A man approximately 80 years old with an unknown medical history was brought to the emergency department from a skilled nursing facility after an unwitnessed arrest. EMTs established return of spontaneous circulation after chest compressions and epinephrine.
The patient was hypotensive (MAP was 40 mm Hg) and hypoxic (SpO2 was 85%) with mask ventilation. The patient was intubated, resuscitated with intravenous fluids, and started on vasopressors. Imaging demonstrated lung consolidation consistent with multifocal pneumonia v. aspiration. Laboratory studies were:
- CBC: WBC: 49.2 (N: 64%, bands: 20%)
- ABG: pH: 7.07, pCO2: 73 mm Hg
- Lactate: 9.1 mmoL/L
The patient was admitted to the medical intensive care unit for cardiopulmonary arrest presumed secondary to hypoxia and septic shock from health care-associated pneumonia or aspiration. The markedly elevated white blood cell count was attributed to a combination of infection and tissue ischemia from transient global hypoperfusion.
Definition: Markedly elevated leukocyte (particularly neutrophil) count without hematologic malignancy. The cutoff is variable at 25,000-50,000. (Eur J Intern Med. 2006;17:394; http://bit.ly/2VEMV02.)
Review of Available Literature
A retrospective review of 135 patients with a WBC of >25,000 found that 48 percent had infection, 15 percent with malignancy, nine percent with hemorrhage, and 12 percent with glucocorticoid or granulocyte colony stimulating therapy. (Eur J Intern Med. 2006;17:394; http://bit.ly/2VEMV02.)
Another retrospective review of 173 patients with a WBC of >30,000 found that 48 percent had infection (7% had Clostridium difficile), 28 percent had tissue ischemia, seven percent had an obstetric process (vaginal or Cesarean delivery), and five percent had a malignancy. (Clin Infect Dis. 2013;57:e177; http://bit.ly/2VRYVA5.)
An observational study of 54 patients with a WBC of >25,000 included consecutive patients presenting to the emergency department who were compared with age-matched controls with moderate leukocytosis (12,000-24,000). Patients with leukemoid reaction were more likely to have an infection, be hospitalized, and die. (QJM. 2007;100:217.)