Blue–green cytoplasmic inclusions in monocytes – a rare indicator of fatal outcome in acute liver failure with Glucose-6-phosphate dehydrogenase deficiency

Diagnostic assessment

In view of the patient’s clinical presentation with jaundice, suspected hemolysis, hepatic dysfunction, and progressive systemic deterioration, a comprehensive diagnostic workup was planned. This included complete hemogram with peripheral smear examination, liver and renal function tests, serum lactate dehydrogenase, ferritin, procalcitonin, amylase, lipase, ammonia, C-reactive protein, microbiological cultures, and viral markers. The results of key laboratory investigations and their serial trends during hospitalization are summarized in Table 1.

Laboratory investigations revealed markedly deranged liver function tests along with elevated lactate dehydrogenase, ferritin, procalcitonin, ammonia, C-reactive protein, amylase, and lipase levels. Renal function tests showed elevated blood urea nitrogen and creatinine levels, consistent with acute kidney injury (AKI). Blood, urine, and endotracheal aspirate cultures showed no growth of microorganisms. Serological testing for human immunodeficiency virus, hepatitis B surface antigen, and hepatitis C virus, along with polymerase chain reaction testing for herpes simplex virus types 1 and 2, was negative. EBV DNA was detected by molecular testing. However, EBV serology and serial viral load measurements were unavailable, and the finding was therefore interpreted as an associated or incidental detection in the setting of severe systemic illness rather than a primary etiological factor.

Peripheral blood smear examination using Leishman stain revealed the following findings:

Red blood cells:

• Macrocytic anemia with basophilic stippling and Howell-Jolly bodies

• Microspherocytes, target cells, schistocytes, and burr cells indicate hemolysis and AKI

• Abundant nucleated red blood cells with dyserythropoietic changes.

White blood cells:

• Marked leukocytosis with left shift up to promyelocyte stage, with cytoplasmic vacuolations, consistent with a leukoerythroblastic reaction

• Monocytes showed dense “blue–green inclusion” bodies – consistent with “death crystals,” as depicted in Figure 1a and b.

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Figure 1:

(a) Peripheral blood smear of a 27-year-old glucose-6-phosphate dehydrogenase –deficient male who presented with fever, jaundice, and abdominal pain following a hemolytic episode after exposure to an unspecified nonsteroidal anti-inflammatory drug, and was subsequently diagnosed with acute fulminant liver failure with multiorgan dysfunction. Leishman-stained peripheral blood smear (light microscopy, ×100 magnification) shows marked leukocytosis with left shift and a leucoerythroblastic reaction. Monocytes demonstrate dense blue–green cytoplasmic inclusions (arrows) consistent with “death crystals.” The background shows features of hemolysis, including anisopoikilocytosis and nucleated red blood cells. (b) Leishman-stained peripheral blood smear (light microscopy, ×1000 oil immersion) shows a monocyte containing dense blue–green cytoplasmic inclusions (arrow) consistent with “death crystals.” The surrounding field shows leukocytosis with left shift, anisopoikilocytosis, and nucleated red blood cells.

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Platelets:

• Thrombocytopenia with giant platelets.

Dense blue–green cytoplasmic inclusions were identified within monocytes on serial peripheral blood smears from day 5 to day 7 of hospitalization and were absent by day 8. Morphological differential diagnoses of cytoplasmic inclusions include Döhle bodies and toxic granulation. Döhle bodies are typically pale blue, non-refractile, and located at the periphery of neutrophils, while toxic granulation appears as coarse azurophilic granules. In contrast, the inclusions observed in this case were dense, blue-green, refractile, and localized within monocytes, features consistent with critical green inclusions described in the literature.

Clinical course

Following admission to the critical care unit, the patient’s clinical condition progressively deteriorated as depicted in Figure 2. On day 2 of hospital admission, the patient had AKI with reduced urine output and elevated blood urea nitrogen and creatinine. During hospitalization, he received intravenous fluids, broad-spectrum antibiotics (piperacillin–tazobactam, polymyxin, colistin, meropenem, minocycline, and teicoplanin), antacids (ranitidine), and an antihypertensive agent (prazosin). Blood transfusion, platelet transfusion, and plasma exchange therapy were administered as required. On day 4, the patient suffered a cardiac arrest and was successfully resuscitated. As his clinical condition worsened, mechanical ventilation, inotropic support, and continuous renal replacement therapy were initiated. Despite intensive supportive therapy, the patient developed progressive multiorgan dysfunction and expired on day 10 of hospitalization.

