QJM: An International Journal of Medicine, 2017, 393–394 doi: 10.1093/qjmed/hcx017 Advance Access Publication Date: 28 February 2017 Clinical picture
CLINICAL PICTURE
Bacterial sepsis, neutrophils and intracellular organisms A 64-year-old male with a history of hepatitis C and alcoholic cirrhosis as well as hepatocellular carcinoma status post left lobectomy and transarterial chemoembolization was transported to our emergency department (ED) due to being unarousable. His initial vital signs were as follow: body temperature 34.7 C, heart rate 102 beats per minute and blood pressure 126/71 mm of mercury. Physical examination revealed swelling of left lower extremity with some blisters around left knee. Laboratory tests showed leukocytosis (29 570/mm3) and lower platelet count (71 000/mm3). The blood smear revealed predominant neutrophilia (21% of segmented neutrohphils, 37% of band neutrophils and 39% of meta-myelocytes) with abundant toxic granulations (Figure 1A). The vacuoles containing bacilliform organisms (Figure 1A, arrow) as well as Do¨hle bodies, the pale blue cytoplasmic inclusions (Figure 1A, arrowhead), were found in neutrophils. Computed tomography of lower extremities revealed fluid accumulation over fascia layer (Figure 1B). Under impression of necrotizing fasciitis, empirical antimicrobial treatment with Ertapenem was prescribed and plastic surgeon was consulted; however, the disease deteriorated rapidly due to refractory septic shock and failure of multiple organs. The patient ultimately died in the ED. Both anaerobic cultures of blood and urine yielded Klebsiella pneumoniae after 3-day incubation.
The association of elevation of white cell count, absolute neutrophil count and band neutrophil count with acute infectious diseases has been documented for decades. Recently, it was reported that morphologic change in neutrophils could be helpful in predicting acute bacterial infections.1,2 The morphologic characteristics included the presence of toxic granulations, Do¨hle bodies and toxic vacuolations in neutrophils. Of these, the presence of toxic granulations was demonstrated to have a predictive role in acute bacterial infections, while the relationship between bacterial infections and vacuolated neutrophils remains controversial.3,4 Overall, severe bacterial infections should be watched out in the consistent presence of leukocytosis with predominant neutrophilia and bandemia, as well as the morphologic changes in neutrophils, such as toxic granulations, Do¨hle bodies and toxic vacuolations.
Photographs and text from: C.-C. Chang, Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei, Taiwan, R.O.C.; J.-T. Sun, Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan, R.O.C. M.-J. Su, Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei, Taiwan, R.O.C.; F.-Y. Chu, Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei,
Figure 1. (A) A band neutrophil with abundant toxic granulations, Do¨hle bodies (arrowhead), and the toxic vacuole containing a bacilliform organism (arrow). (B) Fluid accumulation over fascia layer was found in computed tomography of lower extremities.
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QJM: An International Journal of Medicine, 2017, Vol. 110, No. 6
Taiwan, R.O.C.; School of Medical Laboratory Science and Biotechnology, Taipei Medical University, Taipei, Taiwan, R.O.C.; Graduate School of Biotechnology and Bioengineering, Yuan Ze University, Taoyuan, Taiwan, R.O.C. and Department of Medical Laboratory Science and Biotechnology, Yuanpei University, Hsinchu, Taiwan, R.O.C. email:
[email protected]
Conflict of interest: None declared.
References 1. Al-Gwaiz LA, Babay HH. The diagnostic value of absolute neutrophil count, band count and morphologic changes of
neutrophils in predicting bacterial infections. Med Princ Pract 2007; 16:344–7. 2. Lv J, Zong H, Ma G, Wei X, Zhao Y, Wang Q. Predictive significance of peripheral blood smears in patients with fever of unknown origin: a retrospective study of 2871 cases. Clin Lab 2015; 61:1643–52. 3. Jafri AK, Cass L. Vacuolated neutrophils can predict serious infection. Lab Med 1998; 25:633–6. 4. Adams RC, Dixon JH, Eichner ER. Clinical usefulness of polymorphonuclear leukocyte vacuolization in predicting septicemia in febrile children. Pediatrics 1978; 62:67–70.
