The green bad omen in blood smear and the potential of blood purification therapy: A case report

Rationale: Green inclusions (GI) are distinct morphological features found in phagocytic cells like neutrophils and monocytes. These intracellular structures exhibit bright green color with unclear boundaries, and their origin and clinical significance are still not fully understood. GI carriers, often middle-aged to elderly with liver dysfunction, face higher mortality rates, earning them the nickname “inclusions of death.” This report presents a rare GI-related pediatric case, demonstrating a favorable response to blood purification therapy. Patient concerns: A 10-year-old girl was admitted with recurrent fever, abdominal pain, and neurological symptoms, culminating in a transient cardiac arrest. Blood tests revealed multi-organ injury and a high risk of disseminated intravascular coagulation, while peripheral blood smear detected GI within neutrophil cytoplasm. Diagnosis: The patient was diagnosed with acute necrotizing encephalopathy, severe sepsis, and multiple organ failure. Interventions and outcomes: After receiving multiple sessions of blood purification therapy, peripheral blood GI levels markedly decreased, accompanied by improvements in various laboratory parameters and signs of neurological recovery. Unfortunately, due to financial constraints, the family opted to transfer the patient back to their local hospital, where she succumbed shortly after discharge. Lessons: This case underscores the complexities in managing GI-related pediatric cases. Moreover, it emphasizes the potential benefits of blood purification therapy in such scenarios. Notably, this study highlights a potential correlation between the level of GI in peripheral blood and disease severity, particularly in pediatric cases. While these findings hold clinical significance for the treatment and management of GI-related patients, further research focusing on middle-aged and elderly individuals is imperative to elucidate the fundamental relationship between peripheral blood GI quantity and clinical presentation and to evaluate the efficacy of blood purification in GI-related cases.


Introduction
Green inclusions (GI) is typically observed as a morphological feature found exclusively in cells with phagocytic capacity, such as neutrophils and monocytes, while their presence in lymphocytes has not been reported.These intracellular inclusions, easily recognizable morphologically, appear as bright green structures within the cytoplasm and exhibit either blurry boundaries or round/irregular shapes. [1]e formation mechanism, composition, and clinical significance of GI remain unclear.Hodgson et al, based on Periodic Acid-Schiff staining and Zeihl-Neelsen staining results, proposed that GI may be lysosomal degradation products formed after neutrophils or monocytes phagocytize tissue injury products.They further speculated that GI formation could be attributed to the phagocytic digestion of lipofuscin released by acute liver damage-induced hepatocyte necrosis by monocyte macrophages and Kupffer cells. [2]Previous reports have shown that carriers of YC, WN, and GG contributed equally to this paper.
Written informed consent for publication was obtained from the patient's parents.All patient information was obtained from the Zhongshan Boai Hospital Affiliated to Southern Medical University.All data used and analyzed in the current study are included in this article.

