Extreme Leukocytosis in a Man after a Half Marathon Race

Ericsson F; Jensen NE; Jensen SE

Case Report

Austin Cardio & Cardiovasc Case Rep. 2021; 6(1): 1038.

Extreme Leukocytosis in a Man after a Half Marathon Race

Ericsson F¹, Jensen NE² and Jensen SE¹*

¹Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark

²Odense University, Odense, Denmark

*Corresponding author: Svend Eggert Jensen, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark

Received: June 23, 2021; Accepted: July 12, 2021; Published: July 19, 2021

Introduction

Leukocytosis is most often defined as an elevated white blood cell count greater than 11.0 × 10⁹ per L in adults, and is a relatively common finding. Normal adult levels of leucocytes is 4.5 to 11.0 × 10⁹ per L. It is of importance for clinicians to be able to distinguish nonmalignant from malignant conditions, and to differentiate between the most common non-malignant causes of leukocytosis. Extreme leukocytosis can be seen in a broad spectrum of clinical conditions in the human body under stress. It is most commonly found in patients suffering from leukemia or severe bacterial infections, but can also be seen in people after hard exercise [1-7]. The present clinical case describes a young healthy man, suffering from extreme leukocytosis after a syncope during a half marathon.

Case Presentation

A half marathon is a road running event of 21.0975 km (13.109 miles), half the distance of a marathon. A 39-year-old healthy man suffered from a syncope at the goal line after a half marathon. According to bystanders at the race, the subject’s running initially became wiggly and after a short time he fell over but got his consciousness back moments later. The subject, who was a nonsmoker and in good physical shape, had no medical history nor any family members with medical history of cardiac disease, diabetes or previous syncopations. When asked, he had never experienced palpitations, chest pain during exercise, previous fainting, shortness of breath or any other cardiovascular symptoms. This was his first half marathon race, but he had prepared himself for the race by running 5-15 km three to four times weekly for at least one year prior to the race.

Initial Work-Up

During the ambulance transport to the hospital and on arrival to the emergency department the subject was awake and hemodynamically stable but a bit nauseous. Repeated blood samples were drawn and Electrocardiograms (ECGs) were taken as a standard procedure in the emergency department. Results of the blood samples can be seen in Table 1, and the ECG’s can be seen in Figure 1. A bedside echocardiography was performed, showing a normally structured heart with preserved systolic (LVEF ~ 55%, global longitudinal strain -16.4%, TAPSE 2.5 cm) and normal diastolic function (E’16, normal E/A ratio) and no pericardial effusion. Hypokinesia in the basal anteroseptal segments was reported.

Figure 1: Initial ECG upon arrival: Supraventricular tachycardia with inverted T-waves in the precordial leads V3-V5. No previous ECG was available.

    
    
    Figure 1: Initial ECG upon arrival: Supraventricular tachycardia with inverted T-waves in the precordial leads V3-V5. No previous ECG was available.

Figure 2: Second ECG, taken 1 hour after the first ECG. Now showing inverted T-waves in V3 and V6, as well as flattened out T-waves in V4-5.

    
    
    Figure 2: Second ECG, taken 1 hour after the first ECG. Now showing inverted T-waves in V3 and V6, as well as flattened out T-waves in V4-5.

Figure 3: Third ECG, taken on day 2. Normalisation of the T-waves in the precordial leads.

    
    
    Figure 3: Third ECG, taken on day 2. Normalisation of the T-waves in the precordial leads.

Table 1: Blood tests.




  
    Blood test 
    First blood test (t: + 0) 
    Second blood tests (t: +4    hours 40 min) 
    Third blood test 
    Reference value 
    Units 
  
  
    (t: +28 hours 34 min)
  
  
    CRP 
    <0.5 
    
    
    <8.0 
    mg/l 
  
  
    Total white cell count 
    38 
    27.3 
    18.6 
    3.5-10.0 
    109/l 
  
  
    Neutrofilocytes 
    31.17 
    23.99 
    
    2.00-7.00 
    109/l 
  
  
    Lymphocytes 
    1.89 
    0.99 
    
    1.3-3.5 
    109/l 
  
  
    Monocytes 
    3.69 
    1.97 
    
    0.2-0.7 
    109/l 
  
  
    Eosinophilocytes 
    0.15 
    0 
    
    <0.5 
    109/l 
  
  
    RBC 
    9.4 
    
    
    8.3-10.5 
    109/l 
  
  
    Platelets 
    209 
    
    
    145-350 
    109/l 
  
  
    Potassium: 
    3.8 
    
    
    3.5-4.6 
    mmol/l 
  
  
    Sodium: 
    142 
    
    
    136-146 
    mmol/l 
  
  
    Chloride 
    114 
    
    
    98-106 
    mmol/l 
  
  
    Glucose 
    6.2 
    
    
    4.2-7.8 
    mmol/l 
  
  
    Creatinine 
    136 
    
    
    60-105 
    μmol/l 
  
  
    eGFR /1.73 m2(CKD-EPI) 
    56 
    
    
    >60 
    ml/min 
  
  
    Carbamide 
    8.9 
    
    
    3.2-8.1 
    mmol/l 
  
  
    Creatine kinase (CK) 
    
    
    3474 
    50-270 
    U/l 
  
  
    CK-MB 
    13.2 
    19.5 
    21.1 
    <7.0 
    μg/l 
  
  
    Troponin T (TnT) 
    240 
    124 
    102 
    <14 
    ng/l 
  
  
    Myoglobin 
    
    
    747 
    <75 
    μg/l



Table 1: Blood tests.

Diagnosis and Management

As a result of the echocardiographic findings and the elevated cardiac enzymes (CK-MB and troponin T), and the previously described ECG-changes, treatment was initiated due to suspected NSTEMI (non-ST segment elevation myocardial infarction). The subject was transferred to the department of cardiology and continuous heart rhythm monitoring was performed, but no arrhytmias were detected during hospital stay. Also a Coronary Angiogram (CAG) was performed 22 hours and 17 minutes after arrival which showed no signs of atherosclerosis, nor signs of ongoing or previous myocardial infarction. The elevated Creatinine-Kinase (CK) was interpreted as a result of the physical strain of the subject’s skeletal muscle during the half marathon. The following day, the subjects’ blood samples normalized, and the leucocyte count was reduced from 38.0 x 109/l to 18.6 x 109/l, CK-MB to 21.1 μg/l and TnT from 240 to 102 μg/l. The subject was discharged the day after the CAG in a good condition. No hospital follow-up was planned.

Follow-Up

A senior hematologist was consulted, and it was concluded that the subjects’ symptoms and paraclinical abnormalities was a result of severe exhaustion, and it was decided not to perform any out-ofhospital follow-up.

Conclusion

Extreme leucocytosis (38.0 x 10⁹/l) along with temporary echocardiographic and electrocardiographic changes can be seen in healthy, young adults with no signs of cardiovascular disease as a consequence of extreme physical exercise.

References

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Citation: Ericsson F, Jensen NE and Jensen SE. Extreme Leukocytosis in a Man after a Half Marathon Race. Austin Cardio & Cardiovasc Case Rep. 2021; 6(1): 1038.

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