Neutropenia

Who to refer:

• Neutrophil count <0.5 and evidence of sepsis – contact the on-call haematology registrar for urgent advice
• Neutrophil count <1 on repeat testing
• Neutrophil count <2 on repeat testing and the presence of any of the clinical findings as described above.

Who not to refer:

• People of Afro-Caribbean or Middle Eastern ethnicity have a lower normal range for the neutrophil count (constitutional or ethnic neutropenia). This is of no clinical consequence. Such patients should only be investigated if their neutrophils are <1.0 on repeat testing. No further monitoring required.
• Neutrophil counts consistently >1.5. These patients can be given the diagnosis of chronic idiopathic neutropenia. No further monitoring is required.
• Neutrophil count >1 but <1.5 repeat at 6 months. If clinical features of concern develop or neutrophil counts falls <1 refer to haematology. Otherwise patients can be given a diagnosis of chronic idiopathic neutropenia and no further routine monitoring is required.

How to refer:

SCI gateway to the Department of Haematology WGH or SJH.

For all:

• Assess patient for symptoms e.g. recurrent infections, mouth ulcers etc.
• Establish if patient is of an ethnic background known to be associated with lower neutrophil counts (See ‘Who not to refer’).
• Review medication (see above)
• Examine for lymphadenopathy and splenomegaly
• Repeat FBC:
  • If neutrophil >1 then repeat at 6 weeks
  • If neutrophil count <1 repeat at 1 week.

For persistent neutropenia do the following tests:

• Blood film
• B12 and folate, Ferritin. Treat if deficiency is detected
• HIV, HBV, HCV serology
• If additional clinical features to suggest a diagnosis of SLE, RA or other connective tissue disorder check CCP, ANF, dsDNA (if ANF positive).

Neutropenia in primary care. Hay et al. BMJ. 2014 Sep 11;349.