Chen et al. • Medicine (2024) Medicine
GI are often middle-aged to elderly individuals with concurrent liver dysfunction, exhibiting a significantly high clinical mortality rate.Consequently, some scholars have referred to GI as "inclusions of death." [1,3]In this report, we present a rare case of a pediatric patient who demonstrated an effective response to treatment, but unfortunately, the outcome was disappointing.
Given the severity of patient's condition, she was transported to our hospital by an ambulance.Upon the arrival of the medical team, the patient was unresponsive, had irregular and labored breathing, and moaned, with a significant amount of frothy oral secretions.Physical examination revealed reduced level of consciousness with delayed pupillary light reflexes.She was immediately placed under cardiac monitoring, intubated, connected to a ventilator, and administered fluids before being transported.During transit, the patient had a heart rate of 130.0 beats per minute and blood oxygen saturation levels ranging from 95.0% to 100.0%.Upon arrival at the hospital, the cardiac monitor indicated a drop in heart rate to 60.0 beats per minute, no audible heart sounds and unpalpable arterial pulses, signaling cardiac arrest.Following resuscitation measures, her body temperature was 35.10°C, and her Glasgow Coma Scale score was E1VtM1.
She was maintained on dopamine at 12.50 μg/kg/min, epinephrine at 0.30 μg/kg/min, and norepinephrine at 0.30 μg/kg/ min, with a heart rate of 111.0 beats/min and blood pressure of 60.0/40.0mm Hg.Both pupils had a diameter of 4.0 mm with absent light reflex.Heart sounds were muffled but regular, and the extremities were cool with a capillary refill time of 4.0 seconds.
After a series of clinical treatments, including fluid resuscitation, anti-inflammatory therapy, anti-infective therapy, and blood product transfusions, the patient's hemodynamic status remained unsatisfactory, and there was no significant improvement in multiple organ dysfunction.Therefore, after a multidisciplinary consultation, we decided to initiate blood purification therapy (combined use of hemodialysis and hemoperfusion) for the patient.The blood flow rate was set at 50.0 to 150.0 mL/min, and 400.0 mL of fresh frozen plasma was infused during each treatment session, which lasted for 2.50 hours and was performed every other day.After 2 sessions of treatment, the patient regained consciousness, and there was a significant improvement in her condition.The platelet count increased to 72.0 × 10 9 /L, and the levels of alanine aminotransferase (35.0 U/L), aspartate aminotransferase (88.0 U/L), creatinine (83.0 μmol/L), urea (5.42 mmol/L), lactate dehydrogenase (842.0U/L), CK (102.0U/L), CK-MB (76.0 U/L), procalcitonin (25.09 ng/mL), interleukin (753.0 pg/mg), D-Dimer (55.43 μg/mL), and the percentage of GI-positive cells (1.0%) in peripheral blood and the number and size of GI in the cytoplasm (Fig. 2) all significantly decreased.However, when we were preparing for the next phase of treatment, the patient's family strongly requested to return to their local hospital for further treatment due to financial reasons.Subsequently, through follow-up, we learned with great regret that the patient passed away on the fifth day after discharge.

Discussion
GI are enigmatic intracellular structures observed predominantly in phagocytic cells like neutrophils and monocytes.Despite their distinct morphological characteristics, the origin, composition, and clinical implications of GI remain largely unknown. [1]These green inclusions have garnered attention primarily due to their association with severe liver dysfunction and high mortality rates among middle-aged and elderly individuals, earning them the ominous moniker "inclusions of death."This report presents a unique case of GI in a pediatric patient who exhibited a favorable response to blood purification therapy, shedding light on the complexities surrounding GI-related conditions.
The emergence of GI in peripheral blood smears often raises concerns about the patient's prognosis, and previous studies have hinted at a strong correlation between GI presence and acute liver failure, severe infections, and poor outcomes.6][7] Patients with acute liver injury who present GI-positive cells typically experience a rapid escalation in transaminase levels, worsening clinical conditions within a short timeframe, and alarmingly high mortality rates. [8]owever, there are exceptions to this dire prognosis, with reports suggesting that GI-positive cells can disappear, transaminase levels can decrease, and patients can recover, particularly when the underlying condition is effectively managed, as seen in middle-aged individuals with liver failure due to infections after antibiotic treatment. [9]The variability in patient outcomes highlights the critical role of underlying health conditions and effective clinical interventions.Cases like that of a patient with renal cancer and early metastasis who succumbed within hours of the discovery of GI-positive cells and a contrasting scenario of a high-altitude fall patient with multiple injuries who survived emphasize this variability. [10,11]he case we present here involves a pediatric patient with GI-positive cells and a relatively better initial physical condition compared to most elderly GI-positive cases.However, suboptimal initial management prior to her transfer to our hospital significantly complicated her condition.Despite our team's concerted efforts to stabilize her health, the unfortunate outcome was influenced by family-related decisions.
In summary, this case highlights the dynamic nature of GI-positive cells in peripheral blood smears, with their presence fluctuating alongside the progression or improvement of the underlying disease.The percentage of GI-positive cells could potentially serve as an indicator of disease severity and contribute to prognostic assessments.Therefore, we emphasize the importance of timely communication between laboratory physicians and clinical teams upon the detection of GI-positive cells and advocate for continuous monitoring of peripheral blood smears.Furthermore, our experience suggests that blood purification therapy may offer temporary relief in GI-related cases, although further validation through a larger sample of clinical cases is warranted to establish its efficacy.
In conclusion, this case adds to the growing body of knowledge about GI and underscores the need for ongoing research to unravel the mysteries surrounding these enigmatic inclusions, especially in the context of middle-aged and elderly individuals with liver dysfunction.Such investigations hold the promise of improving the diagnosis, management, and outcomes of GI-related condition, ultimately reducing the burden of these patients and their families.