres-
ent, a diagnosis of prolymphocytic transformation of
CLL is preferred.
Occasionally, HCLV will present with a cells show-
ing prominent nucleoli; however, the characteristic
cytoplasmic villi are usually also present. Mantle cell
lymphoma can also present with circulating lym-
phoma cells that mimic prolymphocytes.
Monomorphic lymphocytosis with large cells
Burkitt lymphoma/leukemia (BL) is the most common
cause of circulating large lymphocytes. BL is an
aggressive disease that is most commonly nodal based.
If >25% of bone marrow is involved, the process is
classified as leukemia. BL generally shows intermedi-
ate to large cells with deeply basophilic cytoplasm,
often with vacuoles. The nuclei are oval to round
with multiple nucleoli. Diffuse large B-cell lymphoma
and B-cell lymphoma with features intermediate
between BL and DLBCL can also show circulating
neoplastic cells. Very rarely, anaplastic large cell lym-
phoma may have circulating lymphoma cells. These
cells typically have irregular nuclei. Circulating lym-
phocytes in MCL may be large; these cells usually
have irregular nuclei and blastic appearing chromatin.
M Y E L O I D L E U KO C Y TO S I S
Myeloid leukocytoses are elevations of neutrophils, eo-
sinophils, basophils, or monocytes. Causes vary by the
type of cell increased, but include infection, medica-
tion, autoimmune disorders, metabolic disorders, and
other reactive states as well as clonal myeloid neo-
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288
D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS 285
plasms. Patient history and clinical findings are neces-
sary to ensure appropriate classification (Figure 3).
Neutrophilia
Neutrophils are the most abundant leukocyte and play
a key role in immune defense from bacterial infec-
tions. These cells are short-lived, and the bone mar-
row production rate is astronomical, with an
additional reserve pool of cells available. Typically,
only the mature, polymorphonuclear forms are pres-
ent in the peripheral blood, with 5–10% band forms.
Immature granulocytes or ‘left-shifted’ forms can be
seen in both reactive and neoplastic conditions. It
should be noted that the ‘band count’ is not reproduc-
ible and its use is not recommended [22].
Reactive neutrophilias can be seen with infection,
particularly bacterial, inflammation, drugs (particularly
steroids, epinephrine, and lithium), colony-stimulating
factors such as G-CSF, metabolic disorders, trauma,
stress, pregnancy, other malignancy, and smoking [17].
Reactive neutrophilias are associated with activated
changes, including toxic granulation, vacuoles, and Do-
hle bodies. The other lineages are generally unremark-
able; however, monocytes may also show toxic changes.
There can be significant morphologic overlap
between reactive neutrophilias and MPN and MDS/
MPN. Chronic myelogenous leukemia (CML) is often
associated with a very high WBC count. There is gen-
erally a pronounced left shift with increased myelo-
cytes. Toxic changes are typically absent. An associated
basophilia and eosinophilia are usually present.
Definitive diagnosis of CML requires demonstration of
the BCR-ABL1 translocation by cytogenetics, FISH, or
molecular genetic methods. Chronic neutrophilic leu-
kemia (CNL) is a myeloproliferative neoplasm charac-
terized by a mature neutrophilia accounting for >80%
of WBC with limited left shift. Definitive diagnosis can
be difficult, as a reactive process must be excluded.
Recent identification of an oncogenic mutation in
CSF3R in CNL may aid in diagnosis [23]. Other MPNs
may show neutrophilia, particularly as a part of a leu-
koerythroblastic picture due to underlying bone mar-
row fibrosis. Dacrocytes (tear-drop shaped red blood
cells) may be present in this case. Atypical chronic
myeloid leukemia (aCML) is a MDS/MPN with neutro-
philia and left shift. There are prominent dysplastic
changes with nuclear hypolobation or bizarrely
286 D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS

Myeloid Leukocytosis
Neutrophilia

Features supporting neoplastic Features supporting reactive

9 9
WBC >50 x 10 /L WBC <50 x 10 /L
Pronounced left shift Predominantly mature
Basophilia or Eosinophilia Toxic granulation and vacuoles
Dacrocytes Döhle bodies
Dysplasia Thrombocytosis

Monocytosis
Features supporting neoplastic Features supporting reactive

Persistent Transient
Promonocytes and blasts Predominantly mature
Dysplasia Reactive changes

Eosinophilia
Features supporting neoplastic Features supporting reactive
Figure 3. Diagnostic algorithm for
Persistent
myeloid leukocytosis. Most
Transient
Immature cells present Clinical presence of drugs, allergy or infection myeloid leukocytoses are
Cytopenias and dysplasia in other lineages
reactive. If there is concern for a
neoplastic process, further
Basophilia
workup including bone marrow
Features supporting neoplastic Features supporting reactive
biopsy and appropriate ancillary
Other lineage abnormalities Rare
testing is required.

