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Total White Blood Cells

Aug 4, 2001

Dear Doctor,

Recently you answered a question regarding the total white blood count during ARS, and you reponse was "Yes, the total WBC (white blood count) may be lower than normal in acute infection. This happens not only in HIV but in most viral illnesses"

So further to this answer, I have two more questions.

1) How normal is it to present with high total white blood cells instead of low white blood cells? 2) Is it possible to have a high white blood count and low CD4 counts?

Please help me understand more..

Response from Dr. Aberg

The white boold count can vary in an individual from day to day. In fact, the white blood count can vary according to the time of the day which is why we recommend that you get your CD4 count drawn about the same time of the day throughout your care.

Hematology (the study of blood) is a course by itself and in fact, there are doctors who specialize in it so I am not going to be able to address all the what if's, etc on a web site. But I will do my best to answer some of your basic concerns.

Typically when one gets a bacterial infection, the white blood count goes up. This increase is predominantly from a type of white blood cells called neutrophils which fight bacterial infections. Frequently when the white bllod cell goes up because of neutrophils fighting infections, the CD4 count goes down. That is why I do not like to check CD4 counts in persons with HIV when they are acutely ill. The CD4 count can be suppressed (lowered) because the neutrophils are out in full force fighting infection. This can be misinterpreted by both the doctor and patient. For instance someone with HIV whose CD4 count is running around 500 gets an acute bacterial infection such as pneumonia. The CD4 count comes back 180 while he is ill. Now the person thinks thay have AIDS! There are many issues regarding this. A month later the person gets their CD4 checked again and it is back into the 500's. Even someone without HIV can have CD4 counts <200 when they have a bacterial infection. Because of this, a CD4 count should never be used as a "surrogate" marker that someone has HIV. Earler in the epidemic, doctors would check CD4 counts on persons admitted to the hospital with infection trying to figure out if maybe the person had HIV. This was totally wrong to do. Only an HIV test can tell you if you have HIV.

So, back to your questions. In primary HIV infection, it is more common to have a low or normal white blood count but if a person has a bacterial infection (and there are other reasons), the white blood count may be elvated. The white blood count can vary and should not be used as a marker for whether someone has HIV or not. In someone who appears healthy and has an abnormal low white blood count or low lymphocyte count, then this may be a sign of HIV although again, there can be many other reasons. A test for HIV would need to be done to attribute the abnormal white blood count to HIV.

So, in summary, the white blood count can be very helpful in guiding providers to look for an infection, drug reaction, many other non-infectious diseases including leukemias. It cannot tell you the exact type of infection a person. I hope this helps. As you can see, one has to be careful about interpreting test results and that is why it is not always so easy to figure out what is wrong with someone when they do not feel well.

Cidofovir and PML
thrush during acute viral stage

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