Green Neutrophilic Inclusions are Frequently Associated With Liver Injury and May Portend Short-Term Mortality in Critically Ill Patients

Abstract

Background: Few studies have described an association among acute liver disease, high short-term mortality, and blue-green refractile neutrophilic inclusions on blood smears.

Objective: To describe our experience with 13 patients and compare our data to those from other cases reported in the literature regarding the interplay of acute liver disease, high short-term mortality, and blue-green refractile neutrophilic inclusions on blood smears.

Methods: We performed a retrospective review of blood smears, patient medical information, and outcomes for our 13 studied patients.

Results: The patients in our series had lower short-term mortality than the patients whose cases were reported in the literature (P = .04), and inclusions were identified in 2 patients who were not critically ill. In 3 patients without liver enzyme elevation, elevated lactate dehydrogenase (LDH) levels were present.

Conclusions: Blue-green refractile inclusions are associated with tissue or liver injury; consequently, liver enzyme and LDH testing should be considered when these inclusions are present. These inclusions are more common in critically ill patients but can be observed in patients who are not acutely ill, and the prognosis may not be as dire as previously reported. Greater awareness of these inclusions and their implications will strengthen our understanding of their etiology and diagnostic significance.

Keywords: inclusions; lactate dehydrogenase; liver injury; monocyte inclusions; neutrophil inclusions; tissue injury.