Intended for healthcare professionals

Endgames Case Report

An unexpected finding after a fall from a horse

BMJ 2013; 346 doi: (Published 12 February 2013) Cite this as: BMJ 2013;346:f724
  1. Sophie Raby, foundation year 2 doctor1,
  2. Daniel Greaves, core medical trainee1,
  3. Joseph Padayatty, specialist registrar1,
  4. Brian Huntly, consultant haematologist1
  1. 1Haematology Department, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
  1. Correspondence to: S Raby raby.sophie{at}

A 37 year old jockey was admitted with left sided abdominal pain and fullness one week after a fall from a horse. Before this he had been fit and well. On examination, he was tender in the left upper outer quadrant of his abdomen and his blood pressure was 90/55 mm Hg. A computed tomography scan showed an area of active bleeding in the parenchyma of the spleen and a large subcapsular haematoma.

Blood tests showed a white blood cell count of 259×109/L (reference range 4-11) with the following differential: blasts 3%, promyelocytes 11%, myelocytes 28%, metamyelocytes 19%, neutrophils 21%, basophils 10%, lymphocytes 4%, and eosinophils 4%. His haemoglobin was 109 g/L (130-180), mean cell volume was 80 fL (76-96), and platelets were 201×109/L (150-400). Lactate dehydrogenase was 563 IU/L (70-250; 1 mmol/L=9.01 mg/dL) and uric acid was 600 µmol/L (300-470; 1 µmol/L=0.03 mg/dL).

He underwent emergency splenectomy. Macroscopically, the spleen was greatly enlarged, at 22×13×10 cm, and microscopically it showed a dense infiltrate of left shifted immature myeloid cells.


  • 1 What are the possible causes of a raised white blood cell count?

  • 2 Given the clinical findings, what is the likely diagnosis?

  • 3 What further investigations should be considered?

  • 4 What are the treatment options?

  • 5 Why might allopurinol be started in this patient?


1 What are the possible causes of a raised white blood cell count?

Short answer

A white blood cell count greater than 50×109/L is caused by a primary haematological disease or, less commonly at such a high value, a leukemoid reaction. A leukemoid reaction may be lymphoid or myeloid in nature and is a physiological response of the bone marrow to a strong stimulus, such as infection, drugs, or an underlying solid cancer.

Long answer

Causes of leucocytosis (>11×109/L) can be classified according to cell lineage (box 1).

Box 1 Causes of leucocytosis (>11×109/L)

  • Acute bacterial infections

  • Drugs, such as …

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