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312 Laboratory Medicine in Psychiatry and Behavioral Science
White blood cell (WBC) count (continued)
Increased levels Leukocytosis (WBC count >11.0×10
3
cells/mm
3
) occurs in
the following conditions: acute infection, leukemia, myelo
-
proliferative disorders, tissue trauma, surgery, uremia, cancer
(especially bronchogenic carcinoma), coma, eclampsia, thy
-
rotoxicosis, ingestion of toxins, use of certain medications
(lithium, corticosteroids, epinephrine, colony-stimulating
factors, quinine), NMS, acute hemolysis, acute hemorrhage,
post-splenectomy state, polycythemia vera, tissue necrosis,
seizure, nausea and vomiting, physiological leukocytosis
(e.g., from stress, exercise, pain, heat/cold), and sunlight
exposure.
Decreased levels Leukopenia (WBC count < 4.0×10
3
cells/mm
3
) occurs in the
following conditions: viral infections, bacterial infections,
hypersplenism, primary bone marrow disorders (including
leukemia, aplastic anemia, and pernicious anemia), and
bone marrow depression by heavy metal intoxication, radi-
ation, or drugs.
Interfering factors A diurnal rhythm is seen, with early morning trough WBC
levels and late-afternoon peaks.
WBC values are also influenced by age, sex, exercise, medica-
tions, pregnancy, pain, temperature, altitude, and anesthesia.
Any stress that increases the endogenous epinephrine level
also increases the WBC level.
Cross-references Complete Blood Count
White Blood Cell Count Differential: Basophil
White Blood Cell Count Differential: Eosinophils
White Blood Cell Count Differential: Lymphocytes
White Blood Cell Count Differential: Monocytes
White Blood Cell Count Differential: Neutrophils
American Association for Clinical Chemistry: Lab Tests Online. Available at: https://www.testing.com.
Accessed October 2021.
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Mank V, Brown K: Leukocytosis, in StatPearls. Treasure Island, FL, StatPearls Publishing, 2021. Available
at: https://www.statpearls.com/ArticleLibrary/viewarticle/24216. Accessed October 2021.
Territo M: Overview of leukopenias, in Merck Manual Professional Version. Rahway, NJ, Merck & Co,
2021. Available at:
https://www.merckmanuals.com/professional/hematology-and-oncology/
leukopenias/overview-of-leukopenias
. Accessed October
2021.
https://t.me/med1917
313 Laboratory Tests
White blood cell (WBC) count differential: basophils
Type of test Blood
Background and explanation
of test
Basophils are circulating phagocytes with cytoplasmic gran-
ules containing histamine, heparin, and peroxidase. IgE
binds with high affinity to the cell membrane of the baso
-
phil—and the mast cell, its tissue counterpart—and when a
specific antigen interacts with that IgE, degranulation oc
-
curs, with release of inflammatory mediators.
For this assay, each of the five types of WBCs is counted, and
the value is expressed as a percentage of the total WBC
count. Increases or decreases in the total WBC count and in
each cell type have diagnostic importance. Although the
percentage shows only the relative number of each cell type,
the absolute number can be calculated by multiplying the
percentage of that cell type by the total WBC count. The ab
-
solute value is used to determine whether the count of a par-
ticular cell type is increased.
Each elevated WBC type is related to specific medical con-
ditions. Basophils are associated with immediate hypersen-
sitivity reactions, such as allergic asthma, and some delayed
hypersensitivity reactions, such as contact allergies. They
have a role in immune surveillance for bacteria, viruses,
fungi, and parasites such as helminths that can infect the GI
tract. In addition, basophils can help moderate the effects of
venoms from certain snakes, scorpions, honeybees, and Gila
monsters.
Relevance to psychiatry and Elevated basophil levels can be associated with collagen
behavioral science vascular diseases and hyperthyroidism. Injection of foreign
protein, observed in cases of factitious disorder, may also
cause basophil elevation. Low basophil levels may be seen
with thyrotoxicosis.
