Carl B. Lauter

Eosinophilic and neutrophilic leukemoid reaction in a woman with spindle cell sarcoma: a case report

IntroductionWe report a case of a patient with marked eosinophilia and neutrophilia as a manifestation of a spindle cell sarcoma.Case presentationA 41-year-old African American woman presented with an enlarging, painful mass in her right knee area. Four years previously, she had had a mass similar to this diagnosed as an osteosarcoma, and had undergone a radical resection and hinge-knee replacement. Before the surgery, she was treated with neoadjuvant docetaxel and gemcitabine. A biopsy was taken from the recurrent mass, and histological examination revealed high-grade soft-tissue sarcoma. The patient received no further treatment. Complete blood counts revealed a white blood cell (WBC) count of 13.6 to 17.9 × 109/L, with neutrophils being 8.2 to 10.9 × 109/L and eosinophils 1.8 to 1.9 × 109/L. At readmission six months later, WBC was 126.7 × 109/L, with neutrophils being 57.02 × 109/L and eosinophils 60.82 × 109/L. The eosinophils peaked at 77.79 × 109/L two days later. Evaluations for allergies, infection, and autoimmune mechanisms were negative. Bone marrow revealed increased eosinophils without blasts. After resection, blood counts abruptly decreased to the normal range. Pathology confirmed high-grade spindle cell sarcoma. Approximately one year after resection, the patient was readmitted with metastatic disease to her lungs. During this presentation, her eosinophil and neutrophil count was again increased. WBC was 107.8 × 109/L, with eosinophil count of 47.43 × 109/L and neutrophil count of 44.10 × 109/L. Interleukin-5 was normal, and granulocyte–macrophage colony-stimulating factor (GM-CSF) was elevated at 208.8 (normal < 4.8).ConclusionIn our case, the patient had eosinophilia and neutrophilia associated with a spindle cell sarcoma, possibly representing a paraneoplastic syndrome secondary to GM-CSF. There were no signs of infectious, allergic, or autoimmune causes for the eosinophilia or neutrophilia. Even though the occurrence of eosinophilia and neutrophilia with malignancy is rare, patients who have either condition without an apparent cause should be checked for malignancy.

Antibiotic Therapy of Life-Threatening Infectious Diseases in the Emergency Department

Initial therapy in acutely ill septic patients is necessarily empiric. Although a specific etiologic infectious diagnosis is rarely made in an acute situation, a treatment decision must be made and must be developed from history, physical examination, and minimal laboratory and roentgen studies. Three life-threatening syndromes are discussed: febrile-neutropenic patients with cancer, immunosuppressed patients with fever and lung infiltrates, and patients with acute community-acquired meningitis.