Ep 128: A 72-Year-Old with Elevated White Blood Cell Count
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Hi everyone, welcome back to Harrison's Pod Class. We're your co-hosts. I'm Dr. Kathy Handy. And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine. Welcome to episode 128, a 72-year-old with elevated white blood cell count. Okay, Kathy, today's case is going to be about lab studies. Your patient is a 72-year-old man with an 80-pack year history of smoking who presents to your clinic for his annual physical.

He has a history of hypertension and hyperlipidemia that have been well controlled on losartan and atorvastatin. He used to work in the steel mills, but he finally retired this year. He notes a new cough that has been going on for the past three months, as well as a 30-pound weight loss since his last visit. He denies any fevers, chills, or night sweats. He does say that he's lost his appetite to some extent. His vital signs are normal.

You obtain routine labs which show that he has a new increase in his mature granulocytes but no other abnormalities. Which of the following statements regarding his elevated white cell count is true? Option A: Approximately 70% of patients with solid tumors have granulocytosis. The granulocytosis is the likely cause of his symptoms. Treatment targeting the granulocytosis should begin immediately.

D, 35% of patients with granulocytosis have an underlying cancer. Or E, some tumors have been documented to produce granulocyte colony stimulating factor, which may be contributing to the granulocytosis in this patient.

Interesting. Let's start by saying that isolated granulocytosis is not uncommon, but it's usually related to an acute infection. It is not true that 35% of patients with granulocytosis found on routine testing have an underlying cancer. Okay, so option D is out. But assuming he does not have an infection, we should also clarify that granulocytosis related to a potential malignancy may be a direct response to a myeloproliferative malignancy or a paraneoplastic process.

In the myeloproliferative malignancies, the cell count elevation is due to a proliferation of the myeloid elements. However, this case has me worried about a primary lung malignancy given his work exposure and smoking history. Okay, so that's important. So it seems unlikely that the granulocytosis is causing his symptoms.

Yes, and I'll add that less than 50% of patients with solid tumors have granulocytosis. So not 70%, which is answer A. Okay, so we've eliminated options A, B, and D. Let's move on to discuss the paraneoplastic processes a little bit more.

Well, granulocytosis alone may be a paraneoplastic process. Tumors and tumor cell lines from patients with lung, ovarian, and bladder cancers have been documented to produce granulocyte colony stimulating factor, granulocyte macrophage colony stimulating factor, and or interleukin-6.

However, the etiology of granulocytosis has not been characterized in most patients. Patients with granulocytosis are nearly all asymptomatic, and the differential white blood cell count does not have a shift to immature forms of neutrophils.

Granulocytosis occurs in about 40% of patients with lung and GI cancers, about 20% of patients with breast cancer, 30% of patients with brain tumors and ovarian cancers, and about 20% of patients with Hodgkin's disease, and 10% of patients with renal cell carcinoma. Patients with advanced stage disease are more likely to have granulocytosis than are those with early stage disease. With very rare exception, these elevations are not associated with symptomatic abnormalities. What about the treatment?

The granulocytosis resolves when the underlying cancer is treated. It's not necessary to treat the granulocytosis, so option D is also incorrect. Okay, so the answer is E. Some tumors, some solid tumors particularly, have been documented to produce GCSF, which may be contributing to the granulocytosis found in this patient.

That's correct. So he should be referred for further diagnostic testing and evaluation for a lung malignancy. The extent of the paraneoplastic syndromes parallels the course of the cancer. And he'd be a candidate for a lung cancer screening anyways. Because of his smoking. Correct. Yeah, yeah. Good point. We've discussed that in prior episodes also.

Okay, so the teaching point in this case is that non-infectious granulocytosis may be directly related to a myeloproliferative process, or it may be a paraneoplastic manifestation of a solid relic C. And you can check out this question and other questions like it in Harrison's review questions, and more information can be found on the chapter on paraneoplastic syndromes.

Visit the show notes for links to helpful resources, including related chapters and review questions from Harrisons. And thank you so much for listening. If you enjoyed this episode, please leave us a review so we can reach more listeners just like you.