Lymphocyte Disorders Lymphocytosis

The presentation of lymphocytosis varies somewhat with age. In those older than 12 years, the upper limit of normal is 4000 cells^L. Neonates and young children may have normal absolute lymphocyte counts up to 8000 cells^L. The absolute lymphocyte count can be calculated by multiplying the WBC count by the percentage of lymphocytes in the differential. When an absolute lymphocytosis is encountered, the peripheral smear should be examined for atypical lymphocytes, granular lymphocytes, blastocytes (blasts), smudge cells, and other abnormalities of morphology and diversity.

Lymphocytosis can be classified as primary (malignant) or secondary (reactive). Primary lymphocytosis is defined in the context of an acute or chronic lymphoproliferative disorder, often caused by dysregulation of lymphocyte development and production. Leukemias (chronic lymphocytic, acute lymphocytic, hairy cell), lymphoma, and B-cell lymphocy-tosis are examples of primary or malignant lymphocytosis. Secondary lymphocytosis is defined as a lymphocytosis in a patient who does not have a known hematologic disorder and in whom the lymphocyte count is expected to return to normal in less than 2 months after cessation of the inciting condition. Reactive lymphocytosis can sometimes be mistaken for a primary or malignant lymphocytosis when examining the peripheral blood smear, particularly in infectious mononucleosis with a marked increase in larger, atypical, or transformed lymphocytes. Other causes of secondary lym-phocytosis may generate small lymphocytes, as in pertussis. Viral infections are the most prevalent cause of secondary lymphocytosis, including Epstein-Barr, cytomegalovirus, herpes simplex, varicella, rubella, HIV, adenovirus, and hepatitis. Occasionally, toxoplasmosis and pertussis in children can cause a lymphocytosis that is extremely high, up to levels of 50,000 to 70,000 cells^L. Some forms of extreme stress can cause an increase in lymphocytes, such as cardiovascular collapse, septic shock, status epilepticus, surgery, or major hypersensitivity or allergic disorders. Chronic lymphocytosis may be seen in patients with cancer, sarcoidosis, and certain autoimmune disorders, as well as in cigarette smokers.

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