Blue Green neutrophilic inclusions - poor prognostic indicator in patients presenting with Septic Shock(multiorgan) and DIC




Pham, Thien
Mohanaselvan, Arvindselvan


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Intracytoplasmic blue green granules have been nicknamed Crystals of Death and have been seen as signs of impending fatality. It has been reported in cases that have a complex presentation including, but not limited to, Septic shock, multiorgan failure, multidrug resistant bacteremia resulting in shock, shock liver, shock kidneys etc. Most of the cases that are reported having hepatic failure as one of the main comorbids in the patients. A recent study discussed two similar cases but totally different outcomes and concluded that the presence of comorbidities including ICU stay and multisystem failure lead to a fatal prognosis. Green Neutrophilic Inclusions are frequently associated with liver injury and may portend short-term mortality in critically ill patients. Patients presenting with Septic Shock from multiorgan failure including shock liver tend to develop DIC as a complication. One of the most common hematological findings in DIC is the presence of Schiztocytes. The crystals, if present in patients presenting with Septic Shock, require a complete workup for DIC including D-dimer levels, Fibrin monomers, Fibrin degradation products and Fibrinogen, if there is sufficient time. As most of the patients pass away within hours to days of this peripheral smear presentation, depending on the comorbidities the patient is presenting with, decision has to be made to work up DIC and treat if found. Usually patients presenting with a mild hepatic injury, mild metabolic/lactic acidosis have a better chance at survival compared to patients presenting with full blown shock liver and severe metabolic/lactic acidosis.