Journal of Intensive Care Medicine

1-7
Cytomorphometric Neutrophil and ª The Author(s) 2016
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Monocyte Markers May Strengthen DOI: 10.1177/0885066616682940
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the Diagnosis of Sepsis

Joy Mammen, MD1, Jui Choudhuri, MD1, Joshua Paul, BSc1,

Thomas Isaiah Sudarsan, MD, IDCC2, T. Josephine, DMLT1,
Gowri Mahasampath, MSc3, Vishali Jeyaseelan, MSc, PhD3,
Sukesh C. Nair, MD1, and John Victor Peter, MD, FRACP, FCICM2

Abstract
Background: The diagnosis of sepsis is challenging in the absence of a gold standard test. Recent studies have explored the role
of neutrophil and monocyte volume, conductivity, and scatter (VCS), derived from automated hematology analyzers, in diagnosing
sepsis. We assessed the diagnostic accuracy of VCS parameters in critically ill patients with sepsis. Methodology: In this pro-
spective study, VCS parameters, procalcitonin, and C-reactive protein (CRP) were assessed in patients with proven sepsis (cases)
and 2 control groups (intensive care unit [ICU] patients without sepsis and healthy blood donors). The diagnostic property of
each test was explored by calculating sensitivity, specificity, negative and positive predictive values, and area under the curve
(AUC). Results: The study included 65 patients with sepsis, 58 nonseptic ICU controls, and 98 blood donors. Procalcitonin and
CRP were not significantly different (P > .06) between patients with sepsis and nonseptic patients. Mean (95% confidence interval
[CI]) neutrophil volume (MNV) was significantly higher (P < .001) in patients with sepsis (165.5; 95%CI 161.6-169.4) than in
nonseptic (157.3; 95%CI 154.6-160.1) patients and donors (148.9; 95%CI 147.9-150). A similar pattern was seen with mean
monocyte volume (MMoV). Neutrophil and monocyte conductivity and scatter parameters were variably associated. The AUC
was highest for MMoV (0.74) and lowest for CRP (0.62). Among all parameters, MNV and MMoV had the highest specificity of 85%
and 80%, respectively. Conclusion: In critically ill patients with suspected sepsis, VCS parameters may help strengthen the
diagnostic probability of sepsis. Future studies may explore the role of serial monitoring of VCS to track response to
antimicrobial therapy.

Keywords
sepsis, neutrophils, morphology, impedance, inflammation, VCS, cytomorphometry

