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\begin{document}

\title{Leukemoid Reaction in a Preterm Infant: diagnostic challenge in resource
poor setting. Case report}



\author[1]{Chukwudi Okoli}%
\author[2]{Nwaoma Nwaogu}%
\author[3]{Ifeyinwa Nwafia}%
\affil[1]{Lifeline Children's Hospital}%
\affil[2]{Georges Memorial Hospital Lekki Phase 1}%
\affil[3]{University of Nigeria Faculty of Medical Sciences and Dentistry}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
A preterm neonate delivered at 28 weeks gestation, mother had antenatal
steroid. Blood counts showed leukemoid reaction, blood culture,
procalcitonin and peripheral blood film was normal. Baby was stabilized
in the NICU, recovered and the WBC count done serially showed a downward
trend. The leukemoid reaction was presumed to come from antenatal
steroid use. The diagnostic and management challenges encountered in
managing the infant in resource constrained environment like ours is
presented alongside%
\end{abstract}%



\sloppy


\textbf{Leukemoid Reaction in a Preterm Infant: diagnostic challenge in
resource poor setting. Case report}

Okoli Chukwudi,\textsuperscript{1} Nwaogu
Nwaoma,\textsuperscript{2}Nwafia Ifeyinwa\textsuperscript{3}

\textsuperscript{1}Lifeline Children\textsuperscript{'}s Hospital Lekki,
Lagos Nigeria

\textsuperscript{2}Georges Memorial Hospital Lekki,Lagos Nigeria

\textsuperscript{3}College of Medicine University of Nigeria Ituku
Ozalla Campus Enugu Nigeria

Corresponding Author

Okoli Chukwudi

Department of Haematology / Oncology

Lifeline Children's Hospital Lekki, Lagos.

drchuksokoli@yahoo.com, chukwudi.okoli@npmcn.edu.ng,

Abstract: 73

Word count: 634\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
WBC & White Cell Count\tabularnewline
\midrule
\endhead
CRP & C-reactive protein\tabularnewline
\bottomrule
\end{longtable}

Running Statement: Leukemoid reaction, Preterm, Resource poor

Abstract

A preterm neonate delivered at 28 weeks gestation, mother had antenatal
steroid. Blood counts showed leukemoid reaction, blood culture,
procalcitonin and peripheral blood film was normal. Baby was stabilized
in the NICU, recovered and the WBC count done serially showed a downward
trend. The leukemoid reaction was presumed to come from antenatal
steroid use. The diagnostic and management challenges encountered in
managing the infant in resource constrained environment like ours is
presented alongside.

Introduction

Leukemoid reaction is an extreme form of leukocytosis similar to that
seen in leukemia but caused by other conditions .Leukocytosis exceeding
50,000wbc/mm\textsuperscript{2} with increase in early neutrophil
precursors in the neonatal period is known as neonatal leukemoid
reaction (1).

Leukemoid reaction in the neonatal period can be associated with sepsis,
congenital leukemia, bronchopulmonary dysplasia , prematurity antenatal
steroid use and congenital abnormalities.(2) The incidence of leukemoid
reaction in neonate range between 1.3\% -- 15\%.(3)

We report a case of leukemoid reaction in a preterm infant and the
challenges in managing such diagnosis in resource poor environment.

Case

A preterm female baby was delivered caesarean section at 28 weeks +
4days on account of antepartum hemorrhage and preterm pre labour rupture
of membranes. Apgar scores were 8 and 10 in the first and fifth minute
respectively. Birth Weight was 1450 grams. Baby had respiratory distress
and was admitted and nursed in an incubator with CPAP in the Neonatal
Intensive care Unit. Investigations such as complete blood count (CBC),
C-reactive protein, blood culture, procalcitonin, and peripheral blood
film were sent. Intravenous antibiotic ceftazidime and amikacin was
commenced and later stopped when blood culture did not reveal any
organism. Babies initial investigation results ; WBC 81,000
m/mm\textsuperscript{3} , Neutrophils 66\%, Lymphocytes 25\%, monocytes
9\% Hb 12.8g/dl, Platelets 311 m/mm\textsuperscript{3} on first day of
life and by the 3\textsuperscript{rd} day of life it was ; WBC 93,000
m/mm\textsuperscript{3} , Neutrophils 74\%, Lymphocytes 22.9\%,
monocytes 3.1\% Hb 11.9g/dl, Platelets 260,000 m/mm\textsuperscript{3} .
The blood culture did not yield any organism, procalcitonine and CRP
were normal while peripheral blood film did not show any abnormal cells
and Lumber puncture was normal. Repeated CBC done alternate day showed a
decreasing trend. Bone marrow aspiration and karyotype was not done.
Baby continued to improve and was discharge home and has been seen for
follow up with the complete blood count now normalized.

Discussion

Leukocytosis is a common finding in newborns in the first few days of
life (4). This increase in leucocytes is from a surge or burst in
cytokines (Granulocyte colony stimulating factor and
Granulocyte-macrophage colony-stimulating factor) (5)

Leukemoid reaction have been demonstrated in up to 15\% of preterm
infants in the absence of any identifiable factor.(5) However it has
been found to be more common in preterm infants , infections , antenatal
steroid use , congenital leukemia and transient leukemoid reaction seen
in Down Syndrome.(6)

In our reported case, patient's mother was on progesterone from the
7\textsuperscript{th} -- 15\textsuperscript{th} week of pregnancy and
had one dose of dexamethasone 48 hours prior to delivery, this history
led credence to steroid use by mother being the cause of the leukemoid
reaction in our case.

Our sepsis work-up in the patient was extensive despite the diagnostic
difficulties and challenges faced especially in getting investigation
results in real time in our environment.

Other diagnosis such as congenital leukemia was considered, however the
peripheral blood film result did not reveal any abnormal cells or blast
and the lactate dehydrogenase levels was not elevated. Bone marrow
aspiration was not done due to financial challenges as patient could not
afford it.

Our patient did not get the benefit of a karyotype as this investigation
is not readily available in our environment and when available the
turnaround time is in excess of 4 weeks. The index case did not have any
dysmorphic features hence the possibility of transient
myeloproliferative disease also known as transient abnormal myelopoiesis
a form of leukemia seen in Down syndrome was excluded. (7)

Conclusion

Diagnosing leukemoid reaction in preterm infants in very challenging due
to lack of adequate diagnostic equipment, cost and prolonged turnaround
time of the investigations. These limitations not withstanding any WBC
\textgreater{} 30,000 in any neonate should be thoroughly investigated
to exclude the possibilities of sepsis, congenital leukemia and
transient myeloproliferative disorders.

Conflict of Interest: No conflict of interest to declare.

Reference

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\tightlist
\item
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\item
  .~Rastogi S, Rastogi D, Sundaram R, Kulpa J, Parekh AJ. Leukemoid
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\item
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\item
  Apollonsky N, Shende A, Ouansafi I, Brody J, Atlas M, Aygun B.
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\end{enumerate}

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