Clinical History:
- A 16-year-old boy is brought to the emergency department by his parents becuase he has been complaining of severe abdominal pain for the past day. On physical examination, he had a rigid, board-like abdomen and rebound tenderness in the right lower quandrant. His vital signs include temperature 38.3 C (101 F), pulse 84/minute, respirations 16/minute, and blood pressure 110/65 mm Hg. Laboratory studies include a CBC showing Hgb 14.8 g/dl, Hct 44.4%, MCV 90 fL, platelet count 240,000/microliter, and WBC count 20,000/microliter. A urinalysis is normal. His peripheral blood smear is shown.
- What is the predominant white blood cell present?
The white blood cells present here are polymorphonuclear leukocytes, both segmented neutrophils and band neutrophils, and notice that, at low power, the white blood cell count is higher than in a normal smear. Other cells present on the smear are lymphocytes and monocytes, but these are not increased and not seen in this field. However, the platelets are moderately increased in number.
- What is the name for this type of leukocyte reaction?
The name of this reaction is known as a neutrophilic leukemoid reaction. This is a prounounced neutrophilia. In this case extensive inflammation, as evidenced by the patient's signs suggesting appendiceal rupture, may be driving the process.
- What do you think is the diagnosis in this case?
The diagnosis in this case is acute appendicitis (most, but not all, cases of acute appendicitis are accompanied by peripheral neutrophilia). It is possible that there is another source of inflammation or a vasculitis or there has been trauma, but this is much less likely.
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