Introduction importance. Such biomarkers should also be evaluated against

Sepsis is a leading cause of death in critically ill patients,
particularly in the elderly individuals.1 The diagnosis of sepsis
is challenging as symptoms and signs may be nonspecific.2
Early diagnosis is crucial for prompt initiation of antibiotic
therapy and supportive treatment.3,4 Several biomarkers have
been explored as diagnostic tests in sepsis and include
C-reactive protein (CRP), procalcitonin (PCT), cytokines,
acute-phase reactants, cell-surface biomarkers, and coagulation
markers.5-7 The diagnostic accuracy of these tests has been
disappointing. Although some studies have suggested that PCT
has higher diagnostic accuracy than CRP,7 the role of PCT in
diagnosing sepsis has been challenged.8 The problem is com-
pounded by the lack of a gold standard test for sepsis diagnosis.
While a positive microbial culture strongly suggests infection,
results can be negative due to prior antimicrobial therapy. In
this context, the search for reliable biomarkers assumes
a combination of clinical and laboratory parameters and sever-
ity of illness assessment such as Sequential Organ Failure
Assessment (SOFA) score,9,10 which has been shown to be
prognostic in severe sepsis.11
1
Department of Transfusion Medicine and Immunohaematology, Christian
Medical College, Vellore, Tamil Nadu, India
2
Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu,
India
3
Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu,
India
Corresponding Author:
Joy Mammen, Department of Transfusion Medicine and Immunohaematology,
Christian Medical College Hospital, Vellore 632 004, Tamil Nadu, India.
Email: joymammen@cmcvellore.ac.in
2 Journal of Intensive Care Medicine
Peripheral blood count is commonly used in evaluating sep-
sis. Many centers presently use automated hematology analy-
zers. Other than conventional parameters such as leukocyte
count and immature granulocyte count, some of these auto-
mated machines provide quantitative information on cellular
details of monocyte and neutrophil mainly its volume, content
(conductivity), and granularity (scatter; VCS) parameters.
Since the morphology and characteristics of white cells change
in sepsis, these may be novel biomarkers. Preliminary studies
showed that mean neutrophil volume (MNV) may help diag-
nose and predict treatment efficacy in neonatal sepsis.12 In
some studies, volume parameters performed better than con-
ductivity and scatter.13-15 Other studies suggested that changes
in VCS parameters may occur earlier than biochemical changes
and could help in early diagnosis of sepsis.16,17 The aim of this
study was to assess if specific neutrophil and monocyte para-
meters help strengthen the diagnosis of sepsis in adults. In
addition, these parameters were compared to conventional bio-
chemical markers.
Patients and Methods
This study was conducted over a 1-year period in the med-
ical intensive care unit (ICU) of a tertiary care teaching
hospital. Cases comprised patients admitted with clinical
features consistent with probable or proven sepsis; sepsis
source was identified by history and clinical examination
and corroborated with culture of blood, urine, sputum, or
cavity fluids. Sepsis was diagnosed based on criteria out-
lined in the Surviving Sepsis guidelines.4 Patients with
hematological problems (eg, leukemia, lymphoma, and post-
transplant) were excluded. Two control arms were included
(1) nonseptic ICU controls and (2) healthy blood donors.
Patients were recruited within 24 hours of suspicion of sep-
sis. Blood samples were drawn at the time of suspicion of
sepsis along with blood cultures and other appropriate cul-
tures and biomarkers per the protocol followed in the unit.
This study was a single-point estimation of VCS parameters
at the time of recruitment. Serial estimations were not
undertaken. In nonseptic ICU controls, patients were
recruited at the time of recruitment of cases, and the VCS
samples were drawn within 24 hours of recruitment.
