脾切除术后白细胞和血小板增多:预期发现、感染或其他原因:病例报告。

IF 0.9 Q3 MEDICINE, GENERAL & INTERNAL Journal of Medical Case Reports Pub Date : 2024-10-17 DOI:10.1186/s13256-024-04744-4
Nicolas Gonzalez, Jeffry Nahmias, Lisa X Lee, Matthew Dolich, Michael Lekawa, Allen Kong, Areg Grigorian
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引用次数: 0

摘要

背景:钝性外伤患者脾脏切除术后往往会出现白细胞和血小板增多,从而使术后感染的鉴别变得复杂。虽然血小板计数与白细胞比值有助于诊断鉴别预期的实验室改变和感染,但白血病等诊断往往被忽视:病例介绍:一名 53 岁的西班牙裔男性在腹部遭到袭击和多次击打 4 天后出现腹痛、恶心、心动过速和局灶性腹膜炎。初始白细胞计数为 38.4 × 109/L,血小板计数为 691 × 109/L,脂肪酶为 55 U/L。腹部/盆腔计算机断层扫描显示血肿包裹着胰腺远端,并与胃和结肠相邻。紧急开腹手术显示胰腺几乎被横切,结肠血管断裂,因此必须进行胰腺远端切除术、脾切除术和结肠切除术,并进行主吻合术。术后,他的白细胞、血小板、中性粒细胞、嗜酸性粒细胞和嗜碱性粒细胞持续升高(峰值分别为 70、2293、64、1.1 和 1.2 × 109/L)。尽管进行了败血症检查,包括重复计算机断层扫描,但仍未找到病源。因担心是血液学病因,血液科/肿瘤科进行了会诊,并进行了基因检测和骨髓活检。根据基因检测,包括聚合酶链反应和荧光原位杂交分析,确诊为费城染色体阳性的慢性髓性白血病。骨髓活检显示患者处于慢性期。患者接受了羟基脲治疗,并转为伊马替尼治疗:脾切除术后出现血小板增多是一种常见的并发症,血小板计数与白细胞计数之比为 50 × 109/L)和血小板增多(> 2000 × 109/L)可能暗示着更不祥的预兆,包括慢性髓性白血病,尤其是粒细胞计数升高时。慢性髓性白血病的检查包括外周涂片、骨髓穿刺和费城染色体测定。脾切除术后疫苗仍应在 14 天内接种;但必须考虑癌症治疗的免疫时机。酪氨酸激酶抑制剂是一线疗法,羟基脲预处理对细胞减少的益处仍在研究中。此外,酪氨酸激酶抑制剂还与胃肠道穿孔和伤口愈合受损有关,因此需要高度关注有新肠道吻合术的患者。
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Leukocytosis and thrombocytosis after splenectomy: expected finding, infection, or something else: a case report.

Background: Leukocytosis and thrombocytosis often follow splenectomy in blunt trauma patients, complicating the postoperative identification of infection. While the platelet count to white blood cell ratio provides diagnostic assistance to discern between expected laboratory alterations and infection, diagnoses such as leukemia are often overlooked.

Case presentation: A 53-year-old Hispanic male presented with abdominal pain, nausea, tachycardia, and focal peritonitis 4 days after being assaulted and struck multiple times in the abdomen. Initial white blood cell count was 38.4 × 109/L, platelet count was 691 × 109/L, and lipase was 55 U/L. Computed tomography abdomen/pelvis demonstrated a hematoma encasing the distal pancreas and abutting the stomach and colon. Emergent laparotomy revealed a nearly transected pancreas and devascularized colon, necessitating a distal pancreatectomy, splenectomy, and colonic resection with primary anastomosis. Postoperatively, he had a persistently elevated leukocytosis, thrombocytosis, segmented neutrophils, eosinophilia, and basophilia (peak at 70, 2293, 64, 1.1, and 1.2 × 109/L, respectively). Despite sepsis workup, including repeat computed tomography, no source was identified. Hematology/oncology was consulted for concern for hematologic etiology, with genetic testing and bone marrow biopsy performed. The diagnosis of breakpoint cluster-Abelson gene-positive chronic myeloid leukemia was made based on genetic tests, including polymerase chain reaction and fluorescence in situ hybridization analysis, which confirmed the presence of the Philadelphia chromosome. Bone marrow biopsy suggested a chronic phase. The patient was treated with hydroxyurea and transitioned to imatinib.

Conclusions: Thrombocytosis following splenectomy is a common complication and a plate count to white blood cell count ratio  < 20 indicates infectious etiology. A significantly elevated white blood cell count (> 50 × 109/L) and thrombocytosis (> 2000 × 109/L) may suggest something more ominous, including chronic myeloid leukemia , particularly when elevated granulocyte counts are present. Chronic myeloid leukemia workup includes peripheral smear, bone marrow aspiration, and determination of Philadelphia chromosome. Post-splenectomy vaccines are still indicated within 14 days; however, the timing of immunization with cancer treatment must be considered. Tyrosine kinase inhibitors are the first-line therapy and benefits of pretreatment with hydroxyurea for cytoreduction remain under investigation. Additionally, tyrosine kinase inhibitors have been associated with gastrointestinal perforation and impaired wound healing, necessitating heightened attention in patients with a new bowel anastomosis.

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来源期刊
Journal of Medical Case Reports
Journal of Medical Case Reports Medicine-Medicine (all)
CiteScore
1.50
自引率
0.00%
发文量
436
期刊介绍: JMCR is an open access, peer-reviewed online journal that will consider any original case report that expands the field of general medical knowledge. Reports should show one of the following: 1. Unreported or unusual side effects or adverse interactions involving medications 2. Unexpected or unusual presentations of a disease 3. New associations or variations in disease processes 4. Presentations, diagnoses and/or management of new and emerging diseases 5. An unexpected association between diseases or symptoms 6. An unexpected event in the course of observing or treating a patient 7. Findings that shed new light on the possible pathogenesis of a disease or an adverse effect
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