Persistent leukocytosis in a healthy premie

[abeluchin]

46 days old; former 28 weeker premature baby with persistent leukocytosis for over four weeks now.

Uncomplicated NICU course so far.  Since about the second week of life, the baby has had persistent leukocytosis with wbc count in the low to high 30k's. Baby has had multiple crp done and all normals. Culture from blood and Urine including fungal normal as well. Had a course of Meropenem for suspected UTI with 10k colonies of enterococcus fecalis in the urine; but despite negative repeat urine culture and after treatment; leukocytosis persisted. About two weeks ago; now baby with mild thrombocytopenia 80-90k. Cardiac echo done, renal and abdominal US all normal. Viral culture, RPR and urine CMV all negative as well.

Currently baby is on room air; growing great. Feeding great. Had completed a 7 days with Fluconazole; without any improvement

Hem consulted. Requested a flow cytometry; with left sided neutrophilia with 4% blast. Bone marrow not entertained at this point!

What do you think? Anything comes to mind?

Thanks

[chandas]

1. Consider osteomyelitis and septic arthritis.

2. Leucocyte Adhesion Defects (LAD) cause leukocytosis. Delayed cord separation and lack of pus are indicators; haematology/immunology will be able to check for it.

[Vijaykumar]

caffiene ?

[Stefan Johansson]

@Vijaykumar Do you mean that caffeine can lead to leucocytosis? If yes, I was not aware of it

Could this be a neonatal leukemoid reaction? I am aware this is a "ruling out" diagnosis, but if all testing turns out negative, it would be a likely diagnosis.

[Dr. Saad Ahmed Seth]

IVH? 
If WBC counts are showing upward trend I would do LDH.. if it high I would suggest to repeat flow cytometery, as there are 2 cell lines involved or consider bone marrow.

[PHutchings]

4 hours ago, abeluchin said:

46 days old; former 28 weeker premature baby with persistent leukocytosis for over four weeks now.

Uncomplicated NICU course so far.  Since about the second week of life, the baby has had persistent leukocytosis with wbc count in the low to high 30k's. Baby has had multiple crp done and all normals. Culture from blood and Urine including fungal normal as well. Had a course of Meropenem for suspected UTI with 10k colonies of enterococcus fecalis in the urine; but despite negative repeat urine culture and after treatment; leukocytosis persisted. About two weeks ago; now baby with mild thrombocytopenia 80-90k. Cardiac echo done, renal and abdominal US all normal. Viral culture, RPR and urine CMV all negative as well.

Currently baby is on room air; growing great. Feeding great. Had completed a 7 days with Fluconazole; without any improvement

Hem consulted. Requested a flow cytometry; with left sided neutrophilia with 4% blast. Bone marrow not entertained at this point!

What do you think? Anything comes to mind?

Thanks

And Covid IG G NEGATIVE? 

Any response to immunoglobulin ? 

[manuel perez valdez]

10 hours ago, Dr. Saad Ahmed Seth said:

IVH? 
If WBC counts are showing upward trend I would do LDH.. if it high I would suggest to repeat flow cytometery, as there are 2 cell lines involved or consider bone marrow.

Physiological leucocytosis is common in neonates. Leukemoid reaction is defined as a variable degree of leucocytosis with immature precursors, similar to that occurring in leukaemia but because of other causes. Leukemoid reactions are well-recognised in the neonatal intensive care unit population and are associated with antenatal corticosteroids, Down's syndrome, chorioamnionitis, funisitis and perinatal infections. However, extreme hyperleucocytosis, exceeding a white blood cell count of 100×10⁹/l is rare. In the 7-year period from 2005 to 2012 three premature infants in our hospital presented with extreme hyperleucocytosis. Since there were no signs of neonatal leukaemia, transient myeloid disorder or leucocyte adhesion defect, a leukemoid reaction owing to antenatal corticosteroids, chorioamnionitis and funisitis was diagnosed. No obvious complications of hyperleucocytosis were observed. Therapy was not necessary and the leucocytes normalised spontaneously.
In other hand, should consider bdp. 
https://pediatrics.aappublications.org/content/pediatrics/116/1/e43.full.pdf

[selvanr4]

now the baby is 34 + weeks. Why a drop in platelet in baby growing  great?

i will rather observe and repeat after 72 hrs

[abeluchin]

Baby went home a couple of days ago. Wbc count at the lowest 26k and platelet count persistently above 120k