A diagnosis of community-acquired pneumonia was made if
a patient presented with cough, with or without expectoration,
shortness of breath, or pleuritic chest pain with at least 1 sys-
temic symptom (namely, fever, chills and rigors, and malaise)
and new focal chest signs on clinical examination and no other
explanation for the illness.18 Hospital-acquired pneumonia was
diagnosed18 if there were new chest radiographic opacities and
2 of the following (namely, fever, leukocytosis or leukopenia,
new-onset purulent sputum or change in sputum character,
worsening gas exchange, new-onset or worsening cough or
dyspnea or altered mental status in the elderly individuals, and
no other cause identified). Skin and soft tissue infections (eg,
cellulitis and necrotizing fasciitis) that presented with organ
dysfunction and needing intensive care were diagnosed and
managed per current guidelines.19 An acute central nervous
system (CNS) infection was diagnosed20 if a patient presented
with 2 of the following symptoms (namely, fever, headache,
dizziness, localizing neurological signs, and changing level of
consciousness or confusion) and one of the following (organ-
ism identified on microscopic examination of cerebrospinal
fluid, brain tissue, abscess, or imaging suggestive of acute CNS
infection or diagnostic antibodies for an organism). Urinary
tract infections (UTIs) and catheter-associated UTI were diag-
nosed based on Centre for Disease Control criteria.21 Catheter-
related bloodstream infection was diagnosed if there was
evidence of systemic inflammatory response syndrome attrib-
uted to an intravascular catheter by quantitative culture of the
catheter tip or by differences in growth between catheter and
peripheral venipuncture blood culture specimens. 22 Scrub
typhus was diagnosed when a patient with an acute febrile
illness had an eschar and had a positive scrub immunoglobulin
M (IgM) enzyme-linked immunosorbent assay (ELISA) or a
positive scrub IgM ELISA and defervesence within 48 hours of
initiation of doxycycline or azithromycin therapy.23 Other
infections were diagnosed per standard guidelines.
The VCS parameters were recorded along with blood
counts using an automated hematology analyzer UniCel DxH
800 Coulter Cellular Analysis System (Beckman Coulter Inc,
Brea, California). The analyzer uses direct current impedance
to measure cell volume, conductivity for internal composition
of each cell as determined by radio frequency current, and a
diode laser to measure light scatter for cytoplasmic granular-
ity and nuclear complexity performed on a hydrodynamically
focused single line of cells to incident laser light in the flow
channel. It gives measurements of cellular morphologic
properties, known as cell population data,17 which assist in
classifying the leukocytes based on the location in a high-
dimension cube. The scattered light is detected by photo-
diodes at different angles. Median angle light scatter (MALS),
lower MALS (LMALS), and upper MALS (UMALS) provide
information concerning granularity and the membrane sur-
face. Axial light loss (AL2) of the incident laser is a measure
of cellular diameter and the low angle light scatter provides
cellular complexity index. In addition to VCS parameters,
PCT and CRP were also done within 24 hours of suspected
sepsis and the index culture.
Procalcitonin immunoassays were performed using the
time resolved amplified cryptate emission (TRACE) method
on a BRAMHS KRYPTOR analyzer (B*R*A*M*H*S
GmbH). The test is routinely done in our clinical biochemistry
department as and when samples are received. The lower limit
of detection was 0.02 ng/mL. The CRP assays were done by
nephelometry (BN ProSpec; Siemens, Germany). The lower
limit of the assay was 3.17 mg/L. A value of over 6 mg/L was
considered positive.
The VCS parameters in patients with sepsis were compared
to nonseptic patients and healthy blood donors. Illness sever-
ity was assessed using the SOFA score.10 The study was
approved by the institutional review board and ethics com-
mittee of the hospital.
Mammen et al 3

