Leukocytosis in Pregnancy as a Result of Ectopic Deciduosis

Leukocytosis in Pregnancy as a Result of Ectopic Deciduosis
Karin Sterl, MD1, Shadi Latta, MD2; David Hakimian,MD2
¹Department of Medicine, West Suburban Medical Center
²Deparment of Hematology-Oncology, Advocate Lutheran General Hospital
Pregnancy is a common cause of mild
leukocytosis but a marked elevation in a
patient’s white blood cell (WBC) count can be
clinically challenging. It can be suggestive of
infections, inflammatory diseases, bone marrow
disorders or malignancies. This is a case of
remarkable leukocytosis in an asymptomatic
pregnant female caused by peritoneal ectopic
decidual tissue.
Post-partum course:
Clinical Case:
 Day 10- WBC: 11400/microL
A 35 year old primipara female was diagnosed
with mild leukocytosis in the first trimester of
pregnancy. Since that time her leukocyte count
continued to rise.
Pregnancy course:
 week 32- diagnosed with cholestasis of
pregnancy and started ursodiol
 week 33- WBC: 28000/ microL
 week 36- developed a tooth infection and
completed 7 days of amoxicillin; denied
fevers, chills or sweats; WBC: 42000/microL
; platelet count and hematocrit normal;
 week 37- induction of labor due to cholestasis
was unsuccessful and she underwent cesarian
section; diffuse intraperitoneal white-tan
nodules were noted during the procedure
 Gynecological oncology consulted; assessed
the patient in the operating room and
concluded that the etiology of the nodules was
uncertain; A frozen pathological section
revealed spindle cells. The specimen was sent
for pathologic diagnosis.
 day 1- WBC: 57600 /microL
 day 2- WBC: 63000/microL
 Hematology service consulted to evaluate the
persistent leukocytosis; FISH study for the
BCR-ABL translocation in order to rule out
chronic myelogenous leukemia was negative;
the possibility of deciduosis was explored at
that time and a serum G-CSF level was
ordered and was elevated at 243.9 pg/ml
Peritoneal biopsy results:
Figure 1: Diffuse intraperitoneal white-tan nodules
 nodular to plaque-like proliferation of
epithelioid to spindled cells with abundant
eosinophilic to amphophilic cytoplasm and
an associated mixed (predominantly
neutrophilic) inflammatory cell infiltrate.
The lesional cells were
immunohistochemically positive for
vimentin, progesterone and estrogen
receptors and negative for pan keratins
AE1+3 and MAK-6, CK5/6, calretinin,
HMB-45, EMA and CD117
 these results excluded the possibility of
deciduoid mesotheliomas or metastatic
 Mild leukocytosis is a very common finding
in pregnancy but the WBC count is usually
in the 10,000-15,000/microL range;
significantly elevated WBC count warrants
further workup.
 Consideration was given to other causes of
leukocytosis in our patient: a leukemoid
reaction secondary to cholestasis of
pregnancy during her 32nd gestational week
or the dental infection that the patient
developed during the 36th gestational week;
however, the patients markedly elevated
leukocyte count could not have been a
consequence of these processes; chronic
myelogenous leukemia was ruled out by a
negative FISH study for the BCR-ABL
 Ectopic deciduosis is most commonly seen
in the ovaries, cervix and uterine tubes and
very rarely in the peritoneum. Most cases of
deciduosis are related to normal pregnancy
and are asymptomatic but sometimes it can
be associated with abdominal pain
mimicking appendicitis, hemoperitoneum,
hydronephrosis or mechanical ileus.
 Our case is, to our knowledge, the first one
in the literature describing deciduosis
producing marked leukocytosis without any
accompanying symptoms.
 the placenta was histologically normal.
Figure 2: Nodular to plaque-like proliferation of epithelioid to
spindled cells with abundant eosinophilic to amphophilic
cytoplasm and an associated mixed (predominantly neutrophilic)
inflammatory cell infiltrate with karyorrhectic changes.
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