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Figure 2:

Flow diagram depicting the clinical sequence in a 27-year-old glucose-6-phosphate dehydrogenase–deficient male following exposure to an unspecified nonsteroidal anti-inflammatory drug. The diagram illustrates the temporal progression from acute hemolysis to secondary hepatic dysfunction, acute fulminant liver failure, multiorgan dysfunction, and death. The proposed pathophysiological cascade linking hemolysis, hepatic overload, systemic inflammation, multiorgan failure, and the appearance of blue–green cytoplasmic inclusions is hypothesis-driven and inferential. Detection of Epstein–Barr virus deoxyribonucleic acid is depicted as an associated finding during critical illness rather than a primary causal factor.

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Pathophysiology of inclusions

Blue–green cytoplasmic inclusions in neutrophils and monocytes are uncommon but essential morphological findings in critically ill patients. These inclusions are believed to consist of lipid-rich degradation products that are phagocytosed by leukocytes in situations of severe systemic inflammation, acute liver failure, or widespread cellular necrosis, such as lipofuscin and bile pigments. Previous histochemical studies have demonstrated positive Oil Red O staining, supporting a lipid-rich composition, although the exact molecular nature of these inclusions remains under investigation.^[6]

In the present case, G6PD deficiency constituted a preexisting enzymatic vulnerability, and an acute hemolytic episode temporally followed NSAID exposure. A hypothesis-driven pathophysiological sequence may be postulated in which hemolysis leads to hepatic metabolic overload, systemic inflammatory response, and eventual multiorgan dysfunction; however, definitive mechanistic proof linking each step is lacking.

To better understand the molecular origins, prognostic specificity, and potential triggers of these inclusions, future multicenter studies incorporating electron microscopy, immunocytochemistry, and lipidomic profiling are required.^[6]

Prognostic implications

The literature suggests a strong association between blue–green cytoplasmic inclusions and acute liver injury, particularly in patients with markedly elevated aspartate transaminase and alanine transaminase levels.^[2,4,7] Most reported patients deteriorate rapidly, with death occurring within 1–3 days following the appearance of these inclusions.^[3,5,8] Their presence therefore, appears to reflect advanced systemic injury and may serve as a morphological indicator of impending clinical deterioration.

Comparison with existing literature

Ray et al. described a similar finding in a woman with combined liver and kidney dysfunction who died within 48 hours.^[6] In that case, the number of inclusions increased during hospitalization and peaked shortly before death. Retrospective review revealed that they were present in small numbers from the 1^st day of admission. A large COVID-19 series also showed these inclusions in patients with acute transaminitis, lactic acidosis, and fulminant hepatic failure, with 100% mortality within 10 days.^[1] A case of drug intoxication with acute hepatic injury demonstrated inclusions in neutrophils preceding rapid clinical decline.^[9] In another report, inclusions were identified in a patient with aspiration pneumonia and severe pneumoperitoneum, indicating that non-hepatic critical illness may also be associated with these findings.^[10] In these reports, the emergence of inclusions closely preceded rapid clinical deterioration and death within days, reinforcing their association with advanced systemic injury and poor short-term prognosis.

Unique aspects of the present case

This case represents one of the detailed reports from India documenting blue–green cytoplasmic inclusions in an adult male with G6PD deficiency, who developed an acute hemolytic episode following exposure to an unspecified NSAID, and with associated EBV DNA detection. Unlike most reports describing predominant neutrophilic involvement, the inclusions in this case were observed mainly in monocytes, suggesting a complex or advanced pathophysiological process. Routine reporting of these inclusions in peripheral blood smears has been recommended by some authors,^[2,6,7]. In contrast, others suggest that such reporting may not change outcomes and could influence decisions regarding treatment withdrawal.^[11] Nevertheless, prompt identification may aid clinicians in prognostication and patient management, and in counseling relatives regarding the severity of illness.^[5,12]