Table 1. Baseline Parameters of Cases and ICU Controls.a Table 2. Focus of Sepsis in Cases and Diagnosis in Nonseptic
Controls.
Parameter
(Range) Cases (n ¼ 65) ICU control (n ¼ 58) Septic Patients (n ¼ 65) ICU Controls (n ¼ 58)

Age, mean (95% 43 (17-75) 41 (18-86) Foci of sepsis No Diagnosis No

CI), years
Gender, male/ 27/38 30/29 Respiratory tract infections 19 Seizures/stroke 17
female Ventilator-associated pneumonia 9 Poisoning/hanging 17
SOFA score 8.5 (1-18) 5.0 (0-16) Community-acquired pneumonia 3 Respiratory failure 5
WBC count, /mL 11 600 (4100-54 000) 13 600 (5900-23 400) Hospital-associated pneumonia 2 Pancreatitis/alcoholic 4
Neutrophil, % 85 (56-96) 80 (21-97) hepatitis
Lymphocyte, % 10 (1-38) 11 (0-65) Viral bronchopneumonia 2 Chronic kidney 3
Monocyte, % 5 (0-19) 6 (0-34) disease
Eosinophil, % 0 (0-9) 1 (0-8.3) VAT 1 Othersa 12
Hemoglobin, g/dL 9.7 (5.1-15.4) 11.0 (4.5-17.6) Pulmonary nocardiosis 1
Hematocrit, % 30.2 (14.8-45.8) 33.6 (14.5-55.3) Bronchitis 1
MCV 84.1 (66.3-110.4) 86.9 (64.5-104.2) Urinary tract infections 10
RDW 16.6 (13-32) 15.3 (12.5-25.4) Pyelonephritis 6
Platelet count, /mL 115 000 (5000-734 000) 210 000 (16 000-569 000) Lower UTI 3
Platelet volume, 9.3 (6.6-11.6) 8.5 (6.7-14.6) Catheter-associated UTI 1
fl, mean (SD) Gastrointestinal related 8
Procalcitonin, 33.6 (76) 14.1 (38.7) Spontaneous bacterial peritonitis 4
ng/mL, mean Cholangitis 3
(SD) BSI in ulcerative colitis 1
CRP, mg/L, mean 106.5 (73) 78.2 (62) Skin and soft tissue 6
(SD) Cellulitis 5
Necrotizing fasciitis 1
Abbreviations: ICU, intensive care unit; CI, confidence interval; SD, standard Blood stream infection—catheter 4
deviation; SOFA, sequential organ failure assessment; WBC, white blood cell; related
MCV, mean corpuscular volume; RDW, red cell distribution width. Central nervous system infections 2
a
All values are expressed as median with interquartile (IQR) range unless Pyogenic meningitis 1
specified.
Cryptococcal meningitis 1
Others 16
Scrub typhus 9
Dengue with shock 5
Statistical Analysis Endocarditis 1
A pilot study was performed to determine the sample size Septic arthritis 1
on patients with proven sepsis (n ¼ 26) and healthy controls Abbreviations: No., number of patients; VAT, ventilator-associated tracheo-
(n ¼ 115). These patients were not included in the final bronchitis; BSI, blood stream infection; UTI, urinary tract infection.
a
results of this study. Based on this pilot study, the calcu- Others included severe preeclampsia, myasthenia gravis, metabolic encepha-
lated sample size was 51 cases and 51 controls for 85% lopathy, thoracic aortic aneurysm, pineal glioma, polyneuropathy, and cardio-
genic shock.
sensitivity and specificity, each with 95% confidence inter-
val (CI) and 10% precision; 20% was added for dropouts.
Parameters were initially compared using the t test and
compared between the different groups using analysis of
Results
variance, and subsequently post hoc analysis was also done The study group included 123 ICU patients of whom 65
with Bonferroni correction. Difference in parameters patients had sepsis (cases) and 58 were nonseptic controls.
between various groups with P value <.05 was considered Baseline characteristics and white cell parameters are summar-
statistically significant. The diagnostic property of each test ized in Table 1. The mean age of cases and ICU controls were
was investigated by receiver–operator characteristic (ROC) similar; however, patients with sepsis were sicker (higher
curves. The optimum cutoff value for each variable was SOFA scores) than nonseptic ICU controls (Table 1). The most
tested. Logistic regression analysis was applied to study common foci of sepsis were respiratory tract and primary blood
interaction between the various parameters, MNV, mean stream infections (Table 2); the predominant organisms in
neutrophil conductivity (MNC), mean monocyte volume culture-positive patients were Escherichia coli, Klebsiella, and
(MMoV), mean monocyte conductivity (MMoC), mean neu- Pseudomonas aeroginosa. The most frequent diagnosis in non-
trophil axial light loss (MNAL2), and mean monocyte axial septic controls was seizures, stroke, and poisoning (Table 2).
light loss (MMAL2), and scores were obtained from those The third group consisted of consenting normal healthy blood
which were significant. The sensitivity, specificity, nega- donors with no significant medical history.
tive, and positive predictive values were calculated for the The VCS parameters in the 3 groups are summarized
VCS parameters as well as for PCT and CRP. in Table 3. Mean (95%CI) MNV was significantly higher
4 Journal of Intensive Care Medicine

Table 3. Volume, Conductivity and Scatter (VCS) Parameters and Biochemical Markers in the 3 Groups.

Sepsis Group (n ¼ 65) ICU Controls (n ¼ 58) Blood Donors (n ¼ 98)

Parameter Mean 95% CI Mean 95% CI P Valuea Mean 95% CI

Neutrophils
Volume (MNV) 165.5 161.6-169.4 157.3 154.6-160.1 .001 148.9 147.9-145.0
Conductivity (MNC) 142.4 141.0-143.7 144.8 143.6-146.0 .008 145.6 145.1-146.1
Scatter (MNLMALS) 122.6 119.5-125.7 122.3 118.7-125.8 .898 132.9 131.7-134.1
Scatter (MNAL2) 145.9 143.7-148.1 140.0 137.9-142.1 .0002 155.3 153.0-157.6
Monocytes
Volume (MMoV) 187.2 183.7-191.2 174.9 171.9-177.8 <.001 164.8 163.7-165.9
Scatter (MMLMALS) 73.7 69.6-77.5 69.0 66.2-71.9 .062 70.5 69.3-71.6
Scatter (MMAL2) 128.1 123.8-132.5 120.4 115.6-125.3 .02 119.3 116.3-122.3
Biochemical parameters
Procalcitonin 33.6 13.5-52.7 14.1 3.7-23.1 .073 - -
CRP 106.5 86.6-123.4 78.2 65.6-98.1 0.063 - -