Certain psychotropic medications may cause spurious ele-
vation of basophil levels, as noted in the Interfering Factors
section below.
Preparation of patient Fasting is not required. Any physiological stress should be
avoided just before testing.
Indications •
WBC differential often included as routine component
of CBC
• WBC differential may be added when WBC count is ab-
normal, to help determine the source.
Reference range 15–50 cells/mm
3
0%–1% of total WBC count
Critical value(s) None
Increased levels Basophilia (> 50 cells/mm
3
) is associated with the following
conditions:
• Chicken pox
• Tuberculosis
https://t.me/med1917
314 Laboratory Medicine in Psychiatry and Behavioral Science
White blood cell (WBC) count differential: basophils (continued)
Increased levels (continued) • Allergic reactions
• Collagen vascular disease
• Hyperthyroidism
• Myelocytic leukemia
• Acute basophilic leukemia
• Myeloid metaplasia, myeloproliferative disorders
• Hodgkin’s disease
• Injection of foreign protein
Decreased levels Basopenia (<20 cells/mm
3
) is associated with the following
conditions:
• Acute infection
• Hyperthyroidism
• Physiological stress (e.g., pregnancy, MI)
• Prolonged steroid treatment
• Chemotherapy
• Radiation
• Hereditary absence of basophils
Interfering factors False elevation of basophil levels may be seen in patients
treated with desipramine, paroxetine, triazolam, or venla
-
faxine.
Cross-references Complete Blood Count
White Blood Cell Count
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Kubo M: Mast cells and basophils in allergic inflammation.Curr Opin Immunol 54:74–79, 2018
McPherson RA, Pincus MR: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 24th
Edition. Philadelphia, PA, Elsevier, 2022
Varricchi G, Raap U, Rivellese F, et al: Human mast cells and basophils: how are they similar how are they
different? Immunol Rev 282(1):8–34, 2018
https://t.me/med1917
315 Laboratory Tests
White blood cell (WBC) count differential: eosinophils
Type of test Blood
Background and explanation
of test
Eosinophils are phagocytes and inflammatory modulators
produced in the bone marrow that move from blood to tis
-
sues, where they proliferate in response to immunological
stimuli. Present in large numbers in tissues of the skin,
lungs, and GI tract, these cells function to rid the body of
parasites such as helminths, participate in allergic responses
and asthma, and moderate inflammatory reactions from ba
-
sophils and mast cells that have degranulated.
For this assay, each of the five types of WBCs is counted, and
the value is expressed as a percentage of the total WBC
count. Increases or decreases in the total WBC count and in
each cell type have diagnostic importance. Although the
percentage shows only the relative number of each cell type,
the absolute number can be calculated by multiplying the
percentage of that cell type by the total WBC count. The ab
-
solute value is used to determine whether the count of a par-
ticular cell type is increased.
Relevance to psychiatry and Allergic reactions to psychotropic medications can cause
behavioral science eosinophilia. An epidemic of eosinophilia-myalgia syn-
drome (EMS) recognized in 1989 was linked to consumption
of
L-tryptophan from a single source that may have been
adulterated during the manufacturing process. Patients
experienced chronic myalgias, neuropathy, and skin indura
-
tion in association with high eosinophil counts. Over a 6-
month period, 1,500 people were affected and more than
30 people died.
L-tryptophan sales were subsequently
banned in the United States, and the epidemic subsided. In
2005, the ban was lifted. A new case of
L-tryptophan-
associated EMS was reported in 2011, raising the possibility
that a small risk remains for
L-tryptophan ingestion, possi-
bly for individuals with unknown genetic risk.
Preparation of patient Fasting is not required. Any physiological stress should be
avoided just before testing.
Indications •
WBC differential often included as routine component
of CBC
•
WBC differential may be added when WBC count is ab-
normal to help determine source.
