Conditions Associated with Leukocytosis in a Tertiary Care Hospital, with Particular Attention to the Role of Infection Caused byClostridium difficile

Abstract

Few modern studies have enumerated the conditions associated with leukocytosis. Our clinical experience has implicated Clostridium difficile infection in a substantial proportion of patients with leukocytosis. In a prospective, observational study of 400 inpatients with WBC counts of >/=15,000 cells/mm(3), we documented >/=1 infection in 207 patients (53%). Of these 207 patients, 97 (47%) had pneumonia, 60 (29%) had urinary tract infection, 34 (16%) had soft-tissue infection, and 34 (16%) had C. difficile infection. C. difficile infection was present in 25% of patients with WBC counts of >30,000 cells/mm(3) who did not have hematological malignancy. Other causes of leukocytosis in the 400 patients included physiological stress, in 152 patients (38%); medications or drugs, in 42 (11%); hematological disease, in 22 (6%); and necrosis or inflammation, in 22 (6%). C. difficile infection is a prominent cause of leukocytosis and this diagnosis should be considered for patients with WBC counts of >/=15,000 cells/mm(3), even in the absence of diarrheal symptoms.

Clinical update for the diagnosis and treatment ofClostridium difficileinfection

“…Wanahita found a mean WBC of 15800/mm 3 with 26% of patients having a WBC > 20000/mm 3 and 6% > 30000/mm 3 . In fact, for all patients without a hematologic malignancy who had a WBC > 30000/mm 3 , 25% were found to have CDI [34] . The elevation of WBC may even precede the onset of diarrhea or abdominal discomfort [35] and may be responsible for up to 58% of cases of unexplained leukocytosis in hospitalized patients [36] .…”

“…Leukocytosis, hypoalbuminemia and elevation of baseline serum creatinine are highly suggestive of CDI. Elevated white blood cell (WBC) count is common (50%-60%), as well as increased band forms (47%) and may be marked elevated [34] . Wanahita found a mean WBC of 15800/mm 3 with 26% of patients having a WBC > 20000/mm 3 and 6% > 30000/mm 3 .…”

Znacaj leukocitoze kod bolesnika sa Clostridium difficile infekcijom

“…U fulminantnoj formi bolesti prisutan je difuzni bol u trbuhu, distenzija trbuha, povišena temperatura, hipovolemija, acidoza, hipoalbuminemija i visoke vrednosti leukocitoze, čiji brz porast na nivo između 30 x10 9 /L i 50 x 10 9 /L predstavlja važan upozoravajući indikator razvoja ove forme kolitisa. Kod fulminantne forme moguća je pojava komplikacija u vidu ileusa, toksičnog megakolona i intestinale perforacije [3,10,11]. Ponovna pojava simptoma posle uspešne inicijalne terapije (rekurentna bolest), bilo zbog relapsa prethodne infekcije ili reinfekcije novim sojem, javlja se u 10-25% slučajeva.…”

“…Može se javiti nekoliko dana ili nedelja nakon terapije, a klinička slika može biti slična ili teža nego kod inicijalne infekcije [11]. Poslednjih godina u više studija naglašena je važnost leukocitoze kao jedne od glavnih manifestacija CDI [10].…”

“…Leukocitoza je inače normalan odgovor koštane srži na spoljašnju stimulaciju, bilo da je u pitanju infekci ja, trauma, trovanje, maligna bolest ili neko drugo stanje [13]. Leukocitoza nepoznate etiologije kod hospitalizo vanih bolesnika vrlo često predstavlja sam početak ne prepoznate infekcije izazvane CD [10,14]. U patogenezi CDI, najvažniju ulogu imaju toksini A i B koji dovode do oštećenja epitelnih ćelija mukoze, istovremeno iza zivajući i inflamaciju sa migracijom zapaljenjskih ćelija među kojima su dominantni polimorfonuklearni leu kociti.…”