Inclusions In Neutrophils Research Articles

Green neutrophilic inclusions in patient with drug intoxication: a case report

Green neutrophilic inclusions in patient with drug intoxication: a case report

неЩасливий випадок як поштовх до діагностики хвороби у 16-річного хлопця, пов’язаної з MYH9. Сюжет із практики гематолога

MYH9-related disease (MYH9-RD) is an autosomal dominant hereditary thrombocytopenia caused by mutations in the MYH9 gene with characteristic laboratory features - the presence of giant platelets and basophilic cytoplasmic inclusions in neutrophils (similar to Dele bodies). Patients with MYH9-RD are at high risk for deafness, cataracts, and renal dysfunction, most often occurring in adulthood. Platelet counts in patients with MYH9-RD range from severe thrombocytopenia to near-normal values, although they are usually stable. Propensity for hemorrhagic Complications correlate with platelet count and are usually absent or limited to minor bleeding in patients with mild thrombocytopenia, but may lead to spontaneous and potentially life-threatening bleeding with persistent platelet counts <50×109/l. Purpose - to describe a clinical case of a disease caused by a heterozygous mutation in the MYH9 gene with an emphasis on the importance of genetic tests for the final verification of the disease. Clinical case. Features of diagnosis caused by a heterozygous mutation in the MYH9 gene in a 16-year-old boy are described. Throughout the child's life, the manifestations of the hemorrhagic syndrome were moderate (periodically a small number of bruises on the skin, to which the parents did not pay much attention, bleeding from the gums when brushing the teeth), the child’s blood tests were performed occasionally without determining the number of platelets. The boy suffered a displaced radius fracture as a result of the injury. The orthopedic traumatologist performed an operation of limited reposition of bone fragments followed by implantation of a needle for proper bone fusion without complications. During a general blood test, thrombocytopenia was detected, which prompted the child to be consulted by a hematologist. During the examination at the Western Ukrainian Specialized Pediatric Medical Center, Lviv, it was noted in the hardware count of the hemogram that the number of platelets was 22.0-30.0×109/l, the microscopic count of platelets was 147.0-156.0×109/l, the entire population of platelets was represented by macroforms with mean platelet volume 14.9 fl. We found good aggregation of platelets with ristocytin, and reduced aggregation with epinephrine, arachidonic acid, and adenosine. Verification of the final diagnosis of MYH9-RD caused by a heterozygous mutation in the MYH9 gene occurred by genome sequencing. Therefore, the application of the genome sequencing technique can contribute to the early diagnosis of hereditary macrothrombocytopenia caused by a heterozygous mutation in the MYH9 gene. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Auer-rod like inclusions in mature neutrophils of an early T cell precursor lymphoblastic leukaemia patient after SARS-CoV-2 infection.

British Journal of HaematologyEarly View IMAGES IN HAEMATOLOGY Auer-rod like inclusions in mature neutrophils of an early T cell precursor lymphoblastic leukaemia patient after SARS-CoV-2 infection Ines Jedidi, Corresponding Author Ines Jedidi inesjedidifeki@yahoo.fr orcid.org/0000-0001-9053-0918 Faculty of Pharmacy, Monastir University, Monastir, Tunisia Hematology Laboratory, Habib Bourguiba Hospital, Sfax, TunisiaSearch for more papers by this authorImen Krichen, Imen Krichen Faculty of Pharmacy, Monastir University, Monastir, Tunisia Hematology Laboratory, Habib Bourguiba Hospital, Sfax, TunisiaSearch for more papers by this authorMourad Chaari, Mourad Chaari Faculty of Pharmacy, Monastir University, Monastir, Tunisia Haematology Laboratory, Hedi Chaker Hospital, Sfax, TunisiaSearch for more papers by this authorNour Louati, Nour Louati Faculty of Medicine, Sfax University, Sfax, Tunisia Central Blood Banks and Transfusion Service, TunisiaSearch for more papers by this authorMoez Mdhaffar, Moez Mdhaffar Faculty of Medicine, Sfax University, Sfax, Tunisia Haematology Department, Hedi Chaker Hospital, Sfax, TunisiaSearch for more papers by this author Ines Jedidi, Corresponding Author Ines Jedidi inesjedidifeki@yahoo.fr orcid.org/0000-0001-9053-0918 Faculty of Pharmacy, Monastir University, Monastir, Tunisia Hematology Laboratory, Habib Bourguiba Hospital, Sfax, TunisiaSearch for more papers by this authorImen Krichen, Imen Krichen Faculty of Pharmacy, Monastir University, Monastir, Tunisia Hematology Laboratory, Habib Bourguiba Hospital, Sfax, TunisiaSearch for more papers by this authorMourad Chaari, Mourad Chaari Faculty of Pharmacy, Monastir University, Monastir, Tunisia Haematology Laboratory, Hedi Chaker Hospital, Sfax, TunisiaSearch for more papers by this authorNour Louati, Nour Louati Faculty of Medicine, Sfax University, Sfax, Tunisia Central Blood Banks and Transfusion Service, TunisiaSearch for more papers by this authorMoez Mdhaffar, Moez Mdhaffar Faculty of Medicine, Sfax University, Sfax, Tunisia Haematology Department, Hedi Chaker Hospital, Sfax, TunisiaSearch for more papers by this author First published: 21 March 2023 https://doi.org/10.1111/bjh.18728Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Effects of Blood Storage Time and Temperature on Döhle Body or Döhle Body-like Inclusions in Feline Neutrophils

