Hematology Case Study: Crystal of Death

Case History

A 56 year old female presented with symptoms of sepsis. During surgery, patient bleed profusely and received blood products. However, the patient expired.

Laboratory Findings

  • WBC: 18.8 x 109/L
  • Hemoglobin: 5.6 g/dL
  • Lactate: 8.3 mmol/L
  • AST: 1485
  • ALT: 1625

The blood smear was reviewed for these white blood cell inclusions:

green-incl-1
Image courtesy of Georgia McCauley, PhD, MT(AMT)
green-incl-2.jpg
Image courtesy of Georgia McCauley, PhD, MT(AMT)

Discussion

The image presented reveals to be the “blue green crystal of death”. Medical literature has documented an association between acute hepatic failure and coarse, bright-green neutrophilic inclusions. Upon identification of these unique inclusions patients have been reported to have poor outcomes and usually die within 24-72 hours (Haberichter KL, 2017). The exact nature of these inclusions has yet to be determined; it is postulated that they arise from lipofusion-like substance. Bright green inclusions in neutrophils have been reported as a sign of impending patient death (Hodgson, 2015).

Refractile bright-green irregular inclusions within neutrophils have been reported as a marker of impending patient death. In the three reported cases, death occurred within 2 d of recognition of the inclusions (Harris et al2009; Jazaerly & Gabali, 2014). Disease associations with green neutrophil inclusions included acute liver failure secondary to acetaminophin overdose, lactic acidosis with multisystem organ failure subsequent to trauma (Harris et al2009) and Escherichia coli-associated septic shock (Jazaerly & Gabali, 2014). Harris et al (2009) suggested that the inclusions were related to blood-borne bile products.

green-incl-3.jpg
Image 3 source: Source: Hodgson, 2015

These findings on the peripheral smear should be reported and considered a critical finding. Laboratory professionals and hematologists should acknowledge these inclusions; patients are noted to be seriously ill at the time of detection of neutrophil inclusions and have an ominous 24-72 hour survival period.

References

  1. Haberichter, K. L., & Crisan, D. (2017). Green Neutrophilic Inclusions and Acute Hepatic Failure: Clinical Significance and Brief Review of the Literature. Annals of Clinical & Laboratory Science47(1), 58-61.
  2. Harris, V.N., Malysz, J.& Smith, M.D. (2009) Green neutrophilic inclusions in liver disease. Journal of Clinical Pathology, 62, 853–854.
  3. Hodgson, T. O., Ruskova, A., Shugg, C. J., McCallum, V. J., & Morison, I. M. (2015). Green neutrophil and monocyte inclusions–time to acknowledge and report. British journal of haematology170(2), 229-235.
  4. Jazaerly, T.& Gabali, A.M. (2014) Green neutrophilic inclusions could be a sign of impending death! Blood, 123, 614.

 

ledesma_small

-Carlo Ledesma, MS, SH(ASCP)CM MT(ASCPi) MT(AMT) is the program director for the Medical Laboratory Technology and Phlebotomy at Rose State College in Midwest City, Oklahoma as well as a technical consultant for Royal Laboratory Services. Carlo has worked in several areas of the laboratory including microbiology and hematology before becoming a laboratory manager and program director.