Pituitary
DOI 10.1007/s11102-013-0522-0
Elevated white blood cell counts in Cushings disease: association
with hypercortisolism
Hiba Masri-Iraqi Eyal Robenshtok
Gloria Tzvetov Yossi Manistersky
Ilan Shimon
Springer Science+Business Media New York 2013
Abstract
Background Glucocorticoid receptors are expressed in
white blood cells (WBCs) and are known to play a role in
cell adhesion and WBCs recruitment from bone marrow.
In Cushings disease leukocytosis is frequently mentioned
as laboratory finding. However, there is no data on the
prevalence of this finding among patients, or correlation
with disease severity.
Purpose To investigate the prevalence of leukocytosis in
patients with Cushings disease, alterations in other blood count
parameters and correlation with degree of hypercortisolism.
Methods Data of 26 patients diagnosed and followed for
Cushings disease at our clinic was reviewed. Two patients
had disease relapse after complete remission and were
studied as 2 separate events.
Results Of the 26 patients, 17 were women (71 %),
with a mean age of 39.8 12.7 years. Mean baseline
WBC count was 10,500 2,600 cells/ll and dropped to
8,400 1,900 cells/ll (p \ 0.05) after treatment, mean
neutrophil count at baseline was 7,600 2,600 cells/ll
and dropped to 5,300 1,700 cells/ll (p \ 0.05),
lymphocyte count was 2,000 600 cells/ll and raised
to 2,300 600 cells/ll (p \ 0.05), hemoglobin was
13.7 1.2 g/dl and dropped to 12.8 1.4 g/dl (p \ 0.05),
and platelet number did not change. Elevated WBC count
H. Masri-Iraqi
E. Robenshtok
G. Tzvetov
Y. Manistersky

I. Shimon (&)
Institute of Endocrinology and Metabolism, Beilinson Hospital,
Rabin Medical Center, 49100 Petah Tikva, Israel
e-mail: ilanshi@clalit.org.il
H. Masri-Iraqi
E. Robenshtok
G. Tzvetov
Y. Manistersky

I. Shimon
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv,
Israel
was present in 11/28 cases (40 %). Those patients with
normal baseline WBC (mean 9,000 1,500 cells/ll)
dropped also to 7,700 1,300 cells/ll after treatment
(p \ 0. 05). There was a significant positive correlation
between decrease in UFC secretion and change in WBCs
following treatment (r = 0.67, p \ 0.01).
Conclusions Patients with Cushings disease present with
leukocytosis in approximately 40 % of cases. In most
cases, including those without elevated baseline count, the
WBCs decreased with disease remission, demonstrating
the effect of glucocorticoids on these blood cells.
Keywords Cortisol
Cushings disease

