Patient handout

Leukocytosis symptom-triage (outpatient ddx + ED escalation for blasts / hyperleukocytosis)

PRODUCTION

1. Your condition

This handout is for leukocytosis symptom-triage (outpatient ddx + ed escalation for blasts / hyperleukocytosis). Your care team identified this based on: wbc 11-15k + transient (post-exercise, stress, pregnancy, post-partum, smoking) + normal differential — physiologic stress demargination; reassure + repeat cbc in 2-4 weeks (leucocytosis bjh 2019 pmid 33237040 verify).

Other reasons your team may use this plan: wbc 12-25k + neutrophilia + bands >10% + left shift + toxic granulation + döhle bodies + fever — acute bacterial infection; identify source + empiric antibiotics; route id.sepsis.core.v1 if sepsis criteria met; wbc mild-mod elevation + neutrophilia + chronic inflammation (ra, ibd, vasculitis, gout flare, mi, pancreatitis, post-op) — inflammatory leukocytosis; treat underlying; wbc 11-20k + neutrophilia + recent steroid initiation/escalation (prednisone, iv methylpred) — steroid demargination; benign mechanism (decreased adhesion); reassure.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
STAT heme/onc consult + peripheral smear + flow cytometry; IV isotonic fluids; AVOID RBC transfusion before cytoreduction (raises viscosity); cautious correction of anemia	—	—	—	Leukostasis carries high early mortality; transfusing packed cells before cytoreduction worsens hyperviscosity (Blood Rev 2012)

Plan: Hyperleukocytosis with leukostasis: emergent cytoreduction + leukapheresis + tumor-lysis prophylaxis + definitive induction (Blood Rev 2012; leukostasis is an oncologic emergency)

3. When to call your provider

Contact your care team if any of the following happen:

Blasts on smear → STAT hematology + BMBx + flow cytometry + cytogenetics + route heme.acute-leukemia.core.v1
Hyperleukocytosis >100K + leukostasis sx (dyspnea, AMS, retinal hemorrhage, priapism, hypoxia) → ED + leukapheresis + hydroxyurea (route heme.acute-leukemia.core.v1)
Sepsis criteria met → route id.sepsis.core.v1
DRESS with severe organ involvement (LFT >5x, AKI, myocarditis, encephalitis) → admit + IV steroid
Tumor lysis syndrome features (hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia) → ED + allopurinol/rasburicase + IVF
CML in blast crisis or accelerated phase → emergent hematology + cytoreductive chemo + TKI switch
CLL with autoimmune cytopenia (AIHA + ITP) → steroid + rituximab
Eosinophilic pneumonia / cardiomyopathy → admit + steroid
Refractory hyperleukocytosis despite leukapheresis → ICU
Pediatric leukocytosis with TAM (transient abnormal myelopoiesis in Down syndrome) → pediatric hematology STAT

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

WBC >100K + blasts on smear + leukostasis symptoms (dyspnea/hypoxia, AMS, retinal hemorrhage, priapism, visual changes) — hyperleukocytosis with leukostasis (AML M4/M5, blast crisis CML, ALL) → ED STAT + hematology + hydroxyurea 50-100 mg/kg + leukapheresis + cytoreductive chemo (route heme.acute-leukemia.core.v1)(life-threatening)
WBC >50K + chronic + basophilia + eosinophilia + splenomegaly + LAP score LOW + BCR-ABL/Philadelphia chromosome positive — CML; tyrosine kinase inhibitor (imatinib 400 mg PO daily / dasatinib / nilotinib / bosutinib / ponatinib); route heme.acute-leukemia.core.v1 (NCCN CML PMID 30796100 verify)
WBC >50K + extreme left shift (bands + metas + myelos) + LAP score HIGH (>100) + identifiable trigger (severe infection, sepsis, paraneoplastic, post-G-CSF, severe burns) — leukemoid reaction (NOT CML); treat underlying; pivot vs CML (LAP score historical PMID 23391835 verify; BCR-ABL preferred modern)
Persistent eosinophilia >1500/µL × >6 mo + organ damage (cardiac restrictive cardiomyopathy/Löffler endocarditis, pulm infiltrates, neuro embolic, skin angioedema, GI gastroenteritis) — hypereosinophilic syndrome (HES); FIP1L1-PDGFRA → imatinib; idiopathic → corticosteroid + hydroxyurea + mepolizumab (HES PMID 26573041 verify)
New medication (aromatic AED phenytoin/carbamazepine, allopurinol, vancomycin, sulfa, lamotrigine, dapsone) 2-8 wk prior + rash + fever + lymphadenopathy + eosinophilia + multi-organ (LFT >5x, AKI, myocarditis, pneumonitis) — DRESS syndrome; STOP offending drug + supportive + steroid 1 mg/kg if severe organ involvement
WBC neutrophilic leukocytosis + bands + toxic granulation + Döhle + fever + SIRS/qSOFA/lactate >2 + identified source — bacterial sepsis; route id.sepsis.core.v1 for full Surviving Sepsis Campaign bundle; empiric antibiotics within 1 h
Pediatric (<3 mo) WBC >25-50K + bandemia + congenital infection (sepsis, parvovirus, HSV, syphilis) OR Down syndrome neonate with TAM (transient abnormal myelopoiesis) — pediatric leukemoid; rule out leukemia (10-20% TAM → AML/AMKL); pediatric hematology consult

5. Follow-up

Hematology referral for persistent unexplained / suspected malignancy / HES / CMML / MPN. Smoking cessation. Travel medicine for parasitic. Drug counseling (DRESS cross-reactivity for AEDs). Pertussis vaccination booster. CLL surveillance with Rai/Binet staging q3-6 mo. CML on TKI lifelong + BCR-ABL PCR q3 mo first year. Recurrence prevention.

6. Sources

Guideline: 2019 Leucocytosis BJH + 2018 NCCN CML + ASH CLL Hallek + ICH-eosinophilia + AGA DRESS + Surviving Sepsis Campaign