Hello dear See as per clinical history it seems Severe infection with leukaemia reaction not leukaemia Differential diagnosis includes Sepsis Bone marrow dysorder Iam suggesting some tests for confirmation Please share the result with concerned physician only for better clarity and for safety please donot take any medication without consulting the concerned physician CBC Esr LDH Rft Urine analysis Lft PBS Bcr-abl test Hemogram Serum tsh Serum ferritin Hopefully you recover soon Regards
Hello Doctor, thank you so much for your valuable time and advice. Fortunately, we have already got most of the tests done that you have suggested. Here are the key results from the reports: Peripheral Blood Smear (PBS): Shows Promyelocytes 3%, Metamyelocytes 4%, and Basophils 4%. (TLC is 50,400). The Pathologist has clearly mentioned “Suspicion of Myeloproliferative Disorder” in the impression. CRP: 0.8 mg/L (Absolutely normal, which makes a leukemoid reaction less likely). RFT & Biochemistry: Creatinine has spiked to 1.62. TSH is 9.52. HbA1c is 5.0%. USG Whole Abdomen: Shows a 3.1 mm calculus in the left kidney (which is causing her severe left flank pain) along with a severe UTI (30-40 pus cells in urine). Spleen size is normal. Because of the PBS findings and a completely normal CRP, it looks like an underlying Bone Marrow disorder (possibly CML) running parallel to an acute kidney stone/UTI issue.
Hello dear Thanks for the response. Yes it was one of the suspected provisional diagnosis I suggest you to get opinion of nephrologist since some medication have renal impact Regards
Hello. Based on the details you provided, your mother appears to have a significant acute inflammatory/infectious process, and the doctors are appropriately evaluating whether this is a severe infection causing a leukemoid reaction versus an underlying hematological disorder such as leukemia.
At present, the overall picture seems more suggestive of a severe infection/inflammatory response because: - Very high neutrophils (82.9%) and ANC >42,000 commonly occur in bacterial infections - Urine showing pus cells, protein, and RBCs suggests urinary tract infection/possible pyelonephritis - Fever, weakness, abdominal/flank/back pain fit infection/inflammation - Kidney stones can predispose to urinary infection - Platelet elevation and ESR elevation can also occur reactively in infection/inflammation
A leukemoid reaction means the body is producing an extreme rise in WBCs due to severe stress/infection rather than blood cancer itself. However, because the TLC is extremely high (~51,000), doctors are correctly ruling out leukemia as well. Peripheral smear (PBS), CRP, repeat CBC trends, and possibly additional hematology tests will help differentiate the two.
Features that somewhat favor leukemoid reaction over leukemia at present: - Acute onset - Fever and infection markers - Predominantly mature neutrophils - No mention of blasts yet - Platelets elevated rather than severely low
Important pending reports: - Peripheral blood smear (very important) - CRP/procalcitonin - Blood and urine cultures - LDH if advised - Hematology opinion if counts remain high
The elevated sugars (235–300+) may be stress hyperglycemia or previously unrecognized diabetes, and this also increases infection risk. Breathing discomfort should be monitored carefully because severe infection/sepsis can affect multiple systems.
Things doctors will likely monitor: - Whether WBC count falls after antibiotics - Fever trend - Oxygen saturation - Kidney/liver function - Signs of sepsis
Final Impression / Advice: 1. Current picture more strongly suggests severe bacterial infection with leukemoid reaction, but leukemia still needs exclusion 2. Continue hospital treatment and IV antibiotics as advised 3. Peripheral smear and hematology review are essential 4. Urine infection/renal source should be treated aggressively 5. Monitor blood sugar carefully during illness 6. Immediate escalation if confusion, low BP, worsening breathing, or reduced urine output develops
If you receive the PBS or CRP report, that would provide much more clarity regarding infection vs hematological disease.
Feel free to reach out again.
