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Images in Clinical Hematology
DOI: 10.1016/j.htct.2020.06.008
Open Access
Available online 31 July 2020
Critical blue-green inclusions in neutrophil and monocyte cytoplasm in a healthy patient affected by COVID-19
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Guilherme Dienstmanna,
Corresponding author
guidbio@gmail.com

Corresponding author at: Rua João Alexandre de França, 349, CEP: 89225-140, Joinville, SC, Brazil.
, Samuel Ricardo Comarb, Matheus Leite Ramos de Souzac, Graziela Ruaroa, Luiz Arthur Calheiros Leited
a Sociedade Educacional de Santa Catarina (UNISOCIESC), Joinville, SC, Brazil
b Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
c Universidade da Região de Joinville (UNIVILLE), Joinville, SC, Brazil
d Centro Universitário Cesmac, Maceió, AL, Brazil
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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 72h). 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.

(0.14MB).
Figure 2.

Presence of blue-green inclusions in the monocyte cytoplasm.

(0.08MB).
Conflicts of interest

The authors declare no conflicts of interest.

References
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M.D. Cantu, W.S. Towne, F.N. Emmons, M. Mostyka, A. Borczuk, S.P. Salvatore, 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].
[2]
T. Gorup, A.T. Cohen, A.B. Sybenga, E.S. Rappaport.
Significance of green granules in neutrophils and monocytes.
Proc (Bayl Univ Med Cent), 31 (2017), pp. 94-96
[3]
R. Vicente-Steijn, A. Tomé, F. Maduell, M. Xipell, P. Castro, A. Molina, et al.
Green inclusions in neutrophils: a critical finding that must be reported.
Int J Lab Hem, 42 (2020), pp. e101-e104
Copyright © 2020. Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular
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Hematology, Transfusion and Cell Therapy

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