A 63-year-old man with an esophageal carcinoma was admitted in the surgery unit for a subtotal esophagectomy and vertical gastroplasty. During his postoperative hospital stay the patient developed a septic shock.
In the first day of septic shock, he presented annalitically: hemoglobin concentration 8.2 g/dL, leukocytosis (WBC) 37.46 × 109/L (reference value (RV):4.00–11.00 × 109/L) and neutrophilia (97.4%), platelets count 195 × 109/L (RV:150 –450 × 109/L), C-reactive protein (CRP) 31.4 mg/dL (RV: <0.5 mg/dL) and procalcitonin 13.1 ng/mL (RV:<0.5 ng/mL).
A peripheral blood film was made daily for five days and the following findings were observed (a) neutrophils with granulation, some with vacuolation or Howell-Jolly Body-like (HJBL) inclusions or ring nucleus shape, (b) macropolycytes with granulation, some with HJBL inclusions (more evident in the third day (WBC 42.60×109/L, platelets count 14 × 109/L, CRP 26.6 mg/ dL and procalcitonin 9.6 ng/mL)), (c) Döhle bodies in neutrophils and macropolycytes and (d) apoptotic neutrophils/macropolycytes (more evident in the third day, then decreasing) Figure 1.
Neutrophils with vacuolation (Images A, B, C) or Howell-Jolly Body-like inclusions (Images D, E) or ring nucleus shape (Images C, F), Macropolycytes (Images F, G, H, J), Macropolycytes with Howell-Jolly Body-like inclusions (Image G), Apoptotic neutrophils/macropolycytes (Images I, J) (May-Grünwald-Giemsa stain, original magnification x1000).
Serratia marcescens was isolated both from the blood culture and a vascular catheter.
Macropolycytes are polymorphonuclear leucocytes with a diameter greater than 14 microns.11 Cooke WE. The macropolycyte. Br Med J. 1927;1(3443):8.2–13. https://doi.org/10.1136/bmj.1.3443.8-a.
https://doi.org/10.1136/bmj.1.3443.8-a...
They are tetraploid and therefore represent a missed cell division.22 Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018.
https://doi.org/10.1002/ajh.22018...
Macropolycytes can be found in pernicious anemia,11 Cooke WE. The macropolycyte. Br Med J. 1927;1(3443):8.2–13. https://doi.org/10.1136/bmj.1.3443.8-a.
https://doi.org/10.1136/bmj.1.3443.8-a...
,33 Wong KF. How big is a macropolycyte? Br J Haematol. 2011;155:1. https://doi.org/10.1011/j.1365-2141.2011.08727.x.
https://doi.org/10.1011/j.1365-2141.2011...
myelodysplastic syndromes,22 Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018.
https://doi.org/10.1002/ajh.22018...
,44 Bain B, Nam D. Neutrophil dysplasia induced by granulocyte colony-stimulating factor. Am J Hematol. 2010;85(5):354. https://doi.org/10.1002/ajh.21659.
https://doi.org/10.1002/ajh.21659...
,55 Goasguen JE, Bennett JM, Bain BJ, Brunning R, Vallespi MT, Tomonaga M, et al. International Working Group on Morphology of MDS (IWGM-MDS). Proposal for refining the definition of dysgranulopoiesis in acute myeloid leukemia and myelodysplastic syndromes. Leuk Res. 2014;38(4):447–53. https://doi.org/10.1016/j.leukres.2013.12.020.
https://doi.org/10.1016/j.leukres.2013.1...
therapy with granulocyte colony-stimulating factor (G-CSF)22 Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018.
https://doi.org/10.1002/ajh.22018...
,44 Bain B, Nam D. Neutrophil dysplasia induced by granulocyte colony-stimulating factor. Am J Hematol. 2010;85(5):354. https://doi.org/10.1002/ajh.21659.
https://doi.org/10.1002/ajh.21659...
,66 Barros Pinto MP, Marques G. The effects of granulocyte colony-stimulating factors (G-CSFs) in leucocytes. Hematol Oncol Stem Cell Ther. 2020;13(1):40–1. https://doi.org/10.1016/j.hemonc.2019.09.001.
https://doi.org/10.1016/j.hemonc.2019.09...
