Leucocytes and Non-Haematological Disease

Aim
To study the basic functions of the different leucocytes and the causes of increases or
decreases in their blood levels.

Delivery objectives
1. Describe and explain the different mechanisms which increase the blood neutrophil
count.
2. Describe and explain the neutrophil features in bacterial infection.
3. List the major causes of neutrophilia and describe the corresponding mechanism
(where possible).
4. Define the term ‘leukaemoid reaction’ and state where it may occur.
5. Explain the term ‘leukaemic hiatus’.
6. Explain the term ‘leucoerythroblastic reaction’.
7. Explain the causes of monocytosis, eosinophilia, basophilia and lymphocytosis.
8. State the major causes of lymphopenia.

Content

Examination of the leucocyte counts in the peripheral blood can provide a great deal of
information regarding non-haematological disease. Each of the blood leucocytes has its
own specific function and so responds differently to stimuli such as infection,
inflammation, etc. The blood must be seen as a transport system for these cells – they
do not fulfill many of their functions while in the blood stream. It is merely carrying them
to where they are needed e.g. to fight infections, suppress inflammatory responses etc.
Doing an FBC and differential count therefore is analogous to monitoring the traffic on a
highway to give you a clue to the state of the country - a large number of military tanks
on their way to the borders certainly gives a clear indication of war, while trucks carrying
consumer goods as well as commuters in cars would suggest a peaceful and prosperous
economy.

Each of the leucocyte types will be considered in turn, their functions reviewed briefly
and classic patterns of response in different conditions described.

A. NEUTROPHILS

Neutrophils are phagocytic cells which are equipped to kill the organisms they encounter.
They contain numerous enzymes and inhibitory proteins which help to kill and break
down organisms, in addition to an enzyme system which generates highly reactive
oxygen metabolites - which are their principal weapon. They also use enzymes to break
down extracellular matrix so that they can enter and move through the tissues.

Neutrophils provide the first line of defense against any invasion by microorganisms. It is
obvious that there have to be sufficient neutrophils available to perform this essential
function and there cannot be any delay in increasing the number available. The body
provides for this by having several different pools of neutrophils which can be mobilized,
rather than relying initially on a time-consuming increase in cell production within the
marrow.

Neutrophils already released from the marrow into the blood form 2 separate pools:

1. The first consists of cells circulating freely in the axial stream of blood. These are
the cells which are counted when a needle is inserted into a vein and a sample
removed for a full blood count.
 2. The second pool is made up of an equal number of cells, also within the vessel
but hugging the endothelium and moving along its surface. These are referred to
as the ‘marginated’ neutrophils and can be returned to the circulating pool by
anything that increases blood flow – exercise, stress, adrenaline etc.

A third pool consists of cells within the bone marrow. These are mature neutrophils as
well as band forms and less mature cells which can be mobilised if necessary. Release of
these cells produces a ‘left shift’ in the peripheral blood.

Note that neutrophils circulate slowly through the spleen and many can be sequestered
in this organ when it is enlarged.

Mechanisms of increased blood neutrophils or neutrophilia

1. Redistribution from the marginating pool into the circulating pool within the blood
2. Release from the marrow pool
3. Decreased or delayed egress from the blood into the tissue
4. Sustained neutrophilia requires an increase in neutrophil production by the bone
marrow.
Note that the neutrophil COUNT as measured by the FBC and differential count can be
increased without actually increasing the total number of neutrophils within the body.

Causes of neutrophilia

1. Infection (especially with bacteria)

This calls several of the above mechanisms into play but the increase in marrow
production and mobilization of the marrow pool produce characteristic features in severe
bacterial infections. These features are easily recognisable on the blood smear and can
be very helpful in determining the cause of the neutrophilia and thus in elucidating the
nature of the patient’s illness.

a) Left shift – the marrow releases band cells and even earlier forms such as
metamyelocytes. In very severe cases all immature cells, including blasts,
promyelocytes and myelocytes may be released in numbers reflecting their
relative concentrations in the marrow.

b) The cells contain an increased density of granules within their cytoplasm –

referred to as ‘toxic granulation’. This is due to increased marrow production but
with the cells skipping one or two divisions in their haste to leave the marrow.
Thus the promyelocyte or myelocyte makes sufficient granules for 2 daughter
cells, but then proceeds to mature without dividing - resulting in the mature cell
having twice the normal number of granules.

c) Döhle bodies may be present. These are the leucocyte equivalent of reticulocytes –
cells released from the marrow with rough endoplasmic reticulum still present in
the cytoplasm. The RER forms small basophilic patches adjacent to the cell
membrane.

d) Circulating neutrophils very occasionally contain recognizable bacteria but more

frequently contain vacuoles, which may result from ingestion of organisms within
the blood stream. This is referred to as “toxic vacuolation”.

