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Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 698-699  

Leukemoid reaction in megaloblastic anemia of the puerperium: An unusual cause

Department of Medicine, Dr. S.N. Medical College, Jodhpur, Rajasthan, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. Hans Raj Pahadiya
Department of Medicine, Dr. S.N. Medical College, Jodhpur - 342 001, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4863.222019

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How to cite this article:
Pahadiya HR, Lakhotia M, Choudhary A, Choudhary S. Leukemoid reaction in megaloblastic anemia of the puerperium: An unusual cause. J Family Med Prim Care 2017;6:698-9

How to cite this URL:
Pahadiya HR, Lakhotia M, Choudhary A, Choudhary S. Leukemoid reaction in megaloblastic anemia of the puerperium: An unusual cause. J Family Med Prim Care [serial online] 2017 [cited 2021 Jun 24];6:698-9. Available from: https://www.jfmpc.com/text.asp?2017/6/3/698/222019

Dear Editor,

A 30-year-old vegetarian female from a rural background presented after 5 days of her uneventful full-term normal vaginal delivery because of fatigability, breathlessness, and facial puffiness. Her obstetric history was G3P3A0. Her antepartum history was uneventful, and she irregularly attended antenatal checkup visits. She denied history of bleeding from anywhere in the body, blood transfusion in the past, chronic illness, or addictions. On examination, she had pallor and mild icterus. The vital parameters were stable except a tachycardia of 110 beats/min. There was a hemic murmur on the pulmonary area. Further clinical examination was not contributory. Hemogram revealed anemia, thrombocytopenia, and leukocytosis. Peripheral blood film (PBF) showed macrocytosis, nucleated red blood cell, neutrophilic leukocytosis with few immature cells, and 2% reticulocytes count. The leukocyte alkaline phosphatase (LAP) score was high [Table 1]. The liver function, renal function tests, and coagulation profile were within normal limit. The serum Vitamin B12 level was 169 pg/mL (279–996 pg/mL), and serum folic acid level was 6.1 ng/L (5.4–18.0 ng/mL). The bone marrow aspiration showed megaloblastic erythropoiesis. The blood and urinalysis were sterile. She tested negative for malaria, hepatitis B, and hepatitis C viruses. The chest X-ray, electrocardiogram, and echocardiography were normal. Ultrasonography showed bulky postpartum uterus without any significant abnormality. Treatment consisted of two unit of packed cell given on day 1, injectable methylcobalamin 1000 μg, and tablet folic acid 5 mg given daily. At the end of 7th days, the counts normalized, and the hemoglobin rose to 9.4 g/dL. At the follow-up of one fortnight, she was asymptomatic with normal hematology.
Table 1: Laboratory investigations

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Leukemoid reaction (LR) refers to a reactive, excessive leukocytosis outside the bone marrow in the absence of hematological malignancy and has been described in response to inflammation, severe infection, malignancies, hemorrhage, acute hemolysis, or bone marrow stimulants. There is a significant increase in mature neutrophils in the peripheral blood and a differential count showing marked left shift.[1] The underlying mechanism for LR is attributed to increased cytokines and interleukins production.[2]

Pregnancy is commonly associated with various hematological changes such as anemia, thrombocytopenia, coagulopathy, and leukocytosis. The leukocytes count starts to increase from 4th week of gestation and remain throughout the pregnancy. This occurs because of the physiological stress of the pregnancy and immune tolerance, immunosuppression, and immunomodulation of fetus in pregnancy which leads to inflammatory response.[3] The increase in the leukocytes count is predominantly neutrophilic because of impaired neutrophilic apoptosis in pregnancy. These neutrophils have toxic granulation in cytoplasm, immature forms, and depressed chemotaxis and phagocytic activity with increased oxidative metabolism during pregnancy. This indicates to bone marrow response to an increased drive for erythropoiesis occurring during pregnancy.[4],[5],[6] During throughout of pregnancy, circulating levels of C-reactive protein, granulocyte macrophage colony-stimulating factor, and lactoferrin are found to be increased and their level tends to settle down after the puerperium.[2] LR in puerperium with megaloblastic anemia is rarely reported.[7],[8]

Our case of megaloblastic anemia, presenting in the puerperium, was associated with LR. The total and differential leukocytes counts gradually returned to normal while the folic acid and Vitamin B12 therapy were given. The possible etiology for megaloblastic anemia in our case might be due to dietary deficiency of Vitamin B12 and folic acid in pregnancy. Folic acid requirement is increases, and absorption is decreases during pregnancy. The LR in the puerperium is might be due to outpouring of various stress hormones, steroid hormone, and cytokines secondary to excessive stress and inflammation during delivery. Therefore, a proper septic workup, a good PBF examination, and LAP score should be done to look for the cause of excessive leukocytes count of the puerperium.

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  References Top

Potasman I, Grupper M. Leukemoid reaction: Spectrum and prognosis of 173 adult patients. Clin Infect Dis 2013;57:e177-81.  Back to cited text no. 1
Belo L, Santos-Silva A, Rocha S, Caslake M, Cooney J, Pereira-Leite L, et al. Fluctuations in C-reactive protein concentration and neutrophil activation during normal human pregnancy. Eur J Obstet Gynecol Reprod Biol 2005;123:46-51.  Back to cited text no. 2
Osonuga IO, Osonuga OA, Onadeko AA, Osonuga A, Osonuga AA. Hematological profile of pregnant women in Southwest of Nigeria. Asian Pac J Trop Dis 2011;1:232-4.  Back to cited text no. 3
Gatti L, Tenconi PM, Guarneri D, Bertulessi C, Ossola MW, Bosco P, et al. Hemostatic parameters and platelet activation by flow-cytometry in normal pregnancy: A longitudinal study. Int J Clin Lab Res 1994;24:217-9.  Back to cited text no. 4
Chandra S, Tripathi AK, Mishra S, Amzarul M, Vaish AK. Physiological changes in hematological parameters during pregnancy. Indian J Hematol Blood Transfus 2012;28:144-6.  Back to cited text no. 5
Faupel-Badger JM, Hsieh CC, Troisi R, Lagiou P, Potischman N. Plasma volume expansion in pregnancy: Implications for biomarkers in population studies. Cancer Epidemiol Biomarkers Prev 2007;16:1720-3.  Back to cited text no. 6
Sclare G, Gragg J. A leukaemoid blood picture in megaloblastic anaemia of the puerperium. J Clin Pathol 1958;11:45-8.  Back to cited text no. 7
Lakhotia M, Shah PK, Gupta A, Dadhich S, Jain SS, Agrawal M. Leukaemoid reaction in megaloblastic anemia during puerperium. J Assoc Physicians India 1996;44:744.  Back to cited text no. 8


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