Background: Detecting Döhle body inclusions in cat neutrophils is one of the most relevant toxic changes with clinical significance. It is necessary to study pre-analytical factors such as temperature and blood storage time on the formation of these toxic changes. Objectives: The present study sought to investigate the impact of blood storage time and temperature on Döhle or Döhle-like inclusions in cat neutrophils. Methods: Ethylenediaminetetraacetic acid (EDTA) blood samples were obtained from 8 cats without evidence of Döhle inclusions on fresh blood smears (T0). Samples were stored at room temperature (RT) and 4°C as routine storage temperatures of samples in the laboratory. Smears were prepared 2 (T2), 4 (T4), 8 (T8), and 24 (T24) hours following the blood draw for each storage condition. Döhle or Döhle-like inclusions were assessed on each smear randomly selected. Results: The percentages of neutrophils with Döhle or Döhle-like inclusions in T8 and T24 increased significantly at RT and 4°C, respectively (P<0.001) compared to T0. The smears prepared from blood samples stored at RT contained more neutrophils with Döhle or Döhle-like inclusions than 4°C. A significant difference was not found in the percentages of neutrophils with these inclusions between the two temperatures at any storage times. Conclusion: The development of Döhle body-like in cat neutrophils occurs when the analysis is delayed, especially at higher storage temperatures. This condition may affect diagnosis and clinical decisions. Therefore, the blood smears should be prepared as soon as the blood is drawn to reduce pre-analytical changes.

Green inclusions in peripheral blood neutrophils of a patient with Pandoraea apista bacteraemia.

Green inclusions in peripheral blood neutrophils of a patient with Pandoraea apista bacteraemia.

Early Diagnosis and Results of Enzyme Replacement Therapy in the Patient with Mucopolysaccharidosis Type VI: Clinical Case

Background. Mucopolysaccharidosis type VI (MPS VI, Maroteaux–Lamy syndrome) is rare autosomal-recessive multisystem disease, one of the group of lysosomal storage diseases. The MPS VI pathogenesis is determined by arylsulfatase B enzyme deficiency caused by mutations in the ARSB gene. There are only few published clinical examples of this disease that covers the results of early enzyme replacement therapy (ERT) onset.Clinical case description. The child was suspected to have lysosomal storage disease at the age of 1.5 months, it was based on microscopic analysis of blood smears: Alder abnormality was revealed (granulations and red-violet inclusions in neutrophils, monocytes, lymphocytes cytoplasm). The diagnosis was confirmed at the age of 3 months: increased glycosaminoglycans (GAGs) concentration in the urine, arylsulfatase B activity decrease in dried blood spots, and pathogenic variant c.943C>T (p. R315X) in the ARSB gene in homozygous state were revealed. ERT with galsulfase was started at the age of 7 months. There was decrease in excretion of GAGs in urine to normal level after 9 and 15 months of therapy. Normal growth and body proportions for the patient’s age were determined 3 years after continuous ERT. However, there was progression of multiple dysostosis and joint stiffness, as well as eyes lesion.Conclusion. Early ERT onset cannot completely stop MPS VI progression but it allows to reduce the severity of several symptoms and improves patient’s quality of life.