Regards, Dr. Nirav Jain MBBS, D.Fam.Medicine
Hello Doctor, thank you so much for your detailed guidance. As you advised, we got the pending tests done, and the new reports have provided much more clarity. Here are the latest updates from yesterday and today: CRP Report: 0.8 mg/L (Absolutely Normal) Peripheral Blood Smear (PBS): Pathologist has raised suspicion of “Myeloproliferative Disorder”. Shows Promyelocytes 3%, Metamyelocytes 4%, Basophils 4%. (TLC is 50,400 and Platelets 5.98 Lacs). USG Whole Abdomen: Left kidney shows a 3.1 mm calculus (causing severe left flank pain). Right kidney shows multiple tiny concretions. No hydronephrosis. Spleen is normal (121mm). Biochemistry: Creatinine has increased to 1.62 (probably due to the stone and infection stress). HbA1c is 5.0% (confirming no history of diabetes, previous high sugars were just stress hyperglycemia). TSH is 9.52. Since the CRP is normal and PBS shows immature cells, it seems the elevated WBC is not a Leukemoid Reaction, but rather points towards an underlying CML/Myeloproliferative disorder running parallel to the acute UTI/Kidney stone issue.
Thank you for sharing the updated reports. Yes, with the new information, the picture is now leaning more toward an underlying myeloproliferative neoplasm (especially Chronic Myeloid Leukemia/CML spectrum) rather than a pure leukemoid reaction alone.
The important points supporting this are: - Persistently very high TLC (~50,000) - Marked neutrophilia with left shift - Presence of immature myeloid cells (promyelocytes, metamyelocytes) - Basophilia (4%) is particularly important because basophilia is more suggestive of CML/myeloproliferative disease than simple infection - Persistently elevated platelets (thrombocytosis) - CRP being completely normal despite such high counts argues against severe active bacterial inflammatory response as the sole explanation
At the same time, she likely ALSO has a concurrent urinary tract issue/renal stone-related pain: - Pus cells in urine - Renal calculi - Flank pain - Mild creatinine rise
So your interpretation is medically quite reasonable: there may be an underlying chronic hematological disorder that was incidentally uncovered during evaluation of an acute urinary/kidney issue.
The next most important steps now are: - Hematology consultation urgently - BCR-ABL testing (very important for confirming/excluding CML) - Bone marrow study if advised - LDH, uric acid, repeat CBC trend - Monitoring spleen size clinically and on imaging
The reassuring points currently are: - No blasts mentioned - Spleen not enlarged - Hb only mildly reduced - Platelets elevated rather than falling - Patient appears hemodynamically stable
These findings may fit a chronic-phase myeloproliferative disorder if confirmed.
TSH 9.52 also suggests hypothyroidism, though this is likely a separate issue and not the main cause of these blood count abnormalities. Creatinine rise to 1.62 should be monitored carefully with hydration and treatment of the urinary/stone issue.
Final Impression: 1. Strong suspicion of chronic myeloproliferative disorder/CML spectrum 2. Concurrent UTI/renal calculus issue likely contributing to symptoms 3. Hematology workup (especially BCR-ABL) is now essential 4. Continue current renal/infection management and hydration 5. Monitor CBC, creatinine, uric acid, and electrolytes closely
If BCR-ABL comes positive, treatment options today are generally very effective, especially when diagnosed in chronic phase.
Hello
Your mother’s reports and symptoms strongly suggest that there is a significant ongoing inflammatory or infectious process in the body, and the current treatment and hospital admission are appropriate. A TLC around 50,000 with predominantly neutrophils can occur in two major situations: a severe infection/inflammation causing a leukemoid reaction, or a blood-related disorder such as leukemia. Based on the information you shared, both are still being evaluated, which is why the doctors are waiting for the peripheral smear (PBS), CRP, and possibly further hematology tests.
Several findings point toward a severe infection as a possible explanation:
* Fever, weakness, abdominal/flank pain, and tenderness * Urine showing many pus cells and protein * Kidney stones, which can sometimes trigger urinary infection/inflammation * Very high neutrophils, which commonly rise in bacterial infections * Elevated ESR and stress-related high sugars during illness
A leukemoid reaction is basically an extreme rise in WBC count due to severe infection, inflammation, stress, or another serious illness, and counts can sometimes become very high. The fact that kidney function and liver function are largely preserved is reassuring. However, because the WBC count is extremely elevated, doctors must also rule out hematologic conditions like chronic myeloid leukemia or other bone marrow disorders, especially with the previously high platelet count and anemia.