,77 Campbell LJ, Maher DW, Tay DL, Boyd AW, Rockman S, McGrath K, et al. Marrow proliferation and the appearance of giant neutrophils in response to recombinant human granulocyte colony stimulating factor (rhG-CSF). Br J Haematol. 1992;80:298–304. https://doi.org/10.1111/j.1365-2141.1992.tb08136.x.
https://doi.org/10.1111/j.1365-2141.1992...
HIV infection,22 Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018.
https://doi.org/10.1002/ajh.22018...
,77 Campbell LJ, Maher DW, Tay DL, Boyd AW, Rockman S, McGrath K, et al. Marrow proliferation and the appearance of giant neutrophils in response to recombinant human granulocyte colony stimulating factor (rhG-CSF). Br J Haematol. 1992;80:298–304. https://doi.org/10.1111/j.1365-2141.1992.tb08136.x.
https://doi.org/10.1111/j.1365-2141.1992...
myeloproliferative neoplasms and megaloblastic anemia, infections22 Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018.
https://doi.org/10.1002/ajh.22018...
or as described in our case report, sepsis.11 Cooke WE. The macropolycyte. Br Med J. 1927;1(3443):8.2–13. https://doi.org/10.1136/bmj.1.3443.8-a.
https://doi.org/10.1136/bmj.1.3443.8-a...
,33 Wong KF. How big is a macropolycyte? Br J Haematol. 2011;155:1. https://doi.org/10.1011/j.1365-2141.2011.08727.x.
https://doi.org/10.1011/j.1365-2141.2011...
Very occasional macropolycytes can be seen in the blood films of healthy individuals.22 Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018.
https://doi.org/10.1002/ajh.22018...
,55 Goasguen JE, Bennett JM, Bain BJ, Brunning R, Vallespi MT, Tomonaga M, et al. International Working Group on Morphology of MDS (IWGM-MDS). Proposal for refining the definition of dysgranulopoiesis in acute myeloid leukemia and myelodysplastic syndromes. Leuk Res. 2014;38(4):447–53. https://doi.org/10.1016/j.leukres.2013.12.020.
https://doi.org/10.1016/j.leukres.2013.1...
HJBL inclusions are detached pycnotic nuclear fragments which can be associated with immunosuppressive therapy or chemotherapy,88 Rowe R, Esrick E. Howell-Jolly-like bodies in neutrophils. Blood. 2015;125(17):2729. https://doi.org/10.1182/blood-2015-02-626796.
https://doi.org/10.1182/blood-2015-02-62...
ganciclovir99 Abdel-Monem H, Prakasam A, Thiagarajan P. Howell-Jolly body-like inclusions in neutrophils of a transplant recipient in association with ganciclovir therapy. Arch Pathol Lab Med. 2010;134:809–10. https://doi.org/10.5858/134.6.809.b.
https://doi.org/10.5858/134.6.809.b...
and acquired immunodeficiency syndrome.44 Bain B, Nam D. Neutrophil dysplasia induced by granulocyte colony-stimulating factor. Am J Hematol. 2010;85(5):354. https://doi.org/10.1002/ajh.21659.
https://doi.org/10.1002/ajh.21659...
Döhle bodies are essentially found in infectious and inflammatory conditions. Neutrophils with vacuolation are usually seen in infection and sepsis. Neutrophils with ring nucleus shape can be associated with myelodysplastic syndromes, megaloblastic anemia, infectious or autoimmune diseases1010 Xiong B, Tang ZH, Zou P, Yue QF, Chen WX, Liu XY. Dysplasia features of myelodysplastic syndrome in ethnically chinese people. Acta Haematol. 2014;131(2):126–32. https://doi.org/10.1159/000351272.
https://doi.org/10.1159/000351272...
and sepsis.
Apoptosis is most frequently associated with infection.1111 Shidham V, Swami V. Evaluation of apoptotic leukocytes in peripheral blood smears. Arch Pathol Lab Med. 2000;124:1291– 4. https://doi.org/10.5858/2000-124-1291-EOALIP.
https://doi.org/10.5858/2000-124-1291-EO...
