EHA Library - The official digital education library of European Hematology Association (EHA)

Left shift in granulopoiesis, has been seen in cancer or infection. An accurate marker has been IG (immature granulocyte which includes promyelocytes, myelocytes and metamyelocytes), blasts and bands are excluded from the measurement. In the peripheral blood smear, the appearance of immature granulocytes (IG) is a common finding in infection, inflammation, hematologic malignancy disorders and other factors that stimulate the bone marrow such as Growth-Stimulating Factors (G-CSF). Also, increased granulation in neutrophils indicates serious infection or patients undergoing chemotherapy.

A total of 143 unselected whole-blood samples were collected in tubes with K3-EDTA and were analysed in approximately 3 h of collection. Patients who had their blood counts monitored on a daily basis were excluded. The automated IG % results (a percent of the total white blood count) provided from the hematological analyzer (Sysmex-XE 5000) were divided into three groups IG < 1 (61 samples), IG 1-10 (61 samples), IG > 10 (21 samples) and compared to manual IG counts. The first two groups were similar in regard to sex (39 males - 22 females) and age (8 - 86 years avg = 59,4 years). In the third group there were 14 males and 7 females, the age was 18 to 88 years (avg = 58,4 years). The peripheral blood smears, from flagged reported samples (Imm Gran), were stained with May-Grünwald- Giemsa by Sysmex SP-100 slide system. The immature granulocytes and granularity of the neutrophils, were generated by two expertised physicians. Mean value comparison using paired t-tests was used in order to examine the statistical significance among the groups. The significance level was defined as p < 0.05. All statistical analysis was performed using SPSS 20 and Mc Excel 2010.

In the first group with the automated IG < 1, the manual IG count was zero, so there was an agreement between visual microscopy and SYSMEX XE-5000. In the second group there was also an agreement in comparison to the manual IG. The difference of the mean values of IG1-10 between the manual IG and the automated IG is not statistically significant (p-value > 0,05) showing that there is no difference between the two methods. In the third group there was a difference. The manual IG percentage revealed a higher number of immature granulocytes than the automated IG.  The difference between the microscopic and manual results increased with increasing levels of IG. In the third group, the number of specimen was very low so, in order to acquire reliable results, a larger number of samples should be generated. 

Immature granulocytes (IG) are a predictive useful parameter for the presence of  infection, sepsis, inflammation, treatment with oncolytic drugs or bone marrow activation. For blood samples whose IG was > 1%, a microscopic examination should be operated. In addition, taking into consideration IG% as a marker, a serious number of spurious blood film reviews might be reduced and minimized. Also, the implication to shorter turn-around times would enhance the diagnostic effectiveness.