1. GP LABORATORY MEDICINE UPDATE MEETING Investigation of lymphopaenia and neutropenia in Primary Care Huw Roddie

3. Neutropenia Definition: Isolated neutrophil count below 1.5 x 10 9 /l Primary care assessment and investigation Assess patient for symptoms e.g. recurrent infections, mouth ulcers etc. Establish if patient is of an ethnic background known to be associated with lower neutrophil counts Review medication (see additional notes) Examine for lymphadenopathy and splenomegaly Repeat FBC. If neutrophil >1 then repeat at 6 weeks. If neutrophil count <1 repeat at 1 week For persistent neutropenia do the following tests: –Blood film –B12 and folate, Ferritin. Treat if deficiency is detected –CCP, ANF, dsDNA (if ANF positive) –HIV, HBV, HCV serology

4. Neutropenia Who to refer Neutrophil count <0.5 and evidence of sepsis - contact the on-call haematology registrar for urgent advice Neutrophil count <1 on repeat testing Neutrophil count <2 on repeat testing and the presence of any of the clinical findings as described above

5. Neutropenia Who not to refer People of Afro-Caribbean or Middle Eastern ethnicity have a lower normal range for the neutrophil count (constitutional or ethnic neutropenia). This is of no clinical consequence. Such patients should only be investigated if their neutrophils are <1.0 on repeat testing Neutrophil counts consistently >1.5. These patients can be given the diagnosis of chronic idiopathic neutropenia. No further monitoring required. Neutrophil count >1 but <1.5 recheck annually. If clinical features of concern develop or neutrophil counts falls <1 refer to haematology. Otherwise patient can be given diagnosis of chronic idiopathic neutropenia

6. Lymphopenia Definition: Lymphocyte count on FBC in an adult patient that is below the lower limit of the normal range Lymphopenia is a common finding, especially in elderly patients, where it is frequently of no clinical significance. No further investigation is advised in an elderly patient with a lymphocyte count > 0.5 x10 9 /l in the absence of any concerning symptoms. Lymphopenia may reflect a response to stress such as an acute infection, recent surgery or be iatrogenic secondary to medication, especially immunosuppressant drugs such as steroids. Most cases are reversible and do not require specialist evaluation.

7. Lymphopenia Primary care assessment and investigation FBC Blood film B12 and folate. Treat if deficiency is detected Quantitative immunoglobulins CCP, ANF, dsDNA (if ANF positive) HIV serology in moderate to severe lymphopenia (lymphocyte count <1 x 10 9 /l, and < 0.5 x 10 9 /l in over 70)

8. Lymphopenia Who to refer Lymphocyte count <1 x 10 9 /l and symptomatic patients (weight loss, fever, drenching night sweats) Patients with lymphadenopathy (nodes > 1 cms) and/or splenomegaly Refer as urgent if symptomatic

9. Lymphopenia Who not to refer Isolated lymphopenia with lymphocyte count >1 x 10 9 /l in an otherwise well patient, <70yrs, with normal physical examination and negative investigations. –Repeat FBC x2 at 6 monthly intervals. If no change in blood count then there is no requirement to investigate further unless patient becomes symptomatic Patients >70yrs with a lymphocyte count > 0.5 x 10 9 /l if well Patients with chronic fatigue syndrome