Paradoxically, in very severe infections when the neutrophils are being distributed to the
tissues faster than they can be produced, the neutrophil count in the blood can be
reduced. However, the above features are still seen and can be vitally important in
making the right diagnosis. This is seen particularly at the extremes of life – in neonates
and the elderly.

2. Corticosteroids

Whether endogenously produced or given as a pharmacological agent, corticosteroids

raise the neutrophil count by 3 mechanisms:

a) They mobilize the marrow reserve

b) The marginating pool shifts into the circulatory pool
c) The egress of cells from the blood to the tissue is delayed
Points b and c are the reason that inflammation due to neutrophils is decreased despite
the higher counts – the cells cannot get into the tissues.

Note that corticosteroids do not increase synthesis of neutrophils in the marrow.

3. Exercise

This mobilises cells from the marginating pool

4. Tumours

Non-haemopoietic tumours and Hodgkin lymphomas are occasionally accompanied by

neutrophilia and this is sometimes very extreme with neutrophil counts of 20x10 9/L or
more. This appears to be due to production of haemopoietic growth factors by the
tumour.

5. ‘Spillover’ effect

Stimulation of other haemopoietic cell lines e.g. by haemolysis, platelet destruction or

blood loss, can increase the neutrophil count because the growth factors are not all
100% lineage specific and there is some cross reaction.

6. Non-infectious tissue damage

Trauma, surgery, infection and chemical damage e.g. ketoacidosis can all cause mild
neutrophilia.

7. Pregnancy

Particularly in the final 3 months, pregnancy is associated with mild neutrophilia.

Many of the above causes result from more than one of the mechanisms of neutrophilia.

Leukaemoid reaction

By convention this refers to a leucocytosis exceeding 50x10 9/l but the term is often used
for lower counts. The leucocytosis is not due to a malignancy of the marrow itself so the
blood leucocytes are polyclonal in origin.

It may occur in:

1. Severe infection
2. Carcinoma, particularly of the lung, stomach, breast and liver and in Hodgkin disease

3. Juvenile rheumatoid arthritis

If there is damage or disruption in the bone marrow then there may be a left shift as
well as high counts – this makes the distinction from CML, and even acute leukaemia,
necessary.

Features to look for to help distinguish chronic myeloid leukaemia (CML) and leukaemoid
reactions: basophils, abnormal distribution of neutrophil precursors and dysplastic
features e.g. large platelets may be present in CML, toxic features are present in
infection. Do FISH for t(9;22)

Distinction from acute leukaemia: no leukaemic hiatus, blast count < 20%, possibly no
cytopenias in leukaemoid reaction.

Leukaemic hiatus

In a left shift the cells are released from the marrow in the same proportions as they are
present in the marrow i.e. there should be very few blasts and promyelocytes, more
myelocytes and many more metamyelocytes. In an early acute leukaemia there may still
be some myelocytes and metamyelocytes released from the damaged marrow but there
will be a very much higher percentage of blasts than there are in a normal marrow. The
gap in representation between the blasts and more mature forms is known as the
leukaemic hiatus.

Neutropenia in infections

a) As mentioned previously, overwhelming bacterial infections can cause neutropenia

as the tissue demand for neutrophils outstrips the marrow's capacity to provide
them. This is seen at any age but is more common in neonates and the elderly.
The features of infection are seen in the remaining blood neutrophils and in
septicaemia there may (rarely) be organisms within the neutrophils.

b) Certain bacterial infections typically do not cause neutrophilia; the most notable of
these is typhoid which classically causes a neutropenia.
 c) Viral and rickettsial infections may cause neutropenia, and malaria also does not
elicit a neutrophil response.

d) HIV is frequently associated with neutropenia, either on its own or in association

with other cytopenias. The pathogenesis is often multifactorial and so it may be
very difficult to determine exactly which element is principally responsible.
Possible causes include:
 Production defect 1 – ineffective granulopoiesis, possibly due to cytokine and
growth factor disturbances in the marrow;
 Production defect 2 – marrow replacement by infection e.g. TB granulomas or by
cancers such as lymphoma
 Production defect 3 – folate and cobalamin/Vitamin B12 deficiency are more
common in HIV
 Production defect 4 – drugs, including antiretrovirals
 Peripheral destruction – antibodies to neutrophils (may also be active in the
marrow)
 Splenic sequestration.

Leucoerythroblastic reaction/ anaemia/response

Also known as infiltrative myelopathy or myelophthisic anaemia.