The peripheral smear is very important because it helps doctors see whether the white cells look reactive/infection-related or abnormal/immature as seen in leukemia. CRP and possibly procalcitonin can also support severe infection. Depending on the smear result, they may consider tests such as LDH, bone marrow studies, flow cytometry, or BCR-ABL testing if needed.
Her breathing discomfort, weakness, abdominal tenderness, and high sugars should continue to be monitored closely in the hospital because severe infection can sometimes affect multiple systems even before organ tests become abnormal.
At this stage, it is good that antibiotics and supportive care have already been started. Many patients with severe infections and leukemoid reactions improve once the underlying infection is controlled, but close monitoring is very important until the pending reports clarify the exact cause.
Thank you Feel free to talk
Hello Doctor, thank you so much for the detailed explanation and for your valuable time. We have received the pending reports now, and they clearly point toward a hematological disorder running parallel to the acute UTI/Kidney stone issue: CRP Report: It came back absolutely normal (0.8 mg/L), which makes a leukemoid reaction highly unlikely. Peripheral Blood Smear (PBS): Shows immature cells (Promyelocytes 3%, Metamyelocytes 4%, Basophils 4%). TLC is 50,400. The pathologist’s impression is “Suspicion of Myeloproliferative Disorder.” Biochemistry: Creatinine had spiked to 1.62 due to the infection and a 3.1 mm stone in the left kidney (confirmed by USG). HbA1c is 5.0% (so the previous high sugars were purely stress-induced).
The new reports now suggest that this may be more than just infection. The normal CRP plus PBS showing immature cells and basophils makes a Myeloproliferative Disorder — especially possible Chronic Myeloid Leukemia — more likely.
At the same time, the UTI/kidney stone may still be contributing to her symptoms and kidney creatinine rise.
She should continue hospital treatment and urgently follow up with a hematologist for:
* BCR-ABL test, * repeat CBC/PBS, * and further evaluation.
Patient Details:
57-year-old female, previously leading a normal active life with no known prior hematological malignancy or chronic systemic illness apart from occasional treatment for diabetes mellitus and hypertension. Past thyroid dysfunction was present many years ago but reportedly normalized later. Weight has remained stable around 70 kg for a long duration. No prior history of chronic fever, recurrent infections, appetite loss, weight loss, abnormal bleeding/bruising, recurrent hospitalizations, lymph node swelling, or known splenomegaly.
History of Present Illness:
Current illness started suddenly around 2–3 days prior to admission with first-time severe bilateral lower abdominal/groin pain (both iliac/kokh regions), associated with lower back/flank pain and mild breathing discomfort/heaviness. Fever (~100–100.1°F) also appeared for the first time during the same period. Subsequently patient developed marked weakness, dizziness, abdominal tenderness on touch and intermittent fever. No significant urinary burning, retention or major lower urinary tract symptoms were initially reported. BP remained largely stable during admission and patient remained conscious/oriented.
Urine Examination:
Urine routine microscopy revealed:
- Protein ++ - Pus cells: 30–40/hpf - RBCs: 3–4/hpf - Acidic urine - Specific gravity: 1.010 - Urine sugar: Nil
Findings were suggestive of urinary tract/kidney inflammatory process.
Radiology:
Ultrasound whole abdomen showed:
- Grade 1 fatty liver - Multiple tiny right renal concretions - 3.1 mm left renal calculus - No significant hydronephrosis or major obstruction reported
Hematology/CBC Findings:
Initial CBC:
- TLC approximately 50,950/cu mm - Neutrophils: 82.9% - ANC: ~42,240 - Hemoglobin: ~10 g/dL - Platelets: previously ~9.39 lakh/cu mm - ESR initially ~35 mm/hr
Latest CBC/Hematology:
- Hemoglobin: 9.2 g/dL - RBC count: 4.16 million/cu mm - Hematocrit: 30.5% - MCV: 73.3 fL - MCH: 22.1 pg - MCHC: 30.2 g/dL - RDW-CV: 18.3% - TLC: 50,400/cu mm - Neutrophils: 71% - Lymphocytes: 13% - Monocytes: 4% - Eosinophils: 1% - Basophils: 4% - Metamyelocytes: 4% - Promyelocytes: 3% - Platelet count: 5.98 lakh/cu mm - ESR: 62 mm/hr
Peripheral Blood Smear (PBS):
- Predominantly microcytic hypochromic RBCs with anisocytosis - TLC raised on smear - DLC shows left shift with basophilia - Platelets mildly raised with small platelet clumps - Impression: Microcytic hypochromic anemia with neutrophilic leukocytosis - Advice on report: close hematological follow-up with repeat PBS after control of inflammation/infection to rule out possibility of myeloproliferative disorder
Biochemistry:
- Serum Creatinine: 0.61–0.66 mg/dL - Serum Urea: 24 mg/dL - SGOT(AST): 22 U/L - SGPT(ALT): 14 U/L - CRP Quantitative: 0.8 mg/L (normal) - Mildly elevated alkaline phosphatase and direct bilirubin noted earlier
Viral Markers:
- HBsAg: Non-reactive - Anti-HCV: Non-reactive - HIV: Non-reactive
Metabolic Findings:
During illness, stress hyperglycemia was noted with glucometer readings approximately 235–300+.