Glucocorticoids
Leukocytosis
White blood cells
Introduction
Cushings syndrome was first described in 1912 by Harvey
Cushing [1]. A variety of clinical features and laboratory
findings are attributed to glucocorticoid (GC) excess in
Cushings syndrome with variable reported proportions,
with obesity and weight being the most frequent features,
but also diabetes mellitus, hypertension, hirsutism, osteo-
porosis, hypokalemia, and more [24]. The diagnosis is
complicated due to high prevalence of similar clinical
symptoms and signs in patients without the disorder [4].
One of the characteristic laboratory findings associated
with Cushings syndrome is elevated white blood cells (WBC)
counts, as described early in the 1940s. In a study by de la
Blaze et al. [5] ten patients with Cushings disease were found
to have higher leukocyte counts than normal subjects, with a
tendency for higher percentage of polymorphonuclear (PMN)
cells and lower percentage of lymphocytes.
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However, there is insufficient data regarding the long
term effects of GCs excess on hematologic indices, apart
from the observation of high leukocyte counts in patients
with Cushings syndrome or following exogenous admin-
istration of GCs. Moreover, no data is available regarding
the true prevalence of this finding and alterations in other
blood components as evaluated by complete blood counts.
We conducted a retrospective study on 26 patients with
Cushings disease to describe the true prevalence of leu-
kocytosis in Cushings disease, to compare alterations in
blood cell components before and after treatment for
hypercortisolism, and to correlate WBC counts with dis-
ease activity.
Methods
We retrospectively studied 26 consecutive cases diagnosed
with Cushings disease and followed in the Endocrine
Institute, Rabin Medical Center, Beilinson Hospital, Israel.
Demographic information including age at diagnosis,
gender, urinary free cortisol levels (UFC), complete blood
count (CBC) (hemoglobin, WBCs, neutrophils, lympho-
cytes and platelets) at baseline and following treatment
were collected. Baseline parameters were collected from
the year preceding diagnosis. The study was approved by
the ethical institutional board at the Rabin Medical Center.
The diagnosis of Cushings disease was confirmed by at
least two elevated UFC collections (C2 times the upper limit
of normal; ULN), high or normal range ACTH levels, and a
pituitary lesion consistent with an adenoma seen on MRI (in
24/26 of the patients). Remission was defined as at least 2
measurements of UFC within the normal range achieved
either by pituitary surgery, medical treatment, or both. Only
then WBCs measurements were performed. In patients who
were not in full hormonal remission WBCs data was col-
lected during the lowest measurements of UFC.
CBCs were measured using an automatic ABX Mi-
crosCRP 200 analyzer (Clinical Laboratory International,
Brussels, Belgium). The within-run CV for WBC was
2.7 % using this assay. UFC was measured using radio-
immunoassay for the determination of cortisol in urine
(Beckman Coulter) with high antibody specificity for cor-
tisol and low cross reactivity against other naturally
occurring steroids. The analytical sensitivity is 10 nM. The
intra- and inter-assay CVs were 5.8 and 9.2 %, respec-
tively. Reference levels for 24 h urine collection are
38208 nmol/24 h.
Statistical analysis
Continuous data are presented as means and standard
deviations. Continuous variables were compared using
123
Pituitary
Students t test or MannWhitney U test, as appropriate.
The relationships between UFC and blood count compo-
nents were analyzed using Pearsons correlation. Analysis
was performed using SPSS software (Version 20; SPSS
Inc., Chicago, IL). A p value of less than or equal to 0.05
was considered statistically significant.
Results
Patients characteristics
The study included 26 patients with Cushings disease, 19
females and 7 males, with a mean age at presentation of
39.8 12.7 years; 16 patients had microadenomas, 8 had
macroadenomas, and in two cases there was no visible
adenoma on MRI (Table 1). All patients except two had
transsphenoidal surgery (TSS). The two patients who did
not have surgery were treated medically. Twenty patients
achieved remission, including two patients who experi-
enced transient remission. The mean baseline UFC levels
was 5.4 6.9 9 ULN and dropped to 1 1.1 9 ULN
following treatment.
Blood count changes
Mean WBCs before treatment was 10,500 2,600 cells/ll
(normal \10,800 cells/ll) with 40 % having elevated
WBCs, and dropped to 8,400 1,900 cells/ll (p \ 0.05),
with 11 % having elevated WBCs after treatment. The mean
neutrophil count was 7,600 2,600 cells/ll before treatment
and dropped to 5,300 1,700 cells/ll after treatment
(p \ 0.05), and the mean lymphocyte count was 2,000 600
cells/ll at baseline and increased to 2,300 600 cells/ll
following treatment (p \ 0.05). Hemoglobin was
13.7 1.2 g/dl at baseline and decreased to 12.8 1.4 g/dl
(p \ 0.05) (Fig. 1).
Table 1 Clinical characteristics of 26 patients with Cushings dis-
ease included in the cohort, and 28 events (*) of hypercortisolemia
(including 2 patients with disease relapse)
Age 39.8 12.7
Female/male 19/7
Microadenomas 16/26 (62 %)
Macroadenomas 8/26 (31 %)
Transsphenoidal surgery 24/26 (92 %)
Ketoconazole therapy 12/28* (43 %)
Radiation therapy 4/28* (14 %)
Somatostatin analogue therapy 3/28* (11 %)
Remission 20/28* (71 %)
Pituitary

baseline after treatment * WBCs/ll; n = 11) and patients with normal baseline
13.7
WBC count (n = 15). There was no difference in age,
12.8 gender, or adenoma size between the two groups, and the
*
10.5 mean baseline UFC was not significantly different.
8.4
* Mean WBCs in the group with elevated baseline count was
7.6
12,970 2,260 cells/ll and dropped to 9,620 2,000 cells/
5.3 ll (p \ 0.05) following successful treatment (Fig. 3a). Base-
*

