White Blood Cell Count (WBC) and Differential

White blood cells, or leukocytes, are classified into two main groups: granulocytes and nongranulocytes (also known as agranulocytes).

The granulocytes, which include neutrophils, eosinophils, and basophils, have granules in their cell cytoplasm. Neutrophils, eosinophils, and basophils also have a multilobed nucleus. As a result they are also called polymorphonuclear leukocytes or "polys." The nuclei of neutrophils also appear to be segmented, so they may also be called segmented neutrophils or "segs." The nongranuloctye white blood cells, lymphocytes and monocytes, do not have granules and have nonlobular nuclei. They are sometimes referred to as mononuclear leukocytes.

The lifespan of white blood cells ranges from 13 to 20 days, after which time they are destroyed in the lymphatic system. When immature WBCs are first released from the bone marrow into the peripheral blood, they are called "bands" or "stabs." Leukocytes fight infection through a process known as phagocytosis. During phagocytosis, the leukocytes surround and destroy foreign organisms. White blood cells also produce, transport, and distribute antibodies as part of the body's immune response. Two measurements of white blood cells are commonly done in a CBC:

the total number of white blood cells in a microliter (1x10-6 liters) of blood, reported as an absolute number of "X" thousands of white blood cells, and the percentage of each of the five types of white blood cells. This test is known as a differential or "diff" and is reported in percentages.

Normal values for total WBC and differential in adult males and females are:

Total WBC: 4,500 - 10,000 Bands or stabs: 3 - 5 %

Granulocytes (or polymorphonuclears) o Neutrophils (or segs): 50 - 70% relative value (2500-7000 absolute value) o Eosinophils: 1 - 3% relative value (100-300 absolute value) o Basophils: 0.4% - 1% relative value (40-100 absolute value) Agranulocytes (or mononuclears) o Lymphocytes: 25 - 35% relative value (1700-3500 absolute value) o Moncytes: 4 - 6% relative value (200-600 absolute value)

Each differential always adds up to 100%. To make an accurate assessment, consider both relative and absolute values. For example a relative value of 70% neutrophils may seem within normal limits; however, if the total WBC is 20,000, the absolute value (70% x 20,000) would be an abnormally high count of 14,000. The numbers of leukocytes changes with age and during pregnancy.

On the day of birth, a newborn has a high white blood cell count, ranging from 9,000 to 30,000 leukocytes. This number falls to adult levels within two weeks. The percentage of neutrophils is high for the first few weeks after birth, but then lymphocyte predominance is seen. Until about 8 years of age, lymphocytes are more predominant than neutrophils. In the elderly, the total WBC decreases slightly. Pregnancy results in a leukocytosis, primarily due to an increase in neutrophils with a slight increase in lymphocytes.

Leukocytosis, a WBC above 10,000, is usually due to an increase in one of the five types of white blood cells and is given the name of the cell that shows the primary increase.

Neutrophilic leukocytosis = neutrophilia Lymphocytic leukocytosis = lymphocytosis Eosinophilic leukocytosis = eosinophilia Monocytic leukocytosis = monocytosis Basophilic leukocytosis = basophilia

In response to an acute infection, trauma, or inflammation, white blood cells release a substance called colony-stimulating factor (CSF). CSF stimulates the bone marrow to increase white blood cell production. In a person with normally functioning bone marrow, the numbers of white blood cells can double within hours if needed. An increase in the number of circulating leukocytes is rarely due to an increase in all five types of leukocytes. When this occurs, it is most often due to dehydration and hemoconcentration. In some diseases, such as measles, pertussis and sepsis, the increase in white blood cells is so dramatic that the picture

resembles leukemia. Leukemoid reaction, leukocytosis of a temporary nature, must be differentiated from leukemia, where the leukocytosis is both permanent and progressive. Therapy with steroids modifies the leukocytosis response. When corticosteroids are given to healthy persons, the WBC count rises. However, when corticosteroids are given to a person with a severe infection, the infection can spread significantly without producing an expected WBC rise. An important concept to remember is that, leukocytosis as a sign of infection can be masked in a patient taking corticosteroids. Leukopenia occurs when the WBC falls below 4,000. Viral infections, overwhelming bacterial infections, and bone marrow disorders can all cause leukopenia. Patients with severe leukopenia should be protected from anything that interrupts skin integrity, placing them at risk for an infection that they do not have enough white blood cells to fight. For example, leukopenic patients should not have intramuscular injections, rectal temperatures or enemas. Drugs that may produce leukopenia include:

Antimetabolites Barbiturates Antibiotics Anticonvulsants Antithyroid drugs Arsenicals Antineoplastics Cardiovascular drugs Diuretics Analgesics and anti-inflammatory drugs Heavy metal intoxication

Leukocytes: critical low and high values

A WBC of less than 500 places the patient at risk for a fatal infection. A WBC over 30,000 indicates massive infection or a serious disease such as leukemia.

When a patient is receiving chemotherapy that suppresses bone marrow production of leukocytes, the point at which the count is lowest is referred to as the nadir.