segmented nuclei, abnormal chromatin clumping, and
hypogranularity. There may also be dysplasia in red
blood cells and platelets. A subset of aCML has been
associated with CSF3R mutations.
Eosinophilia
Eosinophilia is most often reactive in nature. The
most common causes are infection, particularly para-
sitic, hypersensitivity reaction, connective tissue dis-
ease, and other malignancy, particularly Hodgkin
lymphoma and T-cell lymphoproliferative disorders.
Pulmonary disease, cardiac disease, gastrointestinal
disease, and adrenal insufficiency can also cause
eosinophilia. Reactive eosinophilia is typically tran-
sient; however, depending on the cause, some may be
chronic. Chronic eosinophilia can lead to systemic
symptoms due to eosinophil degranulation, including
cardiovascular symptoms with cardiac fibrosis.
When reactive causes have been excluded, a clonal
process may be considered. The WHO classification sys-
tem recognizes a category of myeloid and lymphoid
neoplasms with eosinophilia and abnormalities of PDG-
FRA, PDGFRB, and FGFR1. Cytogenetics can detect

© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288

abnormalities of PDGFRB and FGFR1; however, the
common FIP1L1-PDGFRA fusion is cryptic and requires
FISH or molecular studies for identification [24].
Chronic eosinophilic leukemia is a rare MPN character-
ized by eosinophilia with either >2% blasts in the blood,
>5% blasts in the bone marrow, or a clonal cytogenetic
or molecular genetic abnormality. A reactive cause must
be excluded. If there is no increase in blasts and a clonal
abnormality cannot be identified, the process may be
classified as idiopathic hypereosinophilic syndrome if
eosinophil-related tissue damage is present or idiopathic
hypereosinophilia if no damage is identified [25].
Basophilia
Isolated basophilia is extremely uncommon. Reactive
basophilia has been linked to hypersensitivity disor-
ders, iron deficiency, chronic inflammation, and rarely
infection, including influenza and chicken pox [26].
As reactive causes are rare, a finding of basophilia
should prompt further workup to exclude a myelopro-
liferative neoplasm such as CML.
Monocytosis
Reactive monocytosis is associated with chronic infec-
tion, autoimmune disease, splenectomy, and a range
of malignancies, including carcinoma, lymphoma, and
plasma cell myeloma. It can also be seen with neutro-
penia and in regenerating bone marrow following
bone marrow transplant or chemotherapy. If monocy-
tosis is persistent and reactive causes are excluded,
the differential diagnosis includes chronic myelomon-
ocytic leukemia (CMML), acute myelomonocytic leu-
kemia (AMML), CML, juvenile myelomonocytic
leukemia (JMML), atypical CML, and MDS/MPN-
unclassifiable.
Chronic myelomonocytic leukemia is most com-
monly seen in older adults and is associated with a per-
sistent monocytosis with dysplasia in one or more
myeloid lineage. There may be increased blasts, with
promonocytes counted as blast equivalents. Although
immunophenotypic abnormalities may be seen in reac-
© 2014 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2014, 36, 279–288
D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS 287
tive monocytosis, flow cytometric identification of aber-
rant expression of two or more antigens on monocytes
is correlated with CMML [27]. Identification of a clonal
abnormality is helpful to confirm the diagnosis. Bone
marrow evaluation should be performed as AMML may
present with mature monocytosis in the peripheral
blood while immature forms predominate in the mar-
row. JMML is a rare disease seen in children with persis-
tent monocytosis with marked hepatosplenomegaly and
increased hemoglobin F. There is often left shift of the
granulocytes, and dysplasia is minimal.
CONCLUSION
Accurate classification and diagnosis of leukocytosis
require confirmation of automated differential counts
and examination of the peripheral blood smear.
Increased blasts should prompt a workup for acute leu-
kemia, including flow cytometric immunophenotyping
and bone marrow examination with cytogenetic and
molecular genetic tests. In cases with lymphocytosis, a
pleomorphic population of lymphocytes favors a reac-
tive process. Cases with very high lymphocyte counts
or homogenous morphology should be evaluated for a
lymphoproliferative disorder. Flow cytometric immu-
nophenotyping can be helpful as an initial ancillary
test following morphologic review to prove clonality
and guide additional cytogenetic and molecular tests.
Myeloid proliferations can be more difficult to classify.
Correlation with clinical presentation and persistence
of abnormalities can be helpful. Features such as dys-
plasia, basophilia, prominent left shift, increased blasts,
and a very high WBC count (>50 9 109/L) favor a
malignant process. Activated features such as toxic
granulation, vacuolization, and Dohle bodies favor a
reactive etiology. Flow cytometric immunophenotyp-
ing is often less helpful in myeloid disorders, but may
demonstrate an aberrant phenotype or abnormal mat-
uration pattern. A combination of CBC data, clinical
and laboratory findings, and morphologic evaluation is
needed to guide further testing and appropriately clas-
sify patients with leukocytosis.
 288 D. S. CHABOT-RICHARDS AND T. I. GEORGE | LEUKOCYTOSIS
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