2.3
2.0
WBC NEUT LYMPH HGB
Fig. 1 Mean blood cell counts in patients with Cushings disease at
diagnosis and following treatment; the values are the average of a
number of blood counts both before and after surgical and/or medical
treatment. WBC white blood cells (91,000 cells/ll), NEUT neutro-
phils (91,000 cells/ll), LYMPH lymphocytes (91,000 cells/ll), HGB
hemoglobin (g/dl). *p \ 0.05
There was no correlation between pre-treatment UFC
and baseline WBCs levels (Fig. 2). However, there was a
significant positive correlation between decrease in UFC
secretion (DUFC) and change in WBCs (DWBC) fol-
lowing treatment (r = 0.67, p \ 0.01, 2-tailed). It is of
note that this strong correlation is mostly due to one patient
(Fig. 2, right column) who had very high UFC levels
before treatment (up to 34 9 ULN) together with high
WBC counts, and who went into remission following
treatment with normalization of his WBC levels. Upon
further analysis of this case, there were 14 pre-treatment
CBCs showing consistently high WBC levels ([15,000/
ll), and 7 post-therapy CBCs showing consistently normal
WBC levels (\10,000/ll) upon normalization of UFC
levels. According to this data, the patients change in WBC
levels was definitely attributable to the change in UFC.
line neutrophil count was 9,700 2,600 cells/ll and dropped
to 6,300 1,600 cells/ll (p \ 0.05). There were no signifi-
cant alterations in lymphocytes and platelets counts or
hemoglobin concentrations (Fig. 3a).
In the group with normal baseline counts, the mean
WBCs was 9,000 1,400 cells/ll and dropped to
7,700 1,300 cells/ll (p \ 0.05); neutrophil count was
6,200 1,500 cells/ll and dropped to 4,600 1,400 cells/
ll (p \ 0.05); the lymphocyte count raised from
1,800 580 cells/ll at presentation to 2,280 580 cells/
ll after treatment (p \ 0.05); hemoglobin was
13.7 1.2 g/dl and decreased to 12.8 1.4 g/dl
(p \ 0.05) following treatment (Fig. 3b). Platelets count
didnt change significantly.
In a separate analysis of patients who were in remission
(n = 20) and those who did not achieve cortisol normali-
zation (n = 8, including 2 patients with disease relapse), the
baseline UFC was 4 3.8 9 ULN and 8 10 9 ULN,
respectively; the mean lowest UFC after treatment was
A baseline after treatment
* 13.7 12.9
13.0
*
9.6 9.7
6.3
2.2 2.4

Subgroup analysis
WBC NEUT LYMPH HGB
We performed sub-group analysis for the cohort of patients B *
with elevated baseline WBC count (defined as C10,800 baseline after treatment 13.7
12.8
20.00 *
18.00 9.0
16.00 7.7
*
14.00 6.2
12.00 4.6
WBC

10.00 *
1.8 2.3
8.00
6.00
4.00
WBC NEUT LYMPH HGB
2.00
0.00
Fig. 3 Mean blood cell counts in patients with elevated baseline
13.8
15.5
33.8
1.2
1.3
1.5
1.5
1.8
1.8
1.9
2.1
2.2
2.6
2.6
2.6
2.6
3.3
3.4
3.5
3.6
4.0
4.0
4.8
5.2
5.3
5.3
5.5
7.8

WBCs ([10,800 cells/ll) (a) and normal baseline WBCs (b), at

UFC
Fig. 2 Individual relationships between baseline UFC and WBC
counts among patients with Cushings disease. WBC white blood cells
(91,000 cells/ll), UFC (9ULN)
diagnosis and following treatment; the values are the average of a
number of blood counts both before and after treatment. WBC white
blood cells (91,000 cells/ll), NEUT neutrophils (91,000 cells/ll),
LYMPH lymphocytes (91,000 cells/ll), HGB hemoglobin (gr/dl).
*p \ 0.05