Human granulocytic anaplasmosis combined with rhabdomyolysis: a case report

BackgroundHuman granulocytic anaplasmosis (HGA) is a systemic inflammatory response caused by the rickettsial bacterium Anaplasma phagocytophilum. Rhabdomyolysis and acute kidney injury (AKI) are rare complications of HGA. Here, we report a case of HGA concurrent with rhabdomyolysis and AKI in an elderly patient.Case presentationAn 84-year old woman with a medical history of hypertension was hospitalised after two days of fever, dizziness, whole body pain, and general weakness. Laboratory investigations showed severe thrombocytopenia, leukopenia, impaired renal function, and elevated cardiac enzyme and myoglobin levels. On the day after admission, peripheral blood smear revealed morula inclusions in neutrophils, a suggestive finding of HGA. Real-time polymerase chain reaction (PCR) results indicated the presence of A. phagocytophilum. Antibiotics were de-escalated to doxycycline monotherapy. After 10 days of antibiotic treatment, laboratory tests showed complete recovery from HGA complicated with rhabdomyolysis and AKI.ConclusionsHGA can lead to serious complications in patients with associated risk factors. Therefore, in patients with HGA accompanied by rhabdomyolysis, management with antibiotics and hydration should be initiated immediately, and not delayed until diagnostic confirmation.

Role of Next Generation Sequencing in the Diagnosis of Unexplained Thrombocytopenias- an Experience at a Tertiary Care Hospital

▪BACKGROUNDNext Generation Sequencing (NGS) has been enormously rewarding in the field of diagnostic hematology. In particular, the diagnosis of inherited disorders has progressed in leaps and bounds. These patients tend to remain undiagnosed for a long period of time not only because of unavailability of molecular diagnostics but also due to lack of cognizance and atypical presentations.Thrombocytopenia (TCP) is a common hematological presentation and can lead to chronic hospital visits to life-threatening bleeds. Most of these patients have acquired disorders such as immune TCP, malignancies, liver disease etc. However, some of them are likely to have unidentified inherited causes. We thus intended to study the utility of NGS in the definitive diagnosis of unexplained TCPs with or without other cytopenias to understand the clinicopathologic characteristics of these patients.METHODOLOGYThis was a retrospective descriptive study done at two centres over three years from May 2018 to May 2021. Patients with TCP with one of the following: (a) positive family history (b) clinical/ laboratory clues to an inherited cause (c) chronic TCP with no response to conventional therapies and sent for clinical exome sequencing done by NGS were included in the study. Patients who were negative for germline mutations were excluded.Sequencing of targeted genes was performed on the Illumina platform with a mean coverage of >80-100X. Mutations annotated as pathogenic, likely pathogenic and variant of uncertain significance (VUS) were considered clinically significant. VUS are mutations that are difficult to classify as pathogenic and require clinical validation and family testing.RESULTSOur cohort included 18 patients and were divided into two groups- cases of isolated TCP and cases of TCP with anemia and/or neutropenia.Patients presenting with isolated thrombocytopeniaWe had nine cases of isolated TCP out of which there were three cases of X-linked macrothrombocytopenia with MYH9 mutation, two cases of Wiskott Aldrich syndrome (WAS) and one case each of congenital thrombotic thrombocytopenic purpura (TTP), atypical Hemolytic Uremic Syndrome (HUS), Fanconi anemia (FA) and grey platelet syndrome. The demographic and mutational characteristics are described in Table 1. Clinical and laboratory clues were present in 7 cases, such as chronic kidney disease, micro/ macrothrombocytopenia, neutrophil inclusions etc. Bone marrow examination was carried out in 4 cases- the significant dyspoiesis in FA and myelofibrosis in grey platelet syndrome mislead to a diagnosis of MDS and myelofibrosis respectively. Seven patients had received treatment with steroids, immunosuppressants, splenectomy, danazol and TPO mimetics before the NGS diagnosis.Patients presenting with thrombocytopenia and other cytopeniasThis group consisted of nine cases with two cases each of Dyskeratosis Congenita (DKC) and WAS and one case each of TTP, Ghosal hematodiaphyseal dysplasia, Congenital Amegakaryocytic Thrombocytopenia (CAMT), B-cell immunodeficiency with hypogammaglobulinemia type-25 and double homozygous for FA and DKC. The majority of patients in this group were young and had lower platelet counts (Table 2). The most common associated cytopenia was anemia. Phenotypic clues to diagnosis were present in cases of DKC and WAS. The common differentials considered in this group were inherited bone marrow failure syndromes (IBMFS), congenital immunodeficiency syndromes etc. Bone marrow examination was done more frequently in these patients and showed hypocellular marrow in IBMFS and absent megakaryocytes in CAMT. These patients have also been treated with steroids, IVIg, danazol and TPO mimetics.CONCLUSIONPatients with inherited isolated TCPs have a chronic course and heterogenous causes therefore tend to be diagnosed later in life. However, patients with TCPs and other cytopenias tend to present at a younger age with infrequent family history. IBMFS was the most common disorder identified in this latter group of patients. Positive family history, clinical and laboratory clues and absence of response to conventional therapies should prompt workup of inherited causes by NGS to avoid long term ineffectual treatment. Further, NGS mutations, in particular VUS have to be interpreted with caution with the help of parental study, clinical presentation, in-silico analysis and inputs from molecular and genetic experts. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Unusual Morphological and Automated Hematology Analyzer Features in 3 Cases of B-cell Malignancy-associated Type I Cryoglobulinemic Vasculitis.

