infection and normal WBC

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Specializes in assisted living.

Hi!

Just wondering why a WBC would be normal in the presence of an infection. This particular patient was admitted with cellulitis. His labs are 5.3 (4.2-10.5). So not even close to being high. All numbers in the differential are WNL. Is it just a matter of time before the WBC is too high? or what? Thanks :-)

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Specializes in Nephrology.

It all depends on what else is going on with your patient. Those whose immune systems are suppressed do not always have an elevated WBC. Also what is their baseline, it may be elevated for them.

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Might not be an infection. Was a culture submitted?

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Specializes in assisted living.

His culture was positive for Strep. He is on a big dose of antibiotics now....not immunocompromised either...

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Some patients just don't read the same books we do...

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Specializes in Maternal - Child Health.

There are a few possibilities.

This test was done at the very onset of the infection, before the patient's immune system began to respond. If so, subsequent CBC/differentials should show increasing white cell counts.

This individual has a yet unrecognized immune system disorder which is impairing the immune system's ability to mount a response to an infection. If so, subsequent CBC/differentials will probably show consistent low-normal white cell counts.

This individual's white count was elevated at the onset of the infection, but has dropped, which is an ominous sign that the infection is overwhelming the immune system. In this case, the differential may reveal an abnormally high number of bands (immature neutrophils), which the bone marrow releases prematurely in the event of severe infection to aid the few remaining adult neutrophils to fight the infection. (Kind of like sending children into fight when all the adults are dead or bleeding on the battle field.)

It would be interesting to see the patient's progress and CBC/differential over the next few days.

Given that he is hospitalized and on heavy duty antibiotics, I think his physician may be concerned that option #3 above describes his condition.

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How localized was it? If it's not systemic, why would there be elevated WBCs???

Was there the creamy white goop in any wound- or was it all closed and soft tissue? Being admitted for cellulitis perks my brain up for a bunch of other potentially complicating issues...

Will you keep this updated? :) It's interesting when the patients don't follow the rules :D

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Specializes in ED, CTSurg, IVTeam, Oncology.

from wiki:

  • body temperature less than 36°c or greater than 38°c
  • heart rate greater than 90 beats per minute
  • tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide less than 4.3 kpa (32 mmhg)
  • white blood cell count less than 4000 cells/mm³ (4 x 109 cells/l) or greater than 12,000 cells/mm³ (12 x 109 cells/l); or the presence of greater than 10% immature neutrophils (band forms)

the above is a description of systemic inflammatory response syndrome (sirs) in which two of the typical physiologic markers are actually opposite of what you would expect them to be, namely with no fever and no white count, but still septic.

see here also:

http://emedicine.medscape.com/article/168943-overview

http://www.uptodate.com/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis

thus, in the ed, if someone comes looking ill but with a low temperature, we don't discount infection; rather, we routinely draw blood cultures and a lactic acid, along with everything else, just to rule out sirs sepsis.

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Specializes in Med/Surg, Academics.
This individual's white count was elevated at the onset of the infection, but has dropped, which is an ominous sign that the infection is overwhelming the immune system. In this case, the differential may reveal an abnormally high number of bands (immature neutrophils), which the bone marrow releases prematurely in the event of severe infection to aid the few remaining adult neutrophils to fight the infection. (Kind of like sending children into fight when all the adults are dead or bleeding on the battle field.)

I just want to say that that is a spot-on analogy for teaching purposes.

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Specializes in NICU, PICU, PACU.

Agree with Jolie....you have to look at the whole picture...what did the diff show? We see this a lot with preemies...the WBC may be ok but the platelets and diff are totally out of whack!

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Agree with Jolie....you have to look at the whole picture...what did the diff show? We see this a lot with preemies...the WBC may be ok but the platelets and diff are totally out of whack!

i think she said all the diffs wnl.

i too, was wondering if pt was septic OR taking steroids...

which will also suppress immune response.

leslie

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Specializes in assisted living.

Wow! Thanks for your replies everyone! Okay, so the differential was all WNL, no bands. He was set to be discharged the next day so I guess systemic infection was not suspected. xtrn, would WBC's stay normal if infection is only localized? I thought they could go up with any trauma, inflammation, infection etc. Platelets are also normal but dropped from 240 to 200 over one day...is that normal or a concern? The antibiotic is a large dose, but he is also a big guy. I don't need to know all of this...just a patient in clinicals...but boy does it drive me crazy not to know or understand things :-)

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