Leukocyte Count (WBC) 

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The reference range for adults (males and females) is as follows:

Total leukocytes: 4.00-11.0 x 10⁹/L

Neutrophils: 2.5–7.5 x 10⁹/L

Lymphocytes: 1.5–3.5 x 10⁹/L

Monocytes: 0.2–0.8 x 10⁹/L

Eosinophils: 0.04-0.4 x 10⁹/L

Basophils: 0.01-0.1 x 10⁹/L

A white blood cell (WBC) count of less than 4 x 10⁹/L indicates leukopenia.

A WBC count of more than 11 x 10⁹/L indicates leukocytosis.

Decreased WBC count, leukopenia, is seen when supply is depleted by infection or treatment such as chemotherapy or radiation therapy, or when a hematopoietic stem cell abnormality does not allow normal growth/maturation within the bone marrow, such as myelodysplastic syndrome or leukemia. Leukopenia (decrease in WBC) is most often due to a lower number of neutrophils, referred to as neutropenia. Characteristically, the neutrophil count is less than 1.5 x 10⁹/L. ^{[1, 2]}

Elevated WBC, leukocytosis, is seen in response to infection, stress, inflammatory disorders (referred to as reactive leukocytosis), or abnormal production as in leukemia. An increased WBC count can be due to an individual cell component or a combination, depending on the cause. Malaise, chills, and fever, related to infection, are clinically seen in both leukopenia and neutrophilic leukocytosis.

Reactive leukocytosis can be classified on the basis of the white blood cell type affected. Criteria as well as common causes are below.

Neutrophilic leukocytosis occurs when neutrophils are greater than 7.5 x 10⁹/L. Common causes are as follows:

Acute bacterial infections ^[3]

Sterile inflammation/tissue necroses seen in myocardial infarction, burns, crush injuries.

Eosinophilic leukocytosis occurs when eosinophils are greater than 0.4 x 10⁹/L. Common causes are as follows:

Allergic disorders such as asthma, hay fever ^[4]

Parasitic infections

Drug reactions

Basophilic leukocytosis occurs when basophils are greater than 0.1 x 10⁹/L. Causes include rare allergic reactions (IgE mediated).

Monocytosis occurs when monocytes are greater than 0.8 x 10⁹/L. Common causes include the following:

Chronic infections such as tuberculosis

Bacterial endocarditis

Rickettsiosis

Malaria ^[5]

Collagen vascular disease

Inflammatory bowel disease

Lymphocytosis occurs when lymphocytes are greater than 3.5 x 10⁹/L. Common causes are as follows:

Accompanies monocytosis

Viral infections such as hepatitis A, cytomegalovirus (CMV), Epstein-Barr virus (EBV)

Bordetella pertussis

Neoplastic proliferations of white blood cells also cause leukocytosis. These are the malignant proliferations of abnormal clones of white blood cells within the bone marrow that are broadly categorized into lymphoid and myeloid neoplasms depending on the type of white cell proliferation. These malignancies are further characterized by the maturity and differentiation of the individual cell types and are divided into acute leukemias such as acute myeloid leukemia and acute lymphoblastic leukemia and chronic leukemias such as chronic myeloid leukemia and chronic lymphocytic leukemia.

Collection details are as follows:

Specimen: Whole blood

Collection: The blood sample is drawn into a vacuumized purple top tube containing an anticoagulant, ethylenediaminetetraacetic acid (EDTA). This chemical agent prevents the blood sample from clotting.

Panel: Complete blood count

The white blood cell count (WBC) is a component of a complete blood cell count (CBC) and is the enumeration of white blood cells in a small volume of whole blood. The testing is performed on an automated hematology analyzer. The white blood cells (leukocytes) are further divided into phagocytes or myeloid (neutrophils, eosinophils, basophils, monocytes) and immunocytes or lymphoid (lymphocytes). ^[6]

The total white blood cell count is expressed as an absolute number and is further divided into subtypes of white blood cells by a differential WBC count, which is expressed as a percentage and absolute number. Different characteristics of the nuclei and cytoplasm of the cell allow differentiation by instrumentation and microscopy. For microscopy, a blood smear is prepared and stained with a dye preparation called Giemsa stain. These white blood cell types, staining characteristics, and associations are outlined in Table 1.

Table 1. White Blood Cell Types, Characteristics, and Associations (Open Table in a new window)

WBC Type

Characteristics

Associations

Neutrophil

Multilobulated nucleus with small pale pink cytoplasmic granules

Acute infection, bacterial and fungal

Lymphocyte

Mononuclear, scant to moderate blue cytoplasm, occasional cytoplasmic granules

Chronic infection and viral infection

Monocyte

Single folded nucleus, blue-gray cytoplasm, occasional cytoplasmic granules and vacuoles

Chronic infection

Eosinophil

Bilobed nucleus, large pink cytoplasmic granules

Allergic reaction, parasitic infection

Basophil

Bi-lobed nucleus, large brown-black cytoplasmic granules

Allergic reactions, blast crisis in chronic myeloid leukemia

Immature granulocytes

Include metamyelocytes, myelocytes, promyelocytes, and/or blasts

Infections, growth factor therapy, chronic leukemia, and acute leukemia. Commonly referred to as “left shift.”

Formed in the bone marrow by multipotential progenitor cells/hematopoietic stem cells (hematopoiesis), white blood cells are a part of our immune system and play an essential role in protecting the body against infection. The peripheral blood white blood cell count (WBC) and differential count is used to assess the body’s response to certain benign conditions such as acute and chronic infections, inflammatory conditions, allergic reactions, and immunodeficiency states and various hematologic malignancies such as leukemias and lymphomas. It is also used to monitor the response to chemotherapy, growth factors, and immunosuppressive therapies. ^{[7, 8, 9, 10]}

Normal black and Middle Eastern subjects may have lower normal white cell counts. In normal pregnancy, the upper limits are slightly high for total leukocytes (14.5 x 10⁹/L) and neutrophils (11 x 10⁹/L).