This occurs when there is infiltration of the bone marrow, usually by nonhaemopoietic
elements, and sometimes when the marrow is very active but very stressed such as in
septicaemia. This causes release of premature haemopoietic cells and reticulocytes and
results in the presence of cytopenias together with precursors of granulocytes and red
cells (normoblasts) in the blood. A characteristic feature is the presence of red cell
teardrops if the cause is marrow infiltration

Causes:

1. Myelofibrosis

2. Marrow infiltration e.g. carcinoma of the prostate, breast, lung or stomach,

lymphoma, tuberculosis

3. Stressed marrow

4. Extramedullary haemopoiesis can produce a very similar picture

B. MONOCYTES

These cells leave the blood to enter the tissue and become macrophages. Their kinetics
are quite different from those of neutrophils even though they also are responsible for
ingesting and killing microorganisms. Principally there is no marrow reserve of
monocytes waiting to be deployed when there is an infection; an increase in
requirements demands an increase in synthesis so there is a delay of a few days
between the onset of infection and the appearance of a monocytosis in the blood.

Causes of monocytosis

a) Typically, a monocytosis occurs in chronic bacterial infections e.g. tuberculosis

(TB), subacute bacterial endocarditis (SBE), brucellosis
 b) Acute infections associated with a monocytosis include rickettsial infections e.g.
tick bite fever, and protozoan infections e.g. malaria

c) It may occur as a response to non-haematological tumours and to Hodgkin

lymphoma

Monocytopenia

The most frequent cause of this is corticosteroid administration

C. EOSINOPHILS

Unlike neutrophils which die slowly after entering the tissue, eosinophils are designed to
live in the tissues.

They have 2 functions:

1. The killing of parasites (and bacteria) by either ingesting them OR by extruding

the contents of their granules over the surface of the microorganism.
2. The dampening of hypersensitivity and inflammatory reactions and opposing the
actions of mast cells and basophils.

Eosinophilia

From the above it can be deduced that the major causes of eosinophilia are:

a) Parasitic infections

b) Allergy

c) Chronic inflammatory conditions e.g. connective tissue disorders.

They are also increased in Hodgkin disease and in Addison’s disease (as their numbers
are decreased by corticosteroids).

Eosinopenia

This is due to anything increasing corticosteroid levels.

D. BASOPHILS

These cells reside mainly in barrier tissues e.g. skin, mucosae and serosae, providing
chemical mediators of inflammation. They have high affinity FC receptors for IgE. They
are extremely uncommon in the blood, normal levels usually being in the region of 0 –
0,2 x 109/L, and increases in these levels are not often seen.

Basophilia occurs most frequently in chronic myeloid leukaemia but non-haematological

conditions associated with it include hypothyroidism, asthma and some viral infections.

The normal range is too low to be able to define basophilopenia.

Lymphocytes

Circulating lymphocytes are in transit between the lymphoid organs and the tissues. The
majority of lymphocytes in the blood are of T cell origin (80%) and of these most are
CD4 positive cells. The remaining cells are of B cell origin with a few natural killer cells
as well.

Lymphocytosis

This is not common, unlike neutrophilia, and must always be investigated.

Causes:

A. Reactive

1. Infection

Some viral infections can give rise to a lymphocytosis with a very particular appearance
of the lymphocytes. This is known as the Mononucleosis Syndrome and is classically
caused by Epstein Barr virus. However other viruses such as the adenoviruses, hepatitis
viruses, cytomegalovirus virus (CMV) and acute HIV can produce a similar picture, as
can toxoplasmosis.

Other viral infections also can cause a lymphocytosis but the appearance of the
lymphocytes is different and not as helpful in making a diagnosis.

Occasionally certain other infections can also cause a lymphocytosis. Secondary and
congenital syphilis and brucella do this but the classical bacterial infection is Bordetella
pertussis. The latter produces a lymphocytosis promoting factor which attaches to the
lymphocyte surface and prevents migration from the blood to the lymph node.

Acute infectious lymphocytosis occurs in children and young adults but the aetiology has
not yet been determined. It is a non-specific illness accompanied by a lymphocytosis of
20 – 30x109/l lasting 3 – 7 weeks.

2. Drug-induced hypersensitivity.

3. Serum sickness.

4. Post-splenectomy

5. Auto-immune disorders.

6. Smoking.

7. Stress lymphocytosis.

This occurs acutely following cardiovascular collapse and lasts for a couple of hours.

B. Malignancies

Reactive lymphocytosis must be distinguished from malignant proliferations of

lymphocytes - lymphomas, chronic lymphocytic leukaemia, hairy cell leukaemia and
Sezary syndrome can all produce a significant lymphocytosis. Frequently the cells have a
typical appearance which allows the diagnosis to be suspected from the peripheral blood
smear but some, like chronic lymphocytic leukaemia, often cannot be distinguished on
appearance alone.

Lymphopenia.

A. Congenital

Rare congenital immune deficiencies cause lymphopenia.

B. Acquired

1. Infections, especially viral such as chronic HIV, influenza, herpes as well as TB and
typhoid.

2. Iatrogenic causes such as chemotherapy, immunosuppressive drugs (including

corticosteroids) and radiation.

3. Systemic disease such as carcinoma, renal failure, sarcoid.

4. Ethanol abuse.

5. Zinc deficiency.