Abbreviations: MNV, mean neutrophil volume; MNC, mean neutrophil conductivity; MNLMALS, mean neutrophil lower median angle light scatter; MNAL2, Mean
neutrophil axial light loss; MMoV, mean monocyte volume; MMLMALS, mean monocyte lower median angle light scatter; MMAL2, mean monocyte axial light loss;
ICU, intensive care unit; CRP, C-reactive protein; CI, confidence interval.
a
P value between sepsis group and ICU controls; P < .05 considered statistically significant;

(P < .001) in patients with sepsis (165.5 arbitrary units [au];

95%CI 161.6-169.4) than in nonseptic (157.3, 95%CI 154.6-
160.1) patients and donors (148.9; 95%CI 147.9-150). The
MMoV was also significantly higher (P < .001) in patients with
sepsis (187.2; 95%CI 183.7-191.2) when compared to nonsep-
tic patients (174.9; 95%CI 171.9-177.8) and donors (164.8;
95%CI 163.7-165.9). Mean axial light loss for neutrophils and
monocytes was significantly higher in patients with sepsis than
nonseptic patients with nonoverlapping 95% CI, while neutro-
phil conductivity, although statistically significantly different,
had overlapping CIs (Table 3). The performance of these tests
when assessed as the area under the curve (AUC) was at best
modest, with monocyte volume performing better (0.74) than
other parameters; PCT had an AUC of 0.68 and CRP had the
least (0.62) AUC (Figure 1).
The cutoff values for the VCS parameters were determined
using ROC curve (Table 4). Combinations of VCS parameters
Figure 1. Receiver–operating characteristic (ROC) curve for neu-
were similarly analyzed with logistic regression to improve trophil and monocyte volume and procalcitonin and C-reactive pro-
the diagnostic accuracy. The sensitivity for diagnosing sepsis tein (CRP) for the diagnosis of sepsis. The area under the curve (AUC)
was 93% when monocyte volume, neutrophil scatter, or PCT for monocyte volume (mo_v) was highest at 0.74, while for neutrophil
were positive. The sensitivity was 82% when neutrophil vol- volume (ne_v) it was 0.65. The AUC for procalcitonin and CRP were
ume or monocyte volume was accounted for. The specificity 0.68 and 0.62, respectively.
was 87% when both neutrophil and monocyte volume were
considered together. was significant difference between all the groups for the fol-
On post hoc analysis, of the 58 ICU nonseptic controls, 17 lowing parameters: MNV, MNC, MMoV, and mean neutrophil
patients developed features of sepsis and had culture positiv- lower median angle light scatter (Table 6).
ity in the next 72 hours following the index sampling. The
data on the subpopulation of 17 patients (Table 5) were ana-
lyzed separately and compared to culture-negative, nonseptic Discussion
ICU controls (n ¼ 41). The VCS parameters in culture- The search for a good biomarker for sepsis has been limited by
positive patients (n ¼ 17) was significantly different when low diagnostic accuracy of the currently available tests. In the
compared with the nonseptic patients and tended to be close critically ill patient, where there are several infectious and non-
to the values of patients with proven sepsis at the time of infectious causes for fever, it is important that screening tests
index sampling (Figure 2A-D). reliably rule in or rule out sepsis. Cytomorphometric analysis of
Analysis of variance was applied between the 3 groups neutrophils and monocytes offer a new method of improving the
(excluding the culture positive among ICU controls). There diagnosis of sepsis. In this cohort study in the ICU,
Mammen et al 5

Table 4. Sensitivity and Specificity Along With Cutoff Values of the Significant Volume, Conductivity and Scatter Parameters (VCS), C-Reactive
Protein, and Procalcitonin.