Kim AH, Lee W, Kim M, Kim Y, Han K. White blood cell differential counts in severely leukopenic samples: a comparative analysis of different solutions available in modern laboratory hematology. Blood Res. 2014 Jun. 49(2):120-6. [Medline]. [Full Text].

Gulack BC, Englum BR, Lo DD, Nussbaum DP, Keenan JE, Scarborough JE, et al. Leukopenia is associated with worse but not prohibitive outcomes following emergent abdominal surgery. J Trauma Acute Care Surg. 2015 Sep. 79 (3):437-443. [Medline].

Du J, Li L, Dou Y, Li P, Chen R, Liu H. Diagnostic Utility of Neutrophil CD64 as a Marker for Early-Onset Sepsis in Preterm Neonates. PLoS One. 2014. 9(7):e102647. [Medline].

Belsky DW, Shalev I, Sears MR, Hancox RJ, Harrington H, Houts R, et al. Is Chronic Asthma Associated with Shorter Leukocyte Telomere Length at Midlife?. Am J Respir Crit Care Med. 2014 Jun 23. [Medline].

Jairajpuri ZS, Rana S, Hassan MJ, Nabi F, Jetley S. An Analysis of Hematological Parameters as a Diagnostic test for Malaria in Patients with Acute Febrile Illness: An Institutional Experience. Oman Med J. 2014 Jan. 29(1):12-7. [Medline]. [Full Text].

Robert Hutchison, Richard McPherson. Section IV- Hematology. Henry’s Clinical Diagnosis and Management by Laboratory methods. Twenty-First Edition. 2007.

Ahmed A, Eckerl M, Bründl J, Peter J, Lebentrau S, Brookman-May S, et al. Postoperative Leukocytosis After Robotic-Assisted Radical Prostatectomy Is Not Associated with Perioperative Outcome and Histopathological Findings. J Laparoendosc Adv Surg Tech A. 2015 Aug 10. [Medline].

Ekici H, Malatyalioglu E, Kokcu A, Kurtoglu E, Tosun M, Celik H. Do Leukocyte and Platelet Counts Have Benefit for Preoperative Evaluation of Endometrial Cancer?. Asian Pac J Cancer Prev. 2015. 16 (13):5305-10. [Medline].

Bozkurt IH, Aydogdu O, Yonguc T, Koras O, Sen V, Yarimoglu S, et al. Predictive Value of Leukocytosis for Infectious Complications After Percutaneous Nephrolithotomy. Urology. 2015 Jul. 86 (1):25-9. [Medline].

Shvidel L, Bairey O, Tadmor T, Braester A, Ruchlemer R, Fineman R, et al. Absolute lymphocyte count with extreme hyperleukocytosis does not have a prognostic impact in chronic lymphocytic leukemia. Anticancer Res. 2015 May. 35 (5):2861-6. [Medline].

AV Hoffbrand, PAH Moss and JE Pettit. Essential Haematology. Fifth Edition. 2007. 7 and 8.

Robbins, Stanley Leonard, Vinay Kumar, Abul K. Abbas, Ramzi S. Cotran, and Nelson Fausto. Robbins and Cotran Pathologic Basis of Disease. Eighth Edition. WB Saunders Company: Philadelphia; 2010. Chapter 13.

WBC Type

Characteristics

Associations

Neutrophil

Multilobulated nucleus with small pale pink cytoplasmic granules

Acute infection, bacterial and fungal

Lymphocyte

Mononuclear, scant to moderate blue cytoplasm, occasional cytoplasmic granules

Chronic infection and viral infection

Monocyte

Single folded nucleus, blue-gray cytoplasm, occasional cytoplasmic granules and vacuoles

Chronic infection

Eosinophil

Bilobed nucleus, large pink cytoplasmic granules

Allergic reaction, parasitic infection

Basophil

Bi-lobed nucleus, large brown-black cytoplasmic granules

Allergic reactions, blast crisis in chronic myeloid leukemia

Immature granulocytes

Include metamyelocytes, myelocytes, promyelocytes, and/or blasts

Infections, growth factor therapy, chronic leukemia, and acute leukemia. Commonly referred to as “left shift.”

Hina Naushad, MD Assistant Professor, Director, Hematology and Flow Cytometry, Hematopathologist, Department of Pathology, Creighton University Medical Center

Hina Naushad, MD is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, United States and Canadian Academy of Pathology, International Society for Laboratory Hematology, International Clinical Cytometry Society

Disclosure: Nothing to disclose.

Susan Marion, MD, MT(ASCP) Resident Physician in Anatomic and Clinical Pathology, Creighton University Medical Center

Susan Marion, MD, MT(ASCP) is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, College of American Pathologists, Nebraska Medical Association, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Thomas M Wheeler, MD Chairman, Department of Pathology and Immunology, WL Moody, Jr, Professor of Pathology, Professor of Urology, Baylor College of Medicine

Thomas M Wheeler, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Medical Association, American Society for Clinical Pathology, American Society of Cytopathology, American Thyroid Association, American Urological Association, College of American Pathologists, United States and Canadian Academy of Pathology, International Society of Urological Pathology, Harris County Medical Society

Disclosure: Received stock from PathXL for medical advisory board. for: PathXL, Inc.

Leukocyte Count (WBC) 

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