13-22: Neutropenia

ESSENTIALS OF DIAGNOSIS

GENERAL CONSIDERATIONS

Neutropenia is present when the absolute neutrophil count is less than 1800/mcL (1.8 × 10⁹/L), although Black, Asian, and other persons in specific ethnic groups may have normal neutrophil counts as low as 800–1200/mcL (1.2 × 10⁹/L) or even less. The neutropenic patient is increasingly vulnerable to infection by gram-positive and gram-negative bacteria and by fungi. The risk of infection is related to the severity of neutropenia. The risk of serious infection rises sharply with neutrophil counts below 500/mcL (0.5 × 10⁹/L), and a high risk of infection within days occurs with neutrophil counts below 100/mcL (0.1 × 10⁹/L) (“profound neutropenia”). The classification of neutropenic syndromes is unsatisfactory as the pathophysiology and natural history of different syndromes overlap. Patients with “chronic benign neutropenia” are free of infection despite very low stable neutrophil counts; they respond adequately to infections and inflammatory stimuli with an appropriate neutrophil release from the bone marrow. In contrast, the neutrophil count of patients with cyclic neutropenia periodically oscillates (usually in 21-day cycles) between normal and low, with infections occurring during the nadirs. Congenital neutropenia is lifelong neutropenia punctuated with bouts of infection. Both cyclic neutropenia and congenital neutropenia represent problems in mutations in the neutrophil elastase gene ELANE (also called ELA-2).

A variety of bone marrow disorders and non-marrow conditions may cause neutropenia (Table 13–12). All of the causes of aplastic anemia (Table 13–10) and pancytopenia (Table 13–11) may cause neutropenia. The new onset of an isolated neutropenia is most often due to an idiosyncratic reaction to a medication, and agranulocytosis (complete absence of neutrophils in the peripheral blood) is almost always due to a drug reaction. In these cases, examination of the bone marrow shows an almost complete absence of granulocyte precursors with other cell lines undisturbed. This marrow finding is also seen in pure WBC aplasia, an autoimmune attack on marrow granulocyte precursors. Neutropenia in the presence of a normal bone marrow may be due to immunologic peripheral destruction (autoimmune neutropenia), sepsis, or hypersplenism. The presence in the serum of antineutrophil antibodies supports the diagnosis of autoimmune neutropenia but does not prove this as the pathophysiologic reason for neutropenia. Felty syndrome is an immune neutropenia associated with seropositive nodular rheumatoid arthritis and splenomegaly. Severe neutropenia may be associated with clonal disorders of T lymphocytes, often with the morphology of large granular lymphocytes, referred to as CD3-positive T-cell large granular lymphoproliferative disorder. Isolated neutropenia is an uncommon presentation of hairy cell leukemia or MDS. By its nature, myelosuppressive cytotoxic chemotherapy causes neutropenia in a predictable manner.