Reference range 0–0.35×10
9
/L
Critical value(s) Eosinophilia categorized by severity:
• Mild: 0.35–<1.5×10
9
/L
• Moderate: 1.5–5×10
9
/L
• Severe: >5×10
9
/L
Patients with mild eosinophilia lasting ≥6 months, those
with moderate or severe eosinophilia, and those with in-
creasing eosinophilia should be referred for specialist eval-
uation.
https://t.me/med1917
316 Laboratory Medicine in Psychiatry and Behavioral Science
White blood cell (WBC) count differential: eosinophils (continued)
Increased levels • Allergies, hay fever, asthma (most cases of eosinophilia)
• Parasitic or fungal infections
• Allergic drug reactions
• Hematological malignancy
• Atopic skin diseases (eczema, pemphigus)
• Solid tumors
• GI diseases (inflammatory bowel disease, celiac disease)
• Lung diseases
• Connective tissue diseases
• Collagen vascular disease (SLE)
Decreased levels Conditions associated with increased adrenal steroid levels:
• Cushing’s syndrome
• Acute, severe bacterial infection
• Drugs: corticosteroids, ACTH, epinephrine, thyroxine,
or prostaglandins
Interfering factors A diurnal rhythm seen, with the lowest eosinophil counts in
the morning and the counts increasing from noon to mid
-
night or later.
Decreased counts are seen in physiological stress, including
burns, postoperative states, ECT, and labor and delivery.
Cross-references Complete Blood Count
White Blood Cell Count
Allen JA, Peterson A, Sufit R, et al: Post-epidemic eosinophilia-myalgia syndrome associated with L-
tryptophan. Arthritis Rheum 63(11):3633–3639, 2011
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
McPherson RA, Pincus MR: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 24th
Edition. Philadelphia, PA, Elsevier, 2022
Piera-Velazquez S, Wermuth PJ, Gomez-Reino JJ, et al: Chemical exposure-induced systemic fibrosing
disorders: novel insights into systemic sclerosis etiology and pathogenesis.Semin Arthritis Rheum
50(6):1226–1237, 2020
https://t.me/med1917
317 Laboratory Tests
White blood cell (WBC) count differential: lymphocytes
Type of test Blood
Background and explanation
of test
Small cells that migrate to sites of inflammation, lympho-
cytes have a central role in the immune response to infection,
carcinogens, and foreign tissue as well as autoimmunity. The
two main types of lymphocytes are B cells, responsible for
the production of antibodies (humoral immunity), and
T cells, which identify foreign material and process it for
removal (cell-mediated immunity). All lymphocytes origi-
nate in the bone marrow, but T cells mature in the thymus
gland. Most lymphocytes in the circulation are T cells, which
have a life span of months to years, whereas B cells generally
have a life span of days.
B cells mediate the antigen-antibody response that is specific
to the antigen. Cell-mediated immunity involving T cells
includes defense against neoplasms and intracellular path
-
ogens such as HIV and Mycobacterium tuberculosis, delayed
hypersensitivity reactions, graft rejection, and graft-vs.-host
reactions. Types of T cells include CD4+ helper cells, which
assist B cells in making antibodies, and CD8+ cytotoxic cells,
which are capable of
destroying foreign material. In general,
although the immune cells work in concert, extracellular
pathogens are best handled by B cells, and intracellular
pathogens are best handled by T cells.
For this assay, each of the five types of WBCs is counted and
the value is expressed as a percentage of the total WBC
count. Increases or decreases in the total WBC count and in
each cell type have diagnostic importance. Although the
percentage shows only the relative number of each cell type,
the absolute number can be calculated by multiplying the
percentage of that cell type by the total WBC count. The ab
-
solute value is used to determine whether the count of a par-
ticular cell type is increased.
Relevance to psychiatry and In patients with HIV infection, CD4+ helper cell numbers in
behavioral science the circulation can be measured to determine immune status.
The higher this CD4 count, the better the immune system
function. Normal CD4 counts range from 500 to 1,500 cells/
mm
3
. When the count falls below 200 cells/mm
3
, serious op-
portunistic infections may ensue. CD4 testing is no longer
used to determine when antiretroviral therapy should begin,
but it is used to monitor response to therapy.
