Neutropenia

Causes

• DANC (Duffy-null Associated Neutrophil count) - inherited benign neutropenia in individuals of African descent and certain other ethnic groups

• Familial Neutropenia

• Congenital

• Infection

• Medication

• Nutritional

  • B12, Folate, Copper

• Haematological malignancies

  • Large granular lymphocyte leukaemia

  • Hairy cell leukaemia

• Rheumatological

  • Rheumatoid arthritis

  • SLE

• Autoimmune neutropenia

• Aplastic anaemia

• Chronic idiopathic neutropenia

Evaluation:

FBC with differential count should be repeated to confirm the level of Absolute Neutrophil Count

The common causes of isolated mild neutropenia in adults are

• DANC

• Dose-dependent drug-induced neutropenia

• Infections usually viral

Less common causes

• Nutritional deficiencies

• Rheumatology

• Haematology e.g. myelodysplasia

Other accompanying abnormalities

• Esoinophilia and/or basophilia

  • Drugs reaction

  • Allergy

  • Infection especially parasites

  • Cancer

• Lymphocytes

  • Lymphocytosis e.g. Leukemia

  • Lymphopenia e.g. immunodeficiency

• Anaemia

  • Haemolytic anaemia - DIC, TTP

  • Anaemia of chronic disease

  • Macrocytic e.g. B12/Fol

  • Aplastic

  • Myeloplthisic disorders

• Platelet

  • Thrombocytopenia e.g. DIC

  • Thrombocytosis

    • Infection

    • Inflammation

History:

• Active or prior infection or inflammatory process

• Episodic aphthous ulcers and/or infections

  • Cyclic neutropenia

• Previous malignancy

• GIT disorders

  • IBD

  • Bariatric surgery

  • Liver disease

• Infections

  • HIV, EBV, Parasites

• Medications

• Exposures

  • Diet e.g. Vegan

  • Alcohol

  • Organic solvents

  • Travel history

• Family history.

  • Neutropenia

  • Bone marrow failure

  • Haem disorders

• Ethnicity

Examination:

• Evidence of infection

  • Fever

  • Skin erythema, ulcers, fissures

  • Gingivitis, swelling, oral ulceration, dental pain

  • Abnormal respiratory exam

• Findings to help determine the cause

  • Jaundice = liver

  • Joint swelling or bone pain = rheum, infection, malignancy

  • Rash = Rheum or drugs

  • Lymphadenopathy / splenomegaly = Malignancy

  • Neuro / Psych = B12, copper, alcohol, HIV

Peripheral blood smear:

• Neutrophils

  • Toxic granulations or Dohle bodies = sepsis

  • Bilobed or dysplastic neutrophils = MDS or congenital

  • Hypersegmented neutrophils = megaloblastic = B12 / Folate

  • Immature myeloid cells = AML

• Lymphocytes

  • Atypical = viral e.g. EBV, CMV

  • Smudge = CLL

  • Hair-like = Hairy cell leukemia

  • Azurophillic granules = LGL Leukemia

• Red blood cells

  • Macro-ovalocytes = Megaloblastic anaemia

  • Fragmented cells = DIC

  • Tear drop-shaped = Myelophthisic

  • Spiculated = Liver

Blood tests:

• Vitamin B12, Folate, Copper

• LFT and then if needed HIV, Hep B +C

• Coags

• LDH, UEC

• If febrile consider testing for infections if appropriate (EBV, HIV, Hep) or if clinically relevant (CMV, Toxo in pregnancy)

• ESR/CRP may be useful

• Only screen ANA, Anti-DNA, C3 C4 if symptoms

Reference:

Unexplained Neutropenia - UTD