Type I cryoglobulins are monoclonal immunoglobulins produced due to underlying hematological malignancy. Cryoglobulins spontaneously precipitate from serum and plasma at low temperatures and become soluble again on rewarming to 37°C. Processing of blood at temperature lower than 37°C in the laboratory may cause precipitation of cryoglobulins resulting in interferences in the automated cell counter analysis. We report three patients with cryoglobulinemic vasculitis wherein each case had different morphology of cryoglobulin precipitates on peripheral blood film, like needle shaped bluish-gray crystals, amorphous weakly basophilic extracellular deposits extraneously indenting red blood cells and basophilic neutrophilic inclusions respectively. The effect of cryoglobulins on two technologically different automated cell counters based on principles of impedance, Volume-Conductivity-Scatter (VCS) and fluorescence flow cytometry was assessed. This case series provides interesting insight into the varying morphological features of cryoglobulins on May-Grunwald-Giemsa stained blood films and interference caused by cryoglobulins in different automated cell counter analysis resulting in pseudo-leucocytosis, pseudo-thrombocytosis, abnormal histograms and scatterplots. Identification of these hematologic abnormalities and artifacts induced by cryoglobulins is necessary since it may be the first clue leading to the timely diagnosis of cryoglobulinemia and hence the underlying hematological malignancy, as in our cases.

Green neutrophilic inclusions: an underrated abnormality of clinical importance.

Green neutrophilic inclusions: an underrated abnormality of clinical importance.

Sporogonic cycle of Plasmodium falciparum in a human blood sample.

