Critical blue-green inclusions in neutrophil and monocyte cytoplasm in a healthy patient affected by COVID-19

A 44-year-old male patient, healthy and without comorbidities, was diagnosed with COVID-19, dying 2 days after the observation of blue-green crystals inside neutrophils and monocytes in peripheral blood. Such crystals are described as amorphous blue-green inclusions, refringent and shiny, when stained by Romanowsky. They are generally related to severe tissue injury, such as that seen in liver failure and sepsis and, more recently, have been associated with COVID-191. They are also known as “crystals of death”, since most patients (65%) progress quickly to death after their microscopic finding (92% within 72 h). Such inclusions have a high lipid content, which in association with their color and acidic nature, leads us to believe they are deposits of lipofuscin, which represents products of lysosomal degradation of necrotic liver cells that are phagocytized by neutrophils and monocytes (Figures 1 and 2).^1–3

Figure 1
Presence of blue-green inclusions in the neutrophil cytoplasm.

Figure 2
Presence of blue-green inclusions in the monocyte cytoplasm.

References

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  Cantu MD, Towne WS, Emmons FN, Mostyka M, Borczuk A, Salvatore SP, et al. Clinical significance of blue-green neutrophil and monocyte cytoplasmic inclusions in SARS-CoV-2 positive critically ill patients [published online ahead of print, 2020 May 26]. Br J Haematol. 2020, http://dx.doi.org/10.1111/bjh.16882
  » http://dx.doi.org/10.1111/bjh.16882
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  Gorup T, Cohen AT, Sybenga AB, Rappaport ES. Significance of green granules in neutrophils and monocytes. Proc (Bayl Univ Med Cent). 2017;31(1):94-6.
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  Vicente-Steijn R, Tomé A, Maduell F, Xipell M, Castro P, Molina A, et al. Green inclusions in neutrophils: a critical finding that must be reported. Int J Lab Hem. 2020;42:e101-4.

Publication Dates

• Publication in this collection
  07 Dec 2020
• Date of issue
  Oct-Dec 2020

History

• Received
  17 June 2020
• Accepted
  24 June 2020