However, it may also be associated with heat shock, hypoxia, cytotoxic drugs, steroids, viral infections, and radiation.1212 Lach-Szyrma V, Brito-Babapulle F. The clinical significance of apoptotic cells in peripheral blood smears. Clin Lab
In this case report we describe a set of characteristic hematological findings seen in sepsis, which together reinforce this diagnosis. However, if the sepsis is cured and these findings persist, a different disease may exist.
REFERENCES
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1Cooke WE. The macropolycyte. Br Med J. 1927;1(3443):8.2–13. https://doi.org/10.1136/bmj.1.3443.8-a
» https://doi.org/10.1136/bmj.1.3443.8-a -
2Bain BJ. Dysplastic macropolycytes in myelodysplasia-related acute myeloid leukemia. Am J Hematol. 2011;86(9):776. https://doi.org/10.1002/ajh.22018
» https://doi.org/10.1002/ajh.22018 -
3Wong KF. How big is a macropolycyte? Br J Haematol. 2011;155:1. https://doi.org/10.1011/j.1365-2141.2011.08727.x
» https://doi.org/10.1011/j.1365-2141.2011.08727.x -
4Bain B, Nam D. Neutrophil dysplasia induced by granulocyte colony-stimulating factor. Am J Hematol. 2010;85(5):354. https://doi.org/10.1002/ajh.21659
» https://doi.org/10.1002/ajh.21659 -
5Goasguen JE, Bennett JM, Bain BJ, Brunning R, Vallespi MT, Tomonaga M, et al. International Working Group on Morphology of MDS (IWGM-MDS). Proposal for refining the definition of dysgranulopoiesis in acute myeloid leukemia and myelodysplastic syndromes. Leuk Res. 2014;38(4):447–53. https://doi.org/10.1016/j.leukres.2013.12.020
» https://doi.org/10.1016/j.leukres.2013.12.020 -
6Barros Pinto MP, Marques G. The effects of granulocyte colony-stimulating factors (G-CSFs) in leucocytes. Hematol Oncol Stem Cell Ther. 2020;13(1):40–1. https://doi.org/10.1016/j.hemonc.2019.09.001
» https://doi.org/10.1016/j.hemonc.2019.09.001 -
7Campbell LJ, Maher DW, Tay DL, Boyd AW, Rockman S, McGrath K, et al. Marrow proliferation and the appearance of giant neutrophils in response to recombinant human granulocyte colony stimulating factor (rhG-CSF). Br J Haematol. 1992;80:298–304. https://doi.org/10.1111/j.1365-2141.1992.tb08136.x
» https://doi.org/10.1111/j.1365-2141.1992.tb08136.x -
8Rowe R, Esrick E. Howell-Jolly-like bodies in neutrophils. Blood. 2015;125(17):2729. https://doi.org/10.1182/blood-2015-02-626796
» https://doi.org/10.1182/blood-2015-02-626796 -
9Abdel-Monem H, Prakasam A, Thiagarajan P. Howell-Jolly body-like inclusions in neutrophils of a transplant recipient in association with ganciclovir therapy. Arch Pathol Lab Med. 2010;134:809–10. https://doi.org/10.5858/134.6.809.b
» https://doi.org/10.5858/134.6.809.b -
10Xiong B, Tang ZH, Zou P, Yue QF, Chen WX, Liu XY. Dysplasia features of myelodysplastic syndrome in ethnically chinese people. Acta Haematol. 2014;131(2):126–32. https://doi.org/10.1159/000351272
» https://doi.org/10.1159/000351272 -
11Shidham V, Swami V. Evaluation of apoptotic leukocytes in peripheral blood smears. Arch Pathol Lab Med. 2000;124:1291– 4. https://doi.org/10.5858/2000-124-1291-EOALIP
» https://doi.org/10.5858/2000-124-1291-EOALIP -
12Lach-Szyrma V, Brito-Babapulle F. The clinical significance of apoptotic cells in peripheral blood smears. Clin Lab
Publication Dates
-
Publication in this collection
12 Dec 2022 -
Date of issue
2022
History
-
Received
16 June 2021 -
Accepted
30 June 2021 -
Published
14 Sept 2021