Ep 128: A 72-Year-Old with Elevated White Blood Cell Count

This episode presents a 72-year-old man with presumed non-infectious granulocytosis. The discussion focuses on the differential diagnosis and therapy.

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Transcript

[upbeat intro music]

[Dr. Handy] Hi everyone. Welcome

back to Harrison's Podclass.

We're your co-hosts. I'm Dr. Cathy Handy.

[Dr. Wiener] And I'm Dr.

Charlie Wiener and we're joining

you from the Johns Hopkins

School of Medicine.

[music continues]

Welcome to episode 128: a 72-year-old

with elevated white blood cell count.

Okay, Cathy, 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, 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.

B. the granulocytosis is the

likely cause of his symptoms.

C. 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 granulocytes

colony-stimulating factor which may

be contributing to the

granulocytosis in this patient.

[Dr. Handy] 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.

[Dr. Wiener] Okay, so option D. is out.

[Dr. Handy] 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.

[Dr. Wiener] Okay, so that's

important. So it seems unlikely

that the granulocytosis

is causing his symptoms.

[Dr. Handy] Yes, and I'll add

that less than 50% of patients

with solid tumors have granulocytosis.

So not 70%, which is answer A.

[Dr. Wiener] Okay. So we've

eliminated options A, B, and D.

Let's move on to discuss

the paraneoplastic processes

a little bit more.

[Dr. Handy] 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.

[Dr. Wiener] What about the treatment?

[Dr. Handy] The granulocytosis resolves

when the underlying cancer is treated.

It's not necessary to

treat the granulocytosis.

So option D. is also incorrect.

[Dr. Wiener] 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.

[Dr. Handy] That's correct.

So he should be referred for

further diagnostic testing and

evaluation for a lung malignancy.

The extent that the

paraneoplastic syndromes parallels

the course of the cancer,

and he'd be a candidate for a

lung cancer screening anyways.

[Dr. Wiener] Because of his smoking?

[Dr. Handy] Correct.

[Dr. Wiener] 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 malignancy.

[Dr. Handy] And you can

check out this question

and other questions like it in

Harrison's Review Questions,

and more information can

be found in the chapter

on paraneoplastic syndromes.

Visit the show notes for

links to helpful resources,

including related chapters

and review questions from Harrison's.

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.

[upbeat outro music]