Green Inclusions in Neutrophils and Monocytes Are an Indicator of Acute Liver Injury and High Mortality

Characterization of blue-green blood leukocyte inclusions and accompanying clinical, hematologic, and serum biochemical changes in dogs

BACKGROUND

Lipofuscin-like cytoplasmic inclusions have been reported in human blood neutrophils and monocytes but have not been described in dogs. In people, these "green granules of death" have been associated with moderate to severe hepatocellular injury and high mortality.

OBJECTIVES

To describe clinicopathologic abnormalities, diagnoses, and outcomes of dogs with greenish inclusions in blood neutrophils or monocytes, and to determine if the inclusions have features of lipofuscin.

METHODS

Clinical cases were identified prospectively through routine evaluation of CBC samples. Leukocyte inclusions were characterized with routine staining and assessed for iron and autofluorescence. Additional cases were identified by examination of archived blood smears from dogs meeting search criteria for hepatocellular injury, and clinicopathologic findings were recorded.

RESULTS

All 7 prospectively identified dogs with inclusions had inflammation and moderate to marked increases in serum alanine aminotransferase (ALT) activity, as did the 4 dogs identified from the 97 meeting retrospective search criteria. The inclusions were Prussian blue-negative (5/5) with broad-spectrum autofluorescence (5/5) and the appearance of lipofuscin with and without Wright staining. Most clinical diagnoses involved hepatic disorders (5/7 prospective and 3/4 retrospective cases) or pancreatitis (3/7 prospective and 2/4 retrospective cases), and some involved both; 8 of 11 dogs died within 7 days of admission.

CONCLUSIONS

Blue-green cytoplasmic inclusions uncommonly found in blood neutrophils ± monocytes of routine canine blood smears have stained and unstained properties of lipofuscin and suggest the presence of hepatocellular injury, often severe. Reporting these inclusions is recommended to guide clinical management.

Green Cytoplasmic Neutrophilic Inclusion Bodies in a Patient With Aspiration Pneumonia and Bowel Perforation

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. Here, we report a case of blue-green neutrophilic inclusion bodies in a patient with aspiration pneumonia and severe pneumoperitoneum secondary to bowel perforation. These blue-green neutrophilic inclusion bodies offer high prognostic value for physicians, and their presence should be considered a "critical result," indicating the severity of the patient's illness.

Blue-green neutrophilic inclusion bodies with concurrent liver failure as a predictor of imminent death

Objectives

Blue-green, birefractory, poorly-defined, cytoplasmic inclusions in some types of leukocytes are an underdiagnosed finding, which composition and clinical significance is not well understood. Inclusions are only found on peripheral blood smear (PBS).

Case presentation

We report the case of a male with a history of chronic disease (hypertension, obesity, dyslipidemia, and kidney failure) admitted to the emergency room (ER) with shortness of breath, who was later transferred to the intensive care unit (ICU). The patient had a torpid disease course and ultimately died of multiorgan failure, including severe liver failure. When his status exacerbated, these inclusions were observed on PBS in conjunction with liver enzyme abnormalities.

Conclusions

This case confirms that blue-green inclusions on PBS in cases of acute severe liver failure with concurrent lactic acidosis should be immediately reported to the medical team, since it is suggestive of critical status and poor prognosis.

Toll-like receptor 10 controls TLR2-induced cytokine production in monocytes from patients with Parkinson's disease

Peripheral inflammation, particularly mediated by monocytes, can cause neuroinflammation in Parkinson's disease (PD). We investigated the mechanism of TLR2-induced cytokine impairment in peripheral monocytes from PD patients and the association between the presence of CD14⁺ TLR10⁺ monocytes and PD severity. Peripheral blood mononuclear cells from PD patients and healthy individuals were evaluated for TLR expression on monocyte subsets (CD14 and CD16 expression) using flow cytometry. Moreover, cytokines were evaluated using flow cytometry after stimulation with Pam₃ Cys (TLR2/TLR1 agonist) in the absence or presence of neutralizing antibodies to TLR10. The severity of PD was assessed using the unified PD rating scale (UPDRS) and motor activity, anxiety (BAI), depression (BDI), and fatigue (PD Fatigue Scale-16) scales. The frequency of CD14⁺ TLR10⁺ monocytes and expression intensity of TLR2 and TLR10 were higher in patients with PD than healthy individuals. The frequency of intermediate monocytes (CD14⁺⁺ CD16⁺ ) was not significantly increased in patients with PD, but was the main monocyte subset expressing TLR10. The TLR2/TLR1-impaired cytokine production (IL-6, TNFα, IL-8, and IL-10) in PD patients was reversed by neutralizing TLR10. The high frequency of total CD14⁺ TLR10⁺ monocytes was associated with a reduction in the severity of PD according to the evaluation of motor and nonmotor symptoms. Peripheral monocytes from patients with PD showed phenotypic and functional alterations. The expression of TLR10 on monocytes can protect against PD by controlling TLR2-induced cytokine production. Furthermore, data suggested that a low frequency of CD14⁺ TLR10⁺ monocytes indicates the severity of PD. The results identified new opportunities for the development of novel PD neuroprotective therapies.

Clinical pathology resident education during the COVID-19 pandemic

COVID-19 arrived at our medical centre in March 2020 with substantial force. Clinical pathology concepts began to have a new, direct relevance to our residents' lives. As we wondered 'Have I been exposed? Do I need to self-isolate? Are the tests reliable? Am I protecting myself adequately while handling specimens?', these questions drew new interest in laboratory methods, test interpretation and limitations, supply chain issues, safety and quality. By incorporating SARS-CoV-2 teaching points into laboratory medicine lectures, we enlivened concepts of sensitivity, specificity, predictive value and methodologic issues in serologic, molecular and antigen testing for pathology residents. We drew from the emerging literature on SARS-CoV-2 to create lectures and added details from our own institutional experience with COVID-19. When the pandemic fades from memory, clinical pathology education can still benefit from mnemonics, analogies, anecdotes and creative efforts that capture the attention of the audience.