Green-blue Inclusions in Leukocytes and COVID-19: A Sign of Looming Death

Ghachem Ikbel^*, Kaabar Mohamed Yassine and Bachali Asma
^*Correspondence: Ghachem Ikbel, Department of Hematology, Hopital Regional Mohamed Taher Maamouri De Nabeul, Tunisia, Tel: +21650006987, Email:

Keywords

COVID-19 • GBI • Myelocytes • Inclusions

Case Image

A 78 years old man with a history of diabetes and high blood pressure was hospitalized for a severe acute respiratory syndrome COVID-19 in the unit intensive care requiring a mechanic ventilation. Laboratory tests showed an increased leucocytes number (94 × 103/μL) with a predominance of polymorphonuclear cells (92.4 × 103/μL), lymphopenia (0.8 × 103/μL),

aregenerative normochrome anemia (Hemoglobin=5.6 g/dL), normal platelets number, and elevated D-Dimere (6961 ng/mL). Biochimical report showed an elevated LDH (877 U/L), renal failure (urea=76.4 mmol/l, creatinine=277 μmol/l), CRP=90.97 mg/l, hyperkaliemia=7.62mmol/L, hypernatriema=147mmol/L), high lactate (8 mmol/L) but with a normal hepatic function (Aspartate transaminase=38.2 UI/L, Alanine transaminase=24.9UI/L).

Peripheral blood smear examination revealed multiple Green-blue Inclusions (GBI) in polymorphonuclear, in monocytes but also in myelocytes and metamyelocytes cytoplasm cells. The patient died after 48 hours of his microscopic finding and 10 days after initial COVID-19 testing. Such bluegreen inclusions called « crystals of death » were associated with a short-term mortality in 60% with a median of 3 days [1]. Most reports described this crystal inclusion as a critically anomaly in patients with tissue injury seen in liver failure and sepsis and recently described in rare cases of COVID-19 patients [1]. Many hypotheses suggest that GBI was rich of lipofuscin released from lysosomal degradation of necrotic hepatocytes phagocytized by polymorphonuclear cells and monocytes [2]. To our knowledge, this is the first report of GBI described in myelocytes and metamyelocytes cells of peripheral blood smear in COVID-19 patient. The pathogenesis of these inclusions is unclear and need more exploration of their etiology and clinical implications (Figure 1).

Acknowledgments

Dr Ghachem and Dr Kaabar analyse and write the case. Dr Bachali contributed to the content revising.

References

1. Vicente�Steijn, Rebecca, Adriá Tomé, Francisco Maduell and Marc Xipell, et al. "Green inclusions in neutrophils: A critical finding that must be reported." Int J Lab Hematol. 42 (2020): 3.

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2. Cantu, Miguel Dario, William Samuel Towne, Foxwell Nathan Emmons and Maria Mostyka, et al. "Clinical significance of blue�green neutrophil and monocyte cytoplasmic inclusions in SARS�CoV�2 positive critically ill patients." Br J Haematol 190 (2020):

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