Hematology Case 67
Patient Data
35 year old female
Clinical Data
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).
Related Laboratory Results
CBC:
- WBC: 33.81x103 /uL (Neutrophils: 31.22x103 /uL - Lymphocytes:1.9 x103 /uL - Monocytes: 0.55x103 /uL - Eosinophils: 0.3x103 /uL - Basophils: 0.1x103 /uL) "Cell counter Diff. count".
- HGB: 4.5g/dL - MCV: 68.3fL -MCH: 21.6pG - MCHC:31.7% -
- Platelet: 122x103 /uL
PT: 25.7sec. (R.R.: 11-15) - INR: 3.02(R.R.: 0.8 - 1.2) - APTT: 75 sec.(R.R.: 25-40)
L.F.T.: AST: 222 u/L (R.R.: 15-41) - ALT: 65 u/L (R.R.: 17-48) - ALB: 25 g/L (R.R.: 35-50) - Total bilirubin : 272 umol/L (R.R.: 5.1-20.5) - Direct bilirubin: 163 umol/L (R.R.: 1.7-8.6)
R.F.T.: BUN: 14.4mmol/L (R.R.: 2.5-6.4) - Creatinine: 234 umol/L (R.R.: 55-113) -
LDH: 1397u/L (R.R.: 98-192).
Case Picture(s) / Photo(s)
Images Comment / Findings
Peripheral Smear Findings:
Marked neutrophilia with shift to left to myelocytes.
Some neutrophils have toxic granules.
DOHLE bodies are occasionally seen in cytoplasm of some neutrophils. (Blue arrow)
Few neutrophils have cytoplasmic greenish inclusions (crystals) (Green arrow)
Severe microcytic hypochromic anemia.
RBCs show marked anisocytosis and marked poikilocytosis.
RBCs fragments & schistocytes are occasionally seen.
Normoblastemia ~ 2/100 WBCs.
Mild thrombocytopnea.
Final Diagnosis
A case of severe sepsis with bad signs (Greeninsh cytoplasmic neutrophilc crystals) for sepsis workup.
Applying DIC scoring system is recommended.
Additional Note
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.).