Leukoerythroblastosis due to infections can resemble leukemia, differential diagnosis can be difficult. Bone marrow examination is essential for differential diagnosis. Herein we describe a patient with leukoerythroblastosis and hepatosplenomegaly associated with inguinal abscess which was difficult to distinguish from juvenile myelomonocytic leukemia. A 3-month-old boy was admitted to hospital with complaints of fever, vomiting and abdominal distension.
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Immature granulocytes are produced in reponse to infection or inflammation, where they are released form the marrow prematurely to compensate for the loss of granulocytes at the front line trenches. Band forms are not synonymous with immature granulocytes, but are used interchangeably.
A band cell is an immature neutrophil, but not all immature neutrophils are band cells. Essentially, a "band cell" features an elongated band-like nucleus, as opposed to a multilobed one.
These cells are an intermediate step on the way from myelocyte precursor cells to mature segmented neutrophils. If there is any more, that represents a "left shift", a change in the immature:mature ratio. According to Wikipedia , the term originates from some sort of "left-most button arrangement of early cell sorting machines", where the least mature cells myeloblasts were assigned to the left-most button of the manual counter. According to a article by Seebach et al , the utility of this finding in discriminating infectious from non-infectious causes of SIRS is poorer than neutrophil inclusion bodies such as toxic granules.
However, interest in using this parameter in discriminating sepsis from SIRS is still alive Nierhaus et al, This had appeared in Question 3. The question expected the candidates to recognise the phenomenon from a blood film with " nucleated red blood cells, immature granulocytes and band forms observed. There are many more than that, but boradly speaking anything which makles the marrow work harder could potentially promote this appearance.
The best source for this is probably the classic article by Weick et al, but it is not available for the casual Google user. Weick and colleagues reported on a case series of patients with this sort of picture.
Of them, the majority had some sort of malignant disease, and the others were either septic or bleeding tod eath typically from the GI tract. Subsequently, people have published on the finding of leukoerythroblastosis in almost every situation, ranging from pregnancy to the use of granulocyte stimulators. These little peripheral cytoplasmic inclusion bodies in the cytoplasm of neutrophils are thought to be the remnants of the rough endoplasmic reticulum.
They appear during leukemoid reactions, but they are also a feature of severe inflammatory states, and are generally considered to be a part of the "toxic" reaction to infection.
This has come up only once, in Question 9. It is possible that this will never appear again. If one is for some reason interested in this blood film abnormality, one may pursue it further, knowing well that doing so imperils their time-critical exam preparation.
The topic of neutrophil inclusion bodies is so esoteric that there is very little literature published on the subject, and pragmatic exam-oriented sites like LITFL dedicate an appropriately small amount of space to them. An excellent article about these little lumps was written by Weiner and Topley in The bodies were fist discovered in Bain, Barbara J. Sakka, Vissaria, et al. Weiner, W. Kulkarni, M.
Agrawal, and V. Easton, J. Cawley, J. Nierhaus, Axel, et al. Shamdas, Glenn J. Weick, J. Hagedorn, and J. Diagnostic and prognostic significance. Previous chapter: Leukemoid reaction Next chapter: Plasmacytosis and smudge cell lymphocytes. All SAQs related to this topic. All vivas related to this topic. Immature granulocytes and band forms Immature granulocytes are produced in reponse to infection or inflammation, where they are released form the marrow prematurely to compensate for the loss of granulocytes at the front line trenches.
The significance and causes of a "left shift " The following conditions can give rise to an increased proportion of immature neutrophils: Sepsis Haemorrhage due to adrenergic mobilisation of marrow neutrophils Necrosis of any sort, eg. Leukoerythroblastic reaction This had appeared in Question 3. In summary, the possible causes of leukoerythroblastosis are: Bone marrow inflitration "myelophthisis" Leukaemia Myelofibrosis Solid tumour infiltration, eg.
References Bain, Barbara J. Email Address. Send Message.
Leukoerythroblastosis Mimicking Leukemia: A case report