Abstract
Hemophagocytosis is usually observed in bone marrow. But it can be an incidental finding in other body fluids in severe infections like cerebrospinal fluid in case of meningitis. Clinicians need to rule out primary type of hemophagocytic syndrome.
Keywords: CSF, hemophagocytosis, meningitis
Hemophagocytosis is usually observed in bone marrow. But it can be an incidental finding in other body fluids in severe infections like cerebrospinal fluid in case of meningitis. Clinicians need to rule out primary type of hemophagocytic syndrome.
1. CASE
A 39‐year‐old female was presented with pneumococcal meningitis 5 weeks after having endoscopic transsphenoidal drainage of a suprasellar benign cystic macroadenoma. Cerebrospinal fluid cytology (CSF) cytology showed prominent hemophagocytosis in addition to neutrophil leukocytosis.
A 39‐year‐old female had endoscopic transsphenoidal drainage of a suprasellar benign cystic macroadenoma. Five weeks later, she presented with fever, severe headache, vomiting, and neck pain for a day and was diagnosed with bacterial meningitis complicated by cavernous sinus thrombosis. CSF analysis revealed a negative viral screen, Gram‐positive cocci, and bacterial antigen test was positive for Streptococcus pneumoniae, leukocytes = 810/cumm (NR = 0‐10) and RBC = 2000/cumm (NR = 0). CSF cytology showed a very large number of neutrophils in addition to many monocytes and few plasma cells. What was striking is the prominent hemophagocytic activity (Figures 1, 2, 3, 4, 5). This is usually observed in BM aspirate of patients with primary or secondary HLH but a very unusual phenomenon in CSF. This finding should alert the physicians to exclude an underlying primary hemophagocytic lymphohistiocytosis (HLH). Her CBC results showed Hb = 11g/L, leukocytes = 22.6*109/L (neutrophils = 20.1*109/L), plt = 342*109/L. Fibrinogen = 5.4 g/L (NR = 1.7‐3.6 g/L).
FIGURE 1.
Cerebrospinal fluid cytology shows a large number of RBCs, neutrophils, and prominent hemophagocytosis (black empty arrows). Wright's stain. 400x
FIGURE 2.
Cerebrospinal fluid cytology shows a large number of RBCs, neutrophils, and prominent hemophagocytosis (black empty arrows). Wright's stain. 400x
FIGURE 3.
Cerebrospinal fluid cytology shows a large number of RBCs, neutrophils, and prominent hemophagocytosis (black empty arrows) and erythrophagocytosis (red empty arrow). Wright's stain. 400x
FIGURE 4.
Cerebrospinal fluid cytology shows a large number of RBCs, neutrophils, and prominent hemophagocytosis (black empty arrows) and erythrophagocytosis (red empty arrows). Wright's stain. 400x
FIGURE 5.
Cerebrospinal fluid cytology shows a large number of RBCs, neutrophils, and prominent hemophagocytosis (black empty arrows) and phagocytosis of neutrophils (red empty arrows). Wright's stain. 400x
Meningococcal sepsis secondary to an underlying primary HLH has been reported. 1 Another study of 96 cases of primary HLH found that CSF examinations showed abnormalities in 23 patients (39.0%), of which 10 patients had elevated white blood cell counts, and 13 patients had elevated protein contents. 2 The patient did not fulfill the criteria of primary HLH. Meningitis was treated successfully but patient was left with spastic quadriparesis and referred to physiotherapy.
CONFLICT OF INTEREST
None declared.
AUTHOR CONTRIBUTIONS
AMZA: diagnosed the condition, wrote the draft and provided images. RK: provided clinical care for the patient.
ETHICAL APPROVAL
A signed informed consent was obtained from next of kin and is available for review upon request. Constitutional ethical approval is not applicable.
ACKNOWLEDGMENTS
The authors would like to thank Dr. Ammar Al‐Shryani for his help with photography.
Alqasim AMZ, Kariyattil R. Prominent hemophagocytosis in cerebrospinal fluid in a patient with pneumococcal meningitis. Clin Case Rep. 2021;9:e04294. 10.1002/ccr3.4294
DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
REFERENCES
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Associated Data
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Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.