Leukocytosis

Differential Diagnosis in Primary Care, 4th Edition

Numerous disorders cause leukocytosis. How can we recall all possibilities in the differential? The mnemonic VINDICATE would seem to be the answer.

Leukocytosis (obscure causes)

· V—Vascular would call to mind myocardial infarction, pulmonary infarction, cerebral vascular accident, and thrombophlebitis.

· I—Inflammation should bring to mind bacterial infections anywhere in the body, but especially septicemia. Parasitic infections would cause an eosinophilia. Severe systemic fungal infections would also cause leukocytosis. Viral infections are not usually associated with leukocytosis but there are notable exceptions, such as infectious mononucleosis.

TABLE 44. Leg Pain

	V	I	N	D	I	C	A	T	E
	Vascular	Inflammatory	Neoplasm	Degenerative	Intoxication	Congenital	Autoimmune Allergic	Trauma	Endocrine
*Skin*	Embolism	Herpes zoster Carbuncle	Kaposi sarcoma				Pyoderma gangrenosum Periarteritis nodosa	Contusion Laceration
*Subcutaneous Tissue*		Cellulitis Filariasis					Weber–Christian disease	Hematoma
*Muscle, Fascia, and Bursa*		Tetanus Trichinosis Cysticercosis Epidemic myalgia			Low sodium from diuretic Black widow spider bite	McArdle syndrome Myositis ossificans	Dermatomyositis Fibrositis	Hematoma Laceration Rupture	Tetany
*Veins and Capillaries*		Thrombophlebitis Subacute bacterial endocarditis	Hemangioma	Scurvy		Varicose vein Buerger disease	Dermatomyositis Fibrositis	Hemorrhage
*Arteries*	Leriche syndrome Dissecting aneurysm Embolism	Subacute bacterial endocarditis		Arteriosclerosis		Varicose vein Buerger disease	Periarteritis nodosa	Hemorrhage
*Lymphatics*		Lymphangitis Filariasis	Hodgkin lymphoma Lymphangioma			Milroy disease		Hemorrhage
*Nerves*	Ischemic neuropathy Buerger disease	Viral neuritis Tabes dorsalis	Pelvic tumor Neuroma Cord tumor Metastatic tumor			Obturator hernia Porphyria Blood dyscrasia		Fracture Hematoma Ruptured disc	Diabetic neuropathy
*Bone*	Aseptic necrosis	Osteomyelitis Relapsing polychondritis	Osteogenic sarcoma Metastatic carcinoma Multiple myeloma	Scurvy Paget disease	Radiation osteitis	Sickle cell anemia Osteogenesis imperfecta		Fracture Hematoma	Osteomalacia Polyosteotic fibrosa cystica Osteoporosis

· N—Neoplasm would of course prompt the recall of acute and chronic leukemias and agnogenic myeloid metaplasia.

· D—Degenerative disorders do not prompt the recall of any important disorder.

· I—Intoxication would bring to mind various drugs that are associated with a leukocytosis, such as lithium, corticosteroids, and lead.

· C—Congenital would bring to mind Down syndrome.

· A—Allergic and Autoimmune would prompt the recall of anaphylactic shock, asthma, and other diffuse hypersensitivity reactions as well as polyarteritis nodosa and dermatomyositis.

· T—Trauma reminds us that burns, fractures, massive hemorrhage, or contusions of various parts of the body cause a leukocytosis.

· E—Endocrine causes Cushing syndrome, and exogenous corticosteroids cause a leukocytosis. Pregnancy thyroid storm and diabetic ketoacidosis are also associated with a leukocytosis.

Approach to the Diagnosis

Because infection is the most common and often the most life-threatening cause, the history and physical are of most importance in locating a source. All suspicious body fluids should be analyzed and cultured. Urinalysis, urine culture, blood cultures, and spinal fluid cultures are just a few. It is important to look at the blood smear and differential count. If the count is very high, a pathologist or hematologist should be called in without delay. An infectious disease specialist may be necessary.

Other Useful Tests

1. CBC (leukemia)

2. Sedimentation rate (infection)

3. Chemistry panel (liver disease, kidney disease, infarction)

4. Antinuclear antibody (ANA) analysis (collagen disease)

5. Blood smear for malarial parasites (malaria)

6. Monospot test (infectious mononucleosis)

7. Anti-streptolysin O (ASO) titer (rheumatic fever)

8. Bone marrow examination (leukemia)

9. Liver–spleen scan (neoplasm, myeloid metaplasia)

10. Bone scan (metastasis)

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