Parameter Cutoff Sensitivity, % Specificity, % Positive Predictive Value Negative Predictive value

Mean neutrophil volume 162 58 85 86 56

Mean monocyte volume 179 66 80 84 60
Mean neutrophil conductivity 144 71 56 72 54
Mean neutrophil axial light loss 142 66 73 80 57
Mean monocyte axial light loss 129 53 73 76 50
Procalcitonin 0.95 81 53 72 67
C-reactive protein 64.3 68 62 74 55

Table 5. Post Hoc Subgroup Analysis of the Nonseptic Control
Group Separated as Those Who did not Develop Sepsis During Entire
Intensive Care Stay Versus Those Who Subsequently Developed
Sepsis.a
Culture-Negative Culture-Positive P that cytomorphometric neutrophil and monocyte parameters
Parameter Control Group (n ¼ 41) Control Group (n ¼ 17) Value
MNV 154.1 (9.5) 165.3 (9.2)
MNC 145.2 (4.2) 143.8 (5.3)
MMoV 172.1 (11.7) 181.8 (7.3)
MNLMALS 124.5 (12.32) 116.3 (16.3)
MMLMALS 70.8 (10.2) 63.9 (11.5)
Abbreviations: MNV, mean neutrophil volume; MNC, mean neutrophil con-
ductivity; MNLMALS, mean neutrophil lower median angle light scatter; MMoV,
Mean monocyte volume; MMLMALS, mean monocyte lower median angle light
scatter.
a
All values in parentheses indicate 95% confidence interval.
cytomorphometric parameters in 65 patients with proven sepsis
was compared to nonseptic ICU controls (n ¼ 58) and blood
bank donors (n ¼ 98). Our intention was to identify parameters
that would act as early screening indicators to differentiate
patients with sepsis and compare them with existing biochemical
and composite parameters in patients with sepsis and controls.
In this current study, several VCS parameters were found to be
significantly different between patients with sepsis and ICU con-
trols. Of the significant parameters that included, MNV, MMoV,
MNC, MNAL2, and MMoAL2, the most promising parameters
were MNV and MMoV. The AUC of MMoV of 0.74 was much
better than the AUCs of conventionally used parameters, CRP
(0.62) and PCT (0.68). However, it must be pointed out that the
AUC of 0.74 would still be considered as modest. However, when
we excluded, on post hoc analysis, ICU controls who developed
sepsis within the next 72 hours, the MNV and MMoV values in
nonseptic ICU controls were closer to values in blood donors
(Table 6). It is also interesting to note that the MNV and MMoV
values in the culture-positive ICU control group (Table 5)
approximated the values in those with proven sepsis.
The results of the current study are comparable to the results
by Lee and Kim who performed the tests on the same analytic
platform.16 They also observed16 that MNV and MMoV were
higher in the sepsis group than in patients with localized infec-
tion and controls (P ¼ .000). A higher sensitivity (83.3%) and
specificity (78%) with a cutoff of 156.5 was reported by Lee
and Kim,16 when compared to our study (58% sensitivity and
85% specificity) that used a cutoff of 162. The difference in
volumes between patients with sepsis and nonseptic patients
may be due to immature and reactive neutrophils with less
nuclear complexity that is seen in sepsis. These results suggest
may be used as screening tests for sepsis.
Combining different parameters on a composite analysis may
.0001
improve the sensitivity and specificity. On post hoc analysis, we
.315
.002 observed that the sensitivity improved to 93% when either
.040 MMoVs or MNALs were combined with a positive PCT. Simi-
.020 larly, the sensitivity improved to 82% when MNV and MMoV
were accounted for. The specificity was 81% when neutrophil
and monocyte volumes were considered together. These results
are similar to that of Mardi et al17 who observed that when MNV
and MMoV were taken together, they seemed to discriminate
better between sepsis and nonsystemic infections.
The more conventional tests such as PCT and CRP did not
perform well in our setting. However, PCT performed better
than CRP with respect to AUC and had comparable sensitivity.
This is in line with previous studies that compared these 2
biochemical parameters.6,7 C-reactive protein being an acute-
phase reactant has low specificity in adult sepsis.24 Procalcito-
nin, though more sensitive, is affected by other factors such as
SOFA score and Acute Physiology and Chronic health evalua-
tion (APACHE) score that denote severity of illness and there-
fore not completely reliable at differentiating sepsis from other
inflammatory conditions.25,26
It was interesting to note that on post hoc analysis in a subset
of patients who went on to develop overt sepsis (with culture
positivity) within 48 to 72 hours of the initial cytomorphometric
tests, the VCS parameters approximated those with proven sep-
sis at the time of the initial test. This important finding, albeit
preliminary, suggests that morphological changes in early or
subclinical sepsis may antedate biochemical parameters. How-
ever, this needs to be validated in prospective larger cohorts.
There are at least 2 reasons why cytomorphometric neutro-
phil parameters are promising and needs further study. The first
is the positive association between VCS parameters and sepsis
in this and other studies on this subject. The second is the fact
that these parameters are now routinely available on analytical
parameters, obviating the need for additional tests and added
costs. It is also important that further studies explore the role of
serial VCS measurements to track response to therapy in
patients with sepsis.
6 Journal of Intensive Care Medicine

