Leukopenia in the Critically Ill Patient

Heavy metals

Arsenic compounds, gold, mercurial diuretics

Analgesics and NSAID

Acid acetylsalicylic, aminopyrine, benoxaprofen, diclofenac, diflunisal, dipyrone, fenoprofen, indomethacin,ibuprofen,phenylbutazone, piroxicam, sulindac, tenoxicam, tolmetin

Antipsychotics, sedatives, antidepressants

Amoxapine, chlordiazepoxide, clozapine, diazepam, haloperidol, imipramines, meprobamate, phenothiazines, risperidone, tiapridal, upstene

Anticonvulsants

Carbamazepine, ethosuximide, phenytoins, trimethadione, valproic acid

Antithyroid drugs

Carbimazole, methimazole, potassium perchlorate, thiocyanate, thiouracils

Cardiovascular drugs

Acid acetylsalicylic, aprindine, captopril, flurbiprofen, furosemid, hydralazine, methyldopa, nifedipine, phenindione, procainamides, propafenone, propanolol, quinidine, spironolactone, thiazide diuretics, ticlopidine, zestril

Antimicrobials

Cephalosporins, chloramphenicol, ciprofloxacin, clindamycin, cyclines, ethambutol, fasigyne, gentamicin, isoniazid, lincomycin, metronidazole, nitrofurantoin, novobiocin, penicillins, rifampicin,sulfamethoxazole, streptomycin, thiacetazone, vancomycin; Chloroquine, flucytosine, dapsone, hydroxychloroquine, levamizole, mebendazole, pyrimethamine, quinine, quinacrine; Acyclovir, zidovudine, terbinafine

Antihistamines

Brompheniramine, chloropheniramine, cimetidine, methaphenilene, mianserin ranitidine, tripelennamine, thenalidine

Miscellaneous drugs

Acetazolamide, allopurinol, aminoglutethimide, benzafibrate, colchicine, famotidine, flutamide, methazolamide, metoclopramide, levodopa, oral hypoglycemic agents (glibenclamid), penicillamine, retinoic acid, most sulfamides, tamoxifen, deferiprone

(e)

Redistribution caused by splenic sequestration and excessive margination. Diseases associated with splenomegaly and neutropenia include sarcoidosis, lymphomas, tubercolosis, malaria, kala azar, and Gaucher’s disease.

(f)

Deficiencies of dietary vitamins and minerals (vitamin B12, folate, and copper) typically cause neutropenia along with other cytopenias, but isolated and predominant neutropenia is possible.

(g)

Congenital disorders, including Kostmann Syndrome, cyclic neutropenia, Chediak Higashi Syndrome and related congenital disorders [9]. They are diagnosed generally in childhood because of associated infections and/or concomitant lymphoctyte defects.

4.3 Lymphocytopenia

4.3.1 Causes

Lymphocytopenia is defined as a total lymphocyte count less than 1,500/ml. Approximately 80 % of normal adult blood lymphocytes are T lymphocytes and nearly two-thirds of blood T lymphocytes are CD4+ T lymphocytes. Lymphocytopenia can be primary or secondary to other conditions. Primary causes are uncommon and include a wide range of diseases characterized by a quantitative or qualitative stem cell abnormality. Furthermore, primary lymphopenia can be due to defect of lymphocytic cytoskeleton that causes premature destruction of lymphocytes, as observed in Wiskott–Albrich syndrome. Particularly elevated rates of inborn lymphocytopenia occur in some ethnic groups like as Ethiopians and Ckukotka natives.

Acquired lymphocytopenia can be associated to:

(a)

Infectious diseases: The most common infectious disease associated with lymphopenia is the acquired immunodeficiency syndrome. The lymphocytopenia result in part from destruction and/or clearance of CD4+ T cells infected with HIV1–HIV2 [10, 11]. Other viral and bacterial diseases may be associated with lymphopenia. Patient with tuberculosis often have lymphocytopenia that usually resolves 2 weeks after initiating appropriate antimicrobial therapy. A 68 % of adult patients and 92 % of pediatric patients had reduced lymphocytic counts during the 2009 Influenza A pandemic.

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