Current Management:
Patient is admitted and receiving antibiotics, hydration, supportive care, antipyretics and symptomatic treatment. Current/recent medications include IV antibiotics initially, followed by Farotuf 200, Dolo 650, Febuxostat 40 mg, Esosan LSR and hydration/electrolyte support.
Further Workup:
Bone marrow aspiration, bone marrow biopsy and BCR-ABL quantitative testing have now been advised/performed to evaluate persistent neutrophilic leukocytosis with left shift and basophilia.
Clinical Query:
Kindly review whether the overall presentation appears more consistent with severe reactive leukocytosis/leukemoid reaction secondary to infection/inflammation versus chronic myeloproliferative neoplasm/CML or related hematological disorder, and advise regarding further evaluation and management.
Hello Thank you for providing such a detailed summary—this is a complex case, and I understand your concern.
### What the Reports Suggest
1. Extremely High TLC & Neutrophils:
A total leukocyte count (TLC) of 50,950 with 82.9% neutrophils and an absolute neutrophil count of 42,240 is very high. This level is much above what is usually seen in typical infections, even severe ones.
2. Platelets & Hemoglobin:
Platelets are also very high (9.7 lakh), and hemoglobin is mildly low (10.0). High platelets can sometimes be reactive (due to infection/inflammation), but such high counts are also seen in some blood cancers.
3. ESR, Fever, Weakness:
ESR is raised (35), and the patient has intermittent fever, weakness, and some breathing discomfort—these are non-specific but point to a significant ongoing process.
4. Urine Findings:
Pus cells, protein, and RBCs in urine suggest a urinary tract infection (UTI) or possibly pyelonephritis, which can cause fever and high white counts. However, the degree of leukocytosis is still unusually high for a simple UTI.
5. Blood Sugar:
High sugars during illness (stress hyperglycemia or underlying diabetes) can worsen infections and immune response.
### Most Likely Possibilities
- Leukemoid Reaction:
This is a severe, reactive increase in white blood cells, usually due to a major infection (like severe UTI/pyelonephritis, sepsis), inflammation, or certain drugs. The counts can be very high, but rarely as high as seen here. The presence of pus cells and protein in urine supports a severe infection.
- Leukemia (especially acute or chronic myeloid leukemia):
Such extremely high TLC, high platelets, and mild anemia are also classic for leukemia, especially if the peripheral smear (PBS) shows immature or abnormal white cells (blasts, promyelocytes, etc.). The chronic symptoms (weakness, fever, mild anemia) and very high counts make this a strong possibility.
### What Will Help Differentiate
- Peripheral Blood Smear (PBS):
This is the most important next step. If it shows many immature or abnormal cells, leukemia is likely. If it shows only mature neutrophils and no abnormal forms, a leukemoid reaction is more likely.
- CRP/Procalcitonin:
High levels support infection/inflammation.
- Bone Marrow Biopsy (if needed):
If leukemia is suspected, this will confirm the diagnosis.
### What to Do Next
- Continue antibiotics and supportive care for infection, as already started. - Wait for PBS and CRP results—these will guide the next steps. - Consult a hematologist if leukemia is suspected on PBS. - Monitor for new symptoms: bleeding, bruising, severe weakness, or sudden worsening
Bottom line:
With this degree of leukocytosis and high platelets, leukemia is a strong possibility, but a severe infection with a leukemoid reaction is also possible. The PBS will be the key test. Continue current treatment and follow up closely with your doctors and a hematologist.
