Green-blue Inclusions in Leukocytes and COVID-19: A Sign of Looming Death

Clinical and Medical Case Reports

ISSN: 2684-4915

Open Access

Clinical image - (2022) Volume 6, Issue 5

Green-blue Inclusions in Leukocytes and COVID-19: A Sign of Looming Death

Ghachem Ikbel*, Kaabar Mohamed Yassine and Bachali Asma
*Correspondence: Ghachem Ikbel, Department of Hematology, Hopital Regional Mohamed Taher Maamouri De Nabeul, Tunisia, Tel: +21650006987, Email:
Department of Hematology, Hopital Regional Mohamed Taher Maamouri De Nabeul, Tunisia

Date of Submission: 01-May-2022, Manuscript No. cmcr-22-63443; Editor assigned: 03-May-2022, Pre QC No. P-63443; Reviewed: 06-May-2022, QC No. Q-63443; Revised: 12-May-2022, Manuscript No. R-63443; Published: 18-May-2022 , DOI: 10.37421/2684-4915.2022.6.204
Citation: Ikbel, Ghachem, Kaabar Mohamed Yassine and Bachali Asma. “Green-Blue Inclusions in Leukocytes and COVID-19: A Sign of Looming Death.” Clin Med Case Rep 6 (2022): 204.
Copyright: © 2022 Ikbel G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Green-blue Cytoplasmic Inclusions (GBI) in neutrophils and/or monocytes is a rare peripheral blood smears anomaly described in few case reports in patients with acute liver injury, lactic acidosis and recently with COVID-19. Referred to as “crystals of death”, these inclusions are associated with a critical prognosis and death shortly time after identification. Herein, we report a case of GBI finding in neutrophils, monocytes, myelocytes and metamyelocytes cytoplasm’s in a patient with COVID-19.


COVID-19 • GBI • Myelocytes • Inclusions

Case Image

A 78 years old man with a history of diabetes and high blood pressure was hospitalized for a severe acute respiratory syndrome COVID-19 in the unit intensive care requiring a mechanic ventilation. Laboratory tests showed an increased leucocytes number (94 × 103/μL) with a predominance of polymorphonuclear cells (92.4 × 103/μL), lymphopenia (0.8 × 103/μL),


Figure 1: Green-blue inclusions in monocytes, polymorphonuclear, myelocytes and metamyelocytes cytoplasm cells.

aregenerative normochrome anemia (Hemoglobin=5.6 g/dL), normal platelets number, and elevated D-Dimere (6961 ng/mL). Biochimical report showed an elevated LDH (877 U/L), renal failure (urea=76.4 mmol/l, creatinine=277 μmol/l), CRP=90.97 mg/l, hyperkaliemia=7.62mmol/L, hypernatriema=147mmol/L), high lactate (8 mmol/L) but with a normal hepatic function (Aspartate transaminase=38.2 UI/L, Alanine transaminase=24.9UI/L).

Peripheral blood smear examination revealed multiple Green-blue Inclusions (GBI) in polymorphonuclear, in monocytes but also in myelocytes and metamyelocytes cytoplasm cells. The patient died after 48 hours of his microscopic finding and 10 days after initial COVID-19 testing. Such bluegreen inclusions called « crystals of death » were associated with a short-term mortality in 60% with a median of 3 days [1]. Most reports described this crystal inclusion as a critically anomaly in patients with tissue injury seen in liver failure and sepsis and recently described in rare cases of COVID-19 patients [1]. Many hypotheses suggest that GBI was rich of lipofuscin released from lysosomal degradation of necrotic hepatocytes phagocytized by polymorphonuclear cells and monocytes [2]. To our knowledge, this is the first report of GBI described in myelocytes and metamyelocytes cells of peripheral blood smear in COVID-19 patient. The pathogenesis of these inclusions is unclear and need more exploration of their etiology and clinical implications (Figure 1).


Dr Ghachem and Dr Kaabar analyse and write the case. Dr Bachali contributed to the content revising.


  1. Vicente�Steijn, Rebecca, Adriá Tomé, Francisco Maduell and Marc Xipell, et al. "Green inclusions in neutrophils: A critical finding that must be reported." Int J Lab Hematol. 42 (2020): 3.
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  3. Cantu, Miguel Dario, William Samuel Towne, Foxwell Nathan Emmons and Maria Mostyka, et al. "Clinical significance of blue�green neutrophil and monocyte cytoplasmic inclusions in SARS�CoV�2 positive critically ill patients." Br J Haematol 190 (2020):
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