Preparation of patient Fasting is not required. Any physiological stress should be
avoided just before testing.
Indications • WBC differential often included as routine component
of CBC
• Specific subtype counts and assessment of functional
activity of cells are performed in the evaluation of both
lymphoproliferative states (e.g., leukemia, lymphoma)
and immunodeficiency states (e.g., HIV infection, organ
transplantation).
https://t.me/med1917
318 Laboratory Medicine in Psychiatry and Behavioral Science
White blood cell (WBC) count differential: lymphocytes (continued)
Reference range 1.0–4.8 ×10
9
/L (20%–40% of total WBC count)
Normal CD4-to-CD8 ratio >1
Critical value(s) Lymphocyte count <0.5×10
9
/L: The patient should be pro-
tected from infection, especially viral.
Lymphocyte count >5.0×10
9
/L unexplained by acute viral
illness: The patient should be referred for specialist evalua
-
tion.
High lymphocyte count in a patient also showing anemia or
thrombocytopenia: The patient should be referred for spe
-
cialist evaluation.
Increased levels • Lymphatic leukemia or lymphoma
• Infectious lymphocytosis
• Infectious mononucleosis (with Downey cells and posi-
tive heterophile antibodies test)
• Other viral diseases (respiratory tract infections, cyto-
megalovirus, measles, mumps, chickenpox, acute HIV
infection, acute viral hepatitis, toxoplasmosis)
• Certain bacterial diseases (tuberculosis, brucellosis, per-
tussis)
• Crohn’s disease, ulcerative colitis
• Drug hypersensitivity or serum sickness
• Hypoadrenalism, Addison’s disease
• Thyrotoxicosis
• Neutropenia (relative lymphocytosis)
Decreased levels • COVID-19 infection (decrease inversely proportional to
disease severity)
• AIDS, inherited immune disorders
• Immunosuppression with drugs or radiation
• Aplastic anemia
• Hodgkin’s disease, other malignancies
• Severe debilitating illness
• Advanced (miliary) tuberculosis, renal failure, SLE
• ACTH-producing tumors
• Lymphocyte loss through GI tract due to lymphatic
obstruction
• Congestive heart failure
Interfering factors Lymphocyte values may increase after exercise, emotional
stress, or menstruation.
In general, Black patients may show a relative but not abso-
lute increase in lymphocytes.
https://t.me/med1917
319 Laboratory Tests
White blood cell (WBC) count differential: lymphocytes (continued)
Interfering factors (continued) Psychotropic drugs associated with false lymphocyte ele-
vations include gabapenti n, haloperidol, levodopa, opioids,
paroxetine, quazepam, triazolam, valproate, and venlafaxine.
Psychotropic drugs associated with false lymphocyte re-
ductions include alprazolam, aripiprazole, benzodiazepines,
bupropion, folic acid, gabapentin, levetiracetam, lithium,
mirtazapine, phenytoin, quazepam, thiamine, and triazolam.
Cross-references Complete Blood Count
HIV and AIDS
Infectious Mononucleosis
White Blood Cell Count
American Association for Clinical Chemistry: Testing.com. Available at: https://www.testing.com. Ac-
cessed October 2021
Akhavizadegan H, Hosamirudsari H, Alizadeh M, et al: Can laboratory tests at the time of admission
guide us to the prognosis of patients with COVID-19? J Prev Med Hyg 62(2):E321–E325, 2021
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
McPherson RA, Pincus MR: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 24th
Edition. Philadelphia, PA, Elsevier, 2022
Palladino M: Complete blood count alterations in COVID-19 patients: a narrative review. Biochem Med
(Zagreb) 31(3):030501, 2021
https://t.me/med1917
320 Laboratory Medicine in Psychiatry and Behavioral Science
White blood cell (WBC) count differential: monocytes
Type of test Blood
Background and explanation
of test
Monocytes are WBCs uniquely poised for fast mobilization to
sites of inflammation throughout the body. These cells have
important biological functions involving humoral and cell-
mediated immunity, surveillance of the internal environ
-
ment, and orchestration of hematopoiesis. Pathogenic roles
of monocytes have also been described, for example, in the
formation of new blood vessels within atherosclerotic
plaques and arterial walls.
