Hematology Case 67

Post operative deterioration of general condition.

Patient received 2 units of blood.

Post operative (CS) anuria non responsive to fluid replacement.

Tachycardia, hypertension (Post-operative).

Patient looks drowsy

Deep jaundice & pallor.

Distended abdomen & Tender right hypochondondrium.

At time of sample collection: Heart rate :126 b/m - Respiratory Rate: 27 c/m - Blood pressure 100/73 mmHg (On noradrenaline).

• Unfortunately the case died 2 days later.

• Previously termed “Green Crystals of Death,” bright blue‐green inclusion bodies within neutrophils are a rare clinical finding. They have been reported as a predictive sign of mortality in critically ill patients and often accompany acute liver failure, lactic acidosis with multisystem organ failure, or septic shock due to Escherichia coli.  (Michael P. Soos, et al. Blue‐green neutrophilic inclusion bodies in the critically ill patient. Clin Case Rep. 2019;7:1249–1252.)

• Blue-green cytoplasmic neutrophilic inclusion bodies, previously described as "green crystals of death," are a rare but likely underreported finding in critically ill patients. This finding is associated with high mortality, ranging from 31% to 100% in published case studies. These inclusion bodies have been most strongly associated with acute liver injury and lactic acidosis, but they have also been reported in critically ill patients secondary to other etiologies.  (Phillip S. Wozniak, et al. Green Cytoplasmic Neutrophilic Inclusion Bodies in a Patient With Aspiration Pneumonia and Bowel Perforation.  Cureus, 2023; 15(7): e41318.).