Differential

Neutrophils Neutrophils are so named because they are not well stained by either eosin, a red acidic stain, nor by methylene blue, a basic or alkaline stain. Neutrophils, are also known as "segs", "PMNs" or "polys" (polymorphonuclears). They are the body's primary defense against bacterial infection and physiologic stress. Normally, most of the neutrophils circulating in the bloodstream are in a mature form, with the nucleus of the cell being divided or segmented. Because of the segmented appearance of the nucleus, neutrophils are sometimes referred to as "segs." The nucleus of less mature neutrophils is not segmented, but has a band or rod-like shape. Less mature neutrophils - those that have recently been released from the bone marrow into the bloodstream - are known as "bands" or "stabs". Stab is a German term for rod.
Increased neutrophil count

An increased need for neutrophils, as with an acute bacterial infection, will cause an increase in both the total number of mature neutrophils and the less mature bands or stabs to respond to the infection. The term "shift to the left" is often used when determining if a patient has an inflammatory process such as acute appendicitis or cholecystitis. This term is a holdover from days in which lab reports were written by hand. Bands or stabs, the less mature neutrophil forms, were written first on the left-hand side of the laboratory report. Today, the term "shift to the left" means that the bands or stabs have increased, indicating an infection in progress. For example, a patient with acute appendicitis might have a "WBC count of 15,000 with 65% of the cells being mature neutrophils and an increase in stabs or band cells to 10%". This report is typical of a "shift to the left", and will be taken into consideration along with history and physical findings, to determine how the patient's appendicitis will be treated.

In addition to bacterial infections, neutrophil counts are increased in many inflammatory processes, during physical stress, or with tissue necrosis that might occur after a severe burn or a myocardial infarction. Neutrophils are also increased in granulocytic leukemia.
Decreased neutrophil count

A decrease in neutrophils is known as neutropenia. Although most bacterial infections stimulate an increase in neutrophils, some bacterial infections such as typhoid fever and brucelosis and many viral diseases, including hepatitis, influenza, rubella, rubeola, and mumps, decrease the neutrophil count. An overwhelming infection can also deplete the bone marrow of neutrophils and produce neutropenia. Many antineoplastic drugs used to treat cancer produce bone marrow depression and can significantly lower the neutrophil count. Types of drugs that can produce neutropenia include some antibiotics, the psychotropic drug lithium, phenothiazines, and tricyclic antidepressants. Eosinophils Eosinophils are associated with antigen-antibody reactions. The most common reasons for an increase in the eosinophil count are allergic reactions such as hay fever, asthma, or drug hypersensitivity. Decreases in the eosinophil count may be seen when a patient is receiving corticosteroid drugs. Basophils The purpose of basophils is not completely understood. Basophils are phagocytes and contain heparin, histamines, and serotonin. Tissue basophils are also called"mast cells." Similar to blood basophils, they produce and store heparin, histamine, and serotonin. Basophil counts are used to analyze allergic reactions. An alteration in bone marrow function such as leukemia or Hodgkin's disease may cause an increase in basophils. Corticosteroid drugs, allergic reactions, and acute infections may cause the body's small basophil numbers to decrease. Lymphocytes Lymphocytes are the primary components of the body's immune system. They are the source of serum immunoglobulins and of cellular immune response. As a result, they play an important role in immunologic reactions. All lymphocytes are produced in the bone marrow. The B-cell lymphocyte also matures in the bone marrow; the T-cell lymphocyte matures in the thymus gland. The B cells control the antigen-antibody response that is

specific to an offending antigen. The T cells are the master immune cells of the body, consisting of T-4 helper cells, killer cells, cytotoxic cells, and suppressor T-8 cells. The majority of lymphocytes that circulate in the blood are T-lymphocytes, rather than B-lymphocytes. To help diagnose immune system deficiencies such as AIDS, the lab does specialized tests of Tlymphocytes. In the WBC, T and B-lymphocytes are reported together. In adults, lymphocytes are the second most common WBC type after neutrophils. In young children under age 8, lymphocytes are more common than neutrophils. Lymphocytes increase in many viral infections and with tuberculosis. A common reason for significant lymphocytosis is lymphocytic leukemia. The majority of both acute and chronic forms of leukemia affect lymphocytes. Due to research on HIV infection, a virus that affects T-lymphocytes, much more is now known about lymphocytes and their functions. HIV causes a reduction in the total number of lymphocytes as well as changes in the ratios of the types of T-lymphocytes. Corticosteroids and other immunosuppressive drugs also cause lymphopenia. A decreased lymphocyte count of less than 500 places a patient at very high risk of infection, particularly viral infections. It is important when the lymphocyte count is low to implement measures to protect the patient from infection. Monocytes Monocytes are the largest cells in normal blood. They act as phagocytes in some inflammatory diseases and are the body's second line of defense against infection. Phagocytic monocytes produce the antiviral substance interferon. Diseases that cause a monocytosis include tuberculosis, malaria, Rocky Mountain spotted fever, monocytic leukemia, chronic ulcerative colitis and regional enteritis