Historically, monocytes were thought to form in the bone
marrow, circulate in the blood, and then move into tissues,
where they were transformed into macrophages or dendritic
cells. More recently, investigations have shown that most tis-
sue macrophages have an embryonic origin and that conven-
tional dendritic cells have a separate precursor in the bone
marrow.
For this assay, each of the five types of WBCs is counted and
the value is expressed as a percentage of the total WBC count.
Increases or decreases in the total WBC count and in each cell
type have diagnostic importance. Although the percentage
shows only the relative number of each cell type, the absolute
number can be calculated by multiplying the percentage of
that cell type by the total WBC count. The absolute value is
used to determine whether the count of a particular cell type
is increased.
Relevance to psychiatry and In recent years, a complex role for monocytes and other im-
behavioral science mune factors has been identified in a wide variety of psychi-
atric conditions, including TBI, PTSD, major depression,
psychosis, Alzheimer’s disease, HIV-associated neurocogni-
tive impairment, and neuropathic pain, among others.
Changes to the permeability of the blood-brain barrier may
be implicated, but much more research is needed to demon
-
strate the clinical utility of these fi ndings.
Increased monocyte counts may be found in drug abusers
with bacterial endocarditis or other infections and in patients
with tuberculosis or syphilis. Several psychotropic drugs are
associated with spurious changes to monocyte counts, as
noted in the Interfering Factors section below.
Preparation of patient Fasting is not required. Any physiological stress should be
avoided just before testing.
Indications • WBC differential may be included as routine component
of CBC
• WBC differential may be added when the WBC count is
abnormal, to help determine source of abnormality.
Reference range 100–500 cells/mm
3
(3%–7% of total WBC count)
Critical value(s) None
https://t.me/med1917
321 Laboratory Tests
White blood cell (WBC) count differential: monocytes (continued)
Increased levels • Bacterial infection
• Tuberculosis
• Subacute bacterial endocarditis
• Syphilis
Other established causes include leukemia, myeloprolifera-
tive disorders, carcinoma, lymphoma, recovery stage of neu-
tropenia, lipid storage disease, surgical trauma, chronic
ulcerative colitis, enteritis, sprue, collagen diseases, sarcoid-
osis, tetrachloroethane poisoning, and certain parasitic, my-
cotic, and rickettsial diseases.
Decreased levels • HIV infection
• Aplastic anemia
• Overwhelming infection (with neutropenia)
• Hairy cell leukemia
• Steroid (prednisone) treatment
Interfering factors Psychotropic drugs associated with falsely increased mono-
cyte levels include alprazolam, chlorpromazine, haloperi-
dol, paroxetine, and quazepam.
Psychotropic drugs associated with falsely decreased
monocyte levels include alprazolam and triazolam.
Cross-references Complete Blood Count
White Blood Cell Count
Fischbach FT, Fischbach MA: A Manual of Laboratory and Diagnostic Tests, 10th Edition. Philadelphia,
PA, Wolters Kluwer Health/Lippincott Williams and Wilkins, 2018
Guilliams M, Mildner A, Yona S: Developmental and functional heterogeneity of monocytes.Immunity
49(4):595–613, 2018
Jaipersad AS, Lip GY, Silverman S, Shantsila E: The role of monocytes in angiogenesis and atherosclero-
sis. J Am Coll Cardiol 63(1):1–11, 2014
Malcangio M: Role of the immune system in neuropathic pain. Scand J Pain 20(1):33–37, 2019
Morris G, Fernandes BS, Puri BK, et al: Leaky brain in neurological and psychiatric disorders: drivers and
consequences. Aust N Z J Psychiatry 52(10):924–948, 2018
Prinz M, Priller J: The role of peripheral immune cells in the CNS in steady state and disease.Nat Neu-
rosci 20(2):136–144, 2017
https://t.me/med1917
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