No promyelocytes, myeloblasts, or dysplastic features were seen.
#LEFT SHIFTED GRANULOCYTES MANUAL#
Manual review of a blood smear confirmed these results and showed that the immature granulocytes were composed of 5.0% myelocytes and 7.3% metamyelocytes (Image 1A, middle and right panels). An automated differential count (Image 1A, left panel SSC, side scatter SFL, side fluorescence) revealed 59.3% neutrophils (population colored in cyan/teal), 15.3% lymphocytes (magenta), 9.0% monocytes (green), 2.9% eosinophils (red), 1.2% basophils (cyan/teal overlapping with neutrophils in this projection), and 12.3% (1,920 μl −1) immature granulocytes (i.e., promyelocytes, myelocytes, and/or metamyelocytes dark blue, yellow arrows). A complete peripheral venous blood count using a Sysmex XT-1800 i instrument showed a white cell count of 15.6 × 10 3 μl −1, red cell count of 3.6 × 10 6 μl −1, hemoglobin concentration of 10.5 g/dl, hematocrit of 30.8%, mean corpuscular volume of 86.0 fl, mean corpuscular hemoglobin of 29.3 pg, and a platelet count of 351 × 10 3 μl −1. At 23 weeks and 5 days, she was feeling well, and vital signs, physical exam, and urinalysis were normal. She was not taking any medications besides a daily oral multivitamin and iron supplement. Validation studies performed in our own laboratory confirmed that healthy individuals (n=28) have an average IG count of 0.36% (range 0.2% to 0.5%), while inpatients (n=96) have an average IG count of 2.1% (range 2.0% to 6.2%). An increase in IGs of >2% can be a useful in identification of acute infection. Published studies have shown high specificity of IG count for infectious diseases but low sensitivity, precluding the use of such a count as a screening test for sepsis.A 20-year-old woman (G2P1) was followed for an uncomplicated second pregnancy. In addition, the accuracy of these measurements compared to microscopic examination or flow cytometry with monoclonal antibodies has been shown to be high (correlation coefficient of 0.78-0.96). Sysmex XN hematology analyzers perform the IG count as a part of the leukocyte differential count with notably low imprecision (CV near 7%). However, elderly patients, neonates, and patients with myelosuppression may have elevated IGs without an elevation of the neutrophil count. Usually an increase in IGs is accompanied by an increase in the absolute neutrophil count. IGs are usually not detected in healthy individuals but are elevated in patients with bacterial infections, acute inflammatory disorders, cancer (marrow metastasis), tissue necrosis, acute transplant rejection, surgical and orthopedic trauma, myeloproliferative neoplasm, steroid use, and pregnancy. Other immature granulocytes (IGs) including metamyelocytes, myelocytes, and promyelocytes have better morphological definition and together can be used as an alternative to the band count. For example, the 95% confidence limit for 5% bands is 1% to 12%, for 10% bands the limit is 4% to 18%, and for 15% bands the limit is 8% to 24%.
The literature contains at least three different definitions of a band neutrophil, leading to unacceptably wide interobserver variability. Perhaps the greatest problem with the band count is the inability to reproducibly identify band neutrophils. However, most hospitals have stopped performing manual banc counts because they were proven to be inaccurate and imprecise. Historically, measurement of immature myeloid cells such as bands has been considered clinically useful for diagnosis of infection, especially for neonatal sepsis.
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