123

0.6 0.3 9 ULN and 2 1.4 9 ULN, respectively.
There was no significant difference in mean WBCs at
baseline between patients who achieved remission and those
who did not, nor a difference in the magnitude of the post
treatment change.
Discussion
We studied the effects of high cortisol levels on the dif-
ferent blood cell components in patients with Cushings
disease. Leukocytosis was present in 40 % of our cohort
patients, and there was a significant decrease of 20 % in
WBCs and 30 % in neutrophil counts upon UFC decrease
following surgical and/or medical treatments. Moreover,
there was a significant correlation between the decrease in
cortisol secretion and change in WBCs counts. These CBC
alterations in patients with Cushings disease could
potentially serve as another marker for hormonal response
to treatment, and remission during follow-up. However,
many factors including infections, stress, medications,
physiological fluctuations and others can affect WBC
counts making this measurement a non-accurate tool for
assessing treatment efficacy or disease relapse.
Cortisol exerts its main effects through binding to the
nuclear glucocorticoid receptor, inducing a cascade of intra-
cellular signaling and leading to protein synthesis [6]. Cor-
tisol is secreted in response to stress and pain signaling and
due to cytokine stimulation, resulting in hypothalamic
pituitaryadrenal activation. Cortisol binds with high affin-
ity to the glucocorticoid receptor and this complex inhibits
inflammation both through genomic and nongenomic
mechanisms. The rise in cortisol levels in the absence of
active inflammation, like in Cushings syndrome, can cause
immune suppression associated with susceptibility to severe
infections [7]. This is associated with lymphopenia seen
after administration of adrenocorticotrophic hormone
(ACTH), as reported many years ago [8].
Glucocorticoid-induced leukocytosis has been attributed
to several mechanisms including increased release of
PMNs from bone marrow to the circulation [9], delayed
neutrophil apoptosis in the circulation [10], and reduced
cell transfer from blood vessels into tissues [11]. Another
mechanism playing a role is an influx of PMNs from the
intravascular marginated pools of PMNs [9]. These cells
are found in the lungs, liver, spleen and bone marrow, in
close contact with the endothelial cells of small blood
vessels. Stress signals like cortisol and catecholamines can
activate mature granulocytes in these marginated pools to
undergo rapid demargination, resulting in acute elevation
of circulating leukocytes. Cortisol results also in prolon-
gation of their intravascular half-life and delays their dis-
appearance from the circulation [9]. Some of the effects of
123
Pituitary
GCs on blood cells are recognized as their clinical use is
very common, but their long-term effects were not care-
fully investigated, and most published studies on their
hematological effects were designed to show acute effects.
Administration of dexamethasone intravenously or orally
to healthy subjects results in an increase of neutrophil
count and lymphopenia, the increment is in a linear relation
to the dose introduced intravenously but not orally [12].
The long-term effect of GCs on blood counts shown in our
Cushings patients argues against the demargination effect
theory of GCs on granulocytes that was shown shortly
after a single dose of dexamethasone [9, 12], and supports
other studies displaying direct effects of stimulatory factors
on bone marrow release of new PMNs [13].
Importantly, patients with unexplained persistent leu-
kocytosis are often studied extensively for various hema-
tological diseases, sometimes without success. These
patients should be referred also for cortisol measurements,
and Cushings syndrome should be part of the regular
work-up for patients with unexplained leukocytosis, as our
series reveals.
The action of GCs on lymphoid cells is well known and
they are used successfully in the treatment of leukemia and
lymphoma with high lymphocyte counts [14]. In vitro
studies demonstrated that GCs induce apoptosis of human
mature T lymphoid cells [15]. In our cohort lymphocyte
counts increased following cortisol normalization, in line
with the known effects of elevated cortisol on human
lymphocytes. Effects of GCs on platelets are not well
recognized and in some reports patients with elevated
cortisol did not show significant alterations in their platelet
counts [16], whereas other series showed increased num-
bers of platelets in Cushings patients [17]. Although it was
previously thought that platelet cells lack GCs receptors as
they lack a nucleus, it is now well recognized that GCs
affect platelet function through binding to the GC receptors
expressed in human platelets [18], activating nongenomic
processes.
The role of GCs administration in aplastic anemia and
other forms of non-immune hemolytic anemia implies a
direct effect on bone marrow erythropoiesis [19]. GCs
exert their effects on the erythroid line by enhanced
response of red blood cells to erythropoietin or directly by
stimulating cell proliferation [13]. In our cohort, hemo-
globin levels significantly decreased following treatment to
normalize cortisol secretion, in agreement with these
observations.
Like other features of Cushings syndrome such as
overweight, diabetes, hypertension, osteoporosis, plethora
or edema which severity is not linearly related to serum
cortisol or UFC levels, we were not able to show any
correlation between pre-treatment UFC levels and baseline
WBCs counts (Fig. 2). This can be partially explained by
Pituitary
GCs receptor polymorphism which may result in relative
resistance or sensitivity to GCs [20], leading to a different
in vivo response to cortisol. This is also a well-known
phenomenon in the response to GCs treatment in auto-
immune diseases [21].
Our study has several limitations. First, it is a retro-
spective study, and the blood tests were done routinely and
not for the study. Also, the number of blood tests available
for each subject varied between patients. Second, a rela-
tively small number of patients are included in the study
due to the rarity of the disease, and that may cause the lack
of correlation between baseline WBC counts and disease
severity. Third, the study includes only patients with
Cushings disease, so any conclusion cant be instantly
drawn to patients with ACTH-independent Cushings
syndrome, although previous studies showed that exoge-
nous administration of GCs exert the same effects on
blood cell counts.
In conclusion, elevated WBCs is common in patients
with Cushings disease. During remission or hormonal
control of the disease there is significant decrease in neu-
trophil counts and in hemoglobin concentration together
with a rise in lymphocyte numbers. These parameters may
help to identify a trend towards improvement or deterio-
ration in cortisol control. A larger study may clarify the
effects of these changes on disease prognosis and other
features of Cushings syndrome.
Conflict of interest The authors declare that they have no conflict
of interest.
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