A 67-year-old woman presented with fatigue for 4 weeks. She had a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and allergic rhinitis. Her medications included metformin, lisinopril, and verapamil. Her cardiac and pulmonary examinations were normal. She had no fever or lymphadenopathy. The spleen was palpable 5 cm below the left costal margin. Laboratory evaluation revealed a white blood cell (WBC) count of 91 ×103/μL, with 54% neutrophils, 1% blasts, 2% basophils, 8% metamyelocytes, 23% myelocytes, and 1% promyelocytes (increased immature granulocytes). Hemoglobin level was 11.7 g/dL and platelet count was 290 000 (Figure 1).
Sellers MH, Dinner SN. Fatigue and an Elevated White Blood Cell Count. JAMA. 2015;314(6):617-618. doi:10.1001/jama.2015.4882