Thank you
Patient Details:
57-year-old female, previously leading a normal active life with no known prior hematological malignancy or chronic systemic illness apart from occasional treatment for diabetes mellitus and hypertension. Past thyroid dysfunction was present many years ago but reportedly normalized later. Weight has remained stable around 70 kg for a long duration. No prior history of chronic fever, recurrent infections, appetite loss, weight loss, abnormal bleeding/bruising, recurrent hospitalizations, lymph node swelling, or known splenomegaly.
History of Present Illness:
Current illness started suddenly around 2–3 days prior to admission with first-time severe bilateral lower abdominal/groin pain (both iliac/kokh regions), associated with lower back/flank pain and mild breathing discomfort/heaviness. Fever (~100–100.1°F) also appeared for the first time during the same period. Subsequently patient developed marked weakness, dizziness, abdominal tenderness on touch and intermittent fever. No significant urinary burning, retention or major lower urinary tract symptoms were initially reported. BP remained largely stable during admission and patient remained conscious/oriented.
Urine Examination:
Urine routine microscopy revealed:
- Protein ++ - Pus cells: 30–40/hpf - RBCs: 3–4/hpf - Acidic urine - Specific gravity: 1.010 - Urine sugar: Nil
Findings were suggestive of urinary tract/kidney inflammatory process.
Radiology:
Ultrasound whole abdomen showed:
- Grade 1 fatty liver - Multiple tiny right renal concretions - 3.1 mm left renal calculus - No significant hydronephrosis or major obstruction reported
Hematology/CBC Findings:
Initial CBC:
- TLC approximately 50,950/cu mm - Neutrophils: 82.9% - ANC: ~42,240 - Hemoglobin: ~10 g/dL - Platelets: previously ~9.39 lakh/cu mm - ESR initially ~35 mm/hr
Latest CBC/Hematology:
- Hemoglobin: 9.2 g/dL - RBC count: 4.16 million/cu mm - Hematocrit: 30.5% - MCV: 73.3 fL - MCH: 22.1 pg - MCHC: 30.2 g/dL - RDW-CV: 18.3% - TLC: 50,400/cu mm - Neutrophils: 71% - Lymphocytes: 13% - Monocytes: 4% - Eosinophils: 1% - Basophils: 4% - Metamyelocytes: 4% - Promyelocytes: 3% - Platelet count: 5.98 lakh/cu mm - ESR: 62 mm/hr
Peripheral Blood Smear (PBS):
- Predominantly microcytic hypochromic RBCs with anisocytosis - TLC raised on smear - DLC shows left shift with basophilia - Platelets mildly raised with small platelet clumps - Impression: Microcytic hypochromic anemia with neutrophilic leukocytosis - Advice on report: close hematological follow-up with repeat PBS after control of inflammation/infection to rule out possibility of myeloproliferative disorder
Biochemistry:
- Serum Creatinine: 0.61–0.66 mg/dL - Serum Urea: 24 mg/dL - SGOT(AST): 22 U/L - SGPT(ALT): 14 U/L - CRP Quantitative: 0.8 mg/L (normal) - Mildly elevated alkaline phosphatase and direct bilirubin noted earlier
Viral Markers:
- HBsAg: Non-reactive - Anti-HCV: Non-reactive - HIV: Non-reactive
Metabolic Findings:
During illness, stress hyperglycemia was noted with glucometer readings approximately 235–300+.
Current Management:
Patient is admitted and receiving antibiotics, hydration, supportive care, antipyretics and symptomatic treatment. Current/recent medications include IV antibiotics initially, followed by Farotuf 200, Dolo 650, Febuxostat 40 mg, Esosan LSR and hydration/electrolyte support.
Further Workup:
Bone marrow aspiration, bone marrow biopsy and BCR-ABL quantitative testing have now been advised/performed to evaluate persistent neutrophilic leukocytosis with left shift and basophilia.
Clinical Query:
Kindly review whether the overall presentation appears more consistent with severe reactive leukocytosis/leukemoid reaction secondary to infection/inflammation versus chronic myeloproliferative neoplasm/CML or related hematological disorder, and advise regarding further evaluation and management.