Figure 2. Box plot of volume, conductivity, and scatter (VCS) parameters for cases, intensive care unit (ICU) controls (subdivided into culture
positive and culture negative), and healthy blood donors. The (A) mean neutrophil volume (MNV), (B) mean neutrophil conductivity (MNC),
(C) mean monocyte volume (MMoV), and (D) mean neutrophil lower median angle light scatter (MNLMAL) were significantly different between
ICU cases and controls. Culþ indicates culture positive; Cul, culture negative.

Table 6. Analysis of Variance (ANOVA) for the Volume, Conductiv- setting of a developing country with tropical infections may have
ity and Scatter Parameters (VCS) Between the 3 Groups: Study resulted in slight variance in the results of other studies. The time
Group, ICU Control Group (Excluding Culture Positive), and Blood of sampling for VCS studies is crucial. In this study, a single-
Donors.a point estimation of VCS was undertaken at the time of diagnosis
Parameter ICU Sepsis ICU Controls Blood Donor P Value of sepsis. Serial estimations of VCS would have been ideal to
track response to antimicrobial therapy. However, this was
MNV 165.5 (15.7) 154.1 (9.5) 148.9 (5.3) <.0001 beyond the scope of this study. The post hoc analysis of ICU
MNC 142.3 (5.4) 145.2 (4.2) 145.6 (2.4) <.0001 controls, although interesting, needs validation in prospective
MMoV 187.3 (15.7) 172.1 (11.7) 164.8 (5.4) <.0001 studies. We also observed that there were artifactual changes
MNLMALS 122.6 (12.9) 124.5 (12.3) 132.9 (5.9) <.0001
in these parameters when the samples were processed 4 hours
MMLMALS 73.8 (15.7) 70.8 (10.2) 70.4 (5.9) .16
after collection. Despite these limitations, these findings offer a
Abbreviations: ICU, intensive care unit; MNV, mean neutrophil volume; MNC, new and interesting approach to biomarkers in sepsis.
mean neutrophil conductivity; MNLMALS, mean neutrophil lower median angle
light scatter; MMoV, mean monocyte volume; MMLMALS, mean monocyte
lower median angle light scatter.
Conclusions
Cytomorphometric neutrophil and monocyte markers, in par-
The following limits merit mention. The sample size was ticular MNV and MMoV, are promising tests for sepsis diag-
small, and thus these findings need to be confirmed in larger nosis. Since these tests are now available in automated cell
studies. The inclusion of a very sick cohort of patients in the counters that provide these results in addition to cell counts,
Mammen et al
the advantages are that of a rapid turnaround time, avoidance of
multiple sampling, reduced cost, objective results, and increased
diagnostic accuracy over conventional biochemical tests.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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