A 62-year-old woman recently arrived from Angola to start treatment for a papillary adenocarcinoma of the endometrium presented to the emergency room complaining of asthenia and anorexia. Upon admission the patient was afebrile (patient temperature: 35.9°C-37°C). Laboratory data showed: hemoglobin 9.0 g/dL (reference value [RV]: 12.0-15.3 g/dL), leucocytes 5.74 × 109/L (RV: 4-11 × 109/L), platelets 129 × 109/L (RV: 150-450 × 109/L) alanine aminotransferase 39 U/L (RV: 0-33 U/L), aspartate aminotransferase 33 U/L (RV: 0-32 U/L), total bilirubin 1.20 mg/dL (RV: <1.20 mg/dL), γ-glutamyl transferase 47 U/L (RV: 0-40 U/L), lactate dehydrogenase 269 U/L (RV: 100-250 U/L) and c-reative protein 1676 nmol/L (RV: <47.6 nmol/L). A peripheral blood film was performed two to three hours after blood collection (EDTA container) and the following findings were observed: gametocytes (Image 1A), trophozoites (Image 1B,C [appliqué/accolé presentation]), macrogametocytes (sporogonic [Correction added on September 19, 2020, after first online publication: the incorrect word ‘esporogonic’ is changed to ‘sporogonic’ after original publication.] cycle) (Image 1D,E), exflagellated microgametocytes (Image 1F,G), microgamete (Image 1H (microgamete nucleus [arrow]), neutrophil inclusions (Image 1I,J), Döhle bodies (Image 1K,L) and macroplatelets (Image 1M) (May-Grünwald-Giemsa stain, original magnification x1000). A diagnosis of Plasmodium falciparum infection was made, with a parasitemia of 3%. In the natural life cycle of Plasmodium species the presence of the exflagellated microgametocyte, microgamete and macrogametocytes, shown here, occur in the female Anopheles species mosquito.1-3 In the case presented here the presence of these parasite forms could have been induced in vitro due to a decrease in temperature from 35.9°C-37°C (patient temperature) to 17°C-28°C (room temperature), and by a decrease in the dissolved carbon dioxide when the blood comes in contact with the atmospheric environment, and subsequent increase in pH to above 8.0.3, 4 All these environmental changes occurred due to a delay in sample processing, possibly mimicking the changes which occur in the mosquito's gut.1 The presence of microgametes in the peripheral blood film can pose a diagnostic dilemma, leading to a wrong diagnosis of co-infection, because they can mimic Borrelia species or even for an inexperienced observer Trypanosoma species. The distinction can be made since Borrelia species lack nuclei and frequently have a spiral shape, and Trypanosoma species have a kinetoplast and an undulating membrane. Microgametes can be also seen, erroneously, as an artifact. The presence of macroplatelets may pose a problem because they can give false readings on automated cell counters once they can be counted as erythrocytes.5 None. M.P.B.P.: performed the research, analyzed data and wrote the paper. J.M.C.: analyzed data and wrote the paper. Data sharing is not applicable to this article as no new data were created or analyzed in this study. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

The rare green-blue neutrophil inclusion bodies. Worth reporting in blood films? A case of a patient with polytrauma.

Blood films are an easy tool to aid the diagnosis and management of unwell patients and should be prepared in this setting. Green‐blue neutrophil inclusion bodies could be an ominous sign of poor prognosis in critically ill patients.

Unusual presence of green neutrophil inclusions in peripheral blood as a marker of impending patient death

Most state-of-the-art methods in recognizing rotated, scaled, and translated (RST) palmprint image have difficulty to achieve the tradeoff between accuracy and robustness. Inspired by vision processing mechanic, we propose a double biologically inspired transform (DBIT) network. DBIT involves two stages, and each stage has several layers. In the first stage, we first build a convolution layer to highlight the edges at all direction and interval. Then, we construct another two convolution layers to measure local spatial frequency (LSF), which can improve the selectivity of feature maps. Since there is no negative spike in biological neurons, a rectified linear unit and sum pooling are employed to produce a neuron spike. Then, each spike is normalized by their original orientation edge maps, and finally, all spikes are combined to a feature vector. In the second stage, two convolution layers including orientation edge detection and single LSF followed by several subsequent operations are performed once again, which transforms image shift to an invariant spike on final feature maps. Experiments on PolyU multispectral, PolyU II, CASIA, IITD, and COEP database illustrate the effectiveness and robustness of the proposed approach. Remark progresses in feature invariance and selectivity are achieved by the proposed method. Comparing with several existing methods, our approach can achieve better recognition performance under rotation, scaling, translation, and even noise interference.

Intraleukocytic Yeast Inclusions and Toxic Granulation Neutrophils on Peripheral Blood Smear: An Interesting Synergy between Hematology and Microbiology

The presence of yeast neutrophil inclusions was observed and discussed several times in other reports; moreover some works demonstrated how Toxic Granulation Neutrophils (TGNs) are especially helpful in predicting acute bacterial infection, while the development of candidaemia-related TGNs was rarely described and in-depth.

Howell-Jolly Body-Like Inclusions in Neutrophils of Patients With Myelodysplastic Syndrome: A Novel Correlation.

