Lymphopaenia in the diagnosis of paediatric appendicitis: a false sense of security?

Abstract

Background: Appendicitis is a common indication for emergent surgery in children; however, it is a small proportion of presentations with abdominal pain. As viral illness is a common differential diagnosis, lymphopaenia is used by some as a predictor against appendicitis. Furthermore, neutrophil-lymphocyte ratio (NLR) has been found to predict appendicitis. We aimed to verify if lymphopaenia predicted against appendicitis in children. Methods: Retrospective review was conducted for all patients aged 15 years and under presenting with abdominal pain to our institution in 2017, and data including age, white cell count, neutrophil and lymphocyte count, NLR, C-reactive protein and diagnosis of appendicitis were recorded. Statistical analysis was performed using Stata©. Receiver operating characteristic curves for various tests were formed and areas under curve (AUC) compared using regression, P < 0.05 was considered significant. Results: A total of 1263 patients were presented, of whom 546 had their blood performed and were included, 86 had appendicitis and 460 did not. Neutrophilia was the best predictor for appendicitis (AUC = 0.86), significantly higher than NLR (0.81), P < 0.05. Lymphopaenia was a poor negative predictor of appendicitis (AUC = 0.46), and while isolated lymphopaenia was more predictive (AUC = 0.23) this was inferior to the positive prediction of neutrophilia, P < 0.05. Conclusion: The value of isolated lymphopaenia to predict against appendicitis is largely accounted for inherently normal neutrophils, independently lymphopaenia has little value. NLR, while predictive, is a weaker predictor than neutrophilia.

Diagnostic accuracy of blood tests of inflammation in paediatric appendicitis: a systematic review and meta-analysis

“…Reported accuracies ranged from sensitivity 0.18-0.91, and specificity 0.69-0.95 but cut-offs used Open access were dissimilar. [56][57][58] Similarly, the combination of WCC and ANC (>13 300/μL and >10 800/μL respectively) was reported in one study (sensitivity=0.76, specificity=0.82). 59 We found no evidence of publication bias for each test where this was appropriate to assess (online supplemental figure 1).…”

“…Neutrophil to lymphocyte ratio was reported in three studies which was not sufficient to allow a meta-analysis. Reported accuracies ranged from sensitivity 0.18–0.91, and specificity 0.69–0.95 but cut-offs used were dissimilar 56–58. Similarly, the combination of WCC and ANC (>13 300/μL and >10 800/μL respectively) was reported in one study (sensitivity=0.76, specificity=0.82) 59.…”

Neutrophil to lymphocyte ratio as the marker of acute appendicitis and its destructive forms in children

“…Наявна лімфоцитопенія, яка поєднується з вірусною інфекцією і може спричиняти гострий абдомінальний біль у дітей, зумовлює зростання показників СНЛ, що, у свою чергу, може призводити до гіпердіагностики ГА [11]. За результатами нашого дослідження, лімфоцитопенія була у 58,6% дітей з катаральним ГА, у 83,8% -з флегмонозним, у 92,5%з гангренозним і у 100% -з перфоративним ГА.…”

“…(2016), які оцінювали цей показник у дорослих пацієнтів із ГА [19], проте вони збігаються з результатами у педіатричній групі пацієнтів [7,17]. [7,11,17]. Отримані результати наведені у табл.…”

“…СНЛ виявляє ще вищу точність щодо виділення пацієнтів із перфоративним ГА (табл. 4), що також узгоджується з даними літератури [7,11,13].…”