Howell-Jolly body-like inclusions have been previously associated with patients who are human immunodeficiency virus (HIV) infected, taking antiviral medications, and immunosuppressed. These inclusions appear in neutrophils and resemble Howell-Jolly bodies of normoblasts in abnormal erythropoiesis. In granulocytes, they are thought to represent detached nuclear fragments produced from dysplastic granulopoiesis. To the best of our knowledge, no association of Howell-Jolly body-like inclusions and myelodysplastic syndrome (MDS) has been reported previously. To establish an unprecedented correlation of Howell-Jolly body-like inclusions in patients with MDS. Eleven bone marrow cases from patients diagnosed with MDS and 20 bone marrow cases with no significant pathologic alterations were retrospectively reviewed. Detailed medical record review was performed to ensure none of the patients had a history of HIV, or was taking immunosuppressants and/or antiviral medications. Eight of 11 cases (72%) from the study group show detached intracytoplasmic inclusions in a minority (<5%) of mature neutrophils consistent with Howell-Jolly body-like inclusions. No Howell-Jolly body-like inclusions were identified in the control group. Notably, none of the selected patients had a history of HIV or was taking immunosuppressants and antiviral medications. In review of the literature, Howell-Jolly body-like inclusions seem to correlate with immunosuppression and antiviral therapies with nucleoside analogs. We propose that the formation of Howell-Jolly body-like inclusions is the consequence of dysplasia, and hence its correlation not only with the abovementioned conditions, but also with MDS. The inclusions are, however, seen in only a minority of white cells (<5%), which is probably why they were not brought to practicing pathologists' awareness in the past. This study aims to raise awareness and correlate the presence of Howell-Jolly body-like inclusions in MDS.

Inclusions vertes dans les polynucléaires neutrophiles et les monocytes : à propos de deux cas

This study reports a rare cytological observation: the presence of green turquoise cytoplasmic inclusions in neutrophils and monocytes on a blood smear. These inclusions were transiently observed in two patients admitted in intensive care unit for a septic shock complicated by a multivisceral failure leading to patient death. Their presence was concomitant with increased hepatic transaminase levels associated to a severe liver necrosis. Such green inclusions have rarely been reported to date and have been observed in similar clinical contexts with a high risk of mortality. These unusual inclusions, in various number in leukocytes, should not be confused with Döhle bodies and cytologists must be aware about it.

Auer-rod-like Inclusions in the Mature Neutrophils of a T-acute Lymphoblastic Leukemia Patient.

Auer-rod-like Inclusions in the Mature Neutrophils of a T-acute Lymphoblastic Leukemia Patient.

185 Howell-Jolly Body-Like Inclusions in Neutrophils of Patients With Myelodysplastic Syndrome: A Novel Correlation

185 Howell-Jolly Body-Like Inclusions in Neutrophils of Patients With Myelodysplastic Syndrome: A Novel Correlation

Green neutrophilic inclusions: current understanding and review of literature.

Green cytoplasmic inclusions in neutrophils are an uncommon finding on the peripheral blood smear. A comprehensive review of the literature is presented here with the goal of summarizing knowledge to date and increasing awareness. A total of 41 cases have been reported in the literature, indicating the rarity of these green neutrophilic inclusions. Clinically, the inclusions have most consistently been associated with elevated transaminases, hepatic failure, and a high early mortality rate. The precise composition of the inclusions has not been confirmed. Clinicians, hematologists, and laboratory technicians should be educated and have a high level of awareness of green neutrophilic inclusions. A more comprehensive analysis of a larger number of cases will be needed to clarify the true prevalence, associated conditions, biochemical nature, and clinical significance of this unusual finding.

Green inclusions in neutrophils—a case report and review of literature

Green refractile inclusions in neutrophils are a very rare peripheral smear finding with few reported cases in literature. They were thought to be a marker of impending death with a very high mortality rate in the immediate hospitalization period. They were often seen in critically ill patients and often related to liver injury. Clinical and pathophysiologic characterizations of these inclusions are limited due to the rarity of this finding. We describe the case of a 42-year-old woman with tuberous sclerosis and recent renal transplantation who was critically ill due to pneumonia and had elevation of liver enzymes. She was found to have green refractile inclusions on peripheral blood smear on the third day of hospitalization. The patient improved rapidly with treatment and was discharged in 5 days. It appears that prognostic value of these inclusion bodies is doubtful. We also highlight the need to conduct further studies to clarify the link between hepatic injury and the presence of these inclusions.