Photo Quiz: Significant Inclusions in Polymorphonuclear Leukocytes

A 30-year-old female was referred to a tertiary hospital in Bangladesh for evaluation of recurrent fever, weakness, a 1-year history of chronic weight loss, a 15-day course of swelling in both legs, and a 1-month observation of amber-colored urine. On physical examination, the patient was found bedridden, afebrile (body temperature, 36.6°C), anemic, and jaundiced with palpable spleen and liver measuring 8 cm and 2 cm, respectively, from the costal margin. Her body mass index (BMI) was 17.4 at the time of admission. Abdominal ultrasonography revealed moderate ascites, severe splenomegaly, and mild hepatomegaly. Additionally, the chest X-ray showed right-sided pleural effusion. Hematology data included white blood cell (WBC), 7,600/μl (reference value, 4,000 to 11,000/μl); red blood cell, 2.92 million/μl (reference value, 3.5 to 5.5 million/μl); hemoglobin, 7.2 gm/dl (reference value, 12.0 to 15.0 gm/dl); platelet count, 32,000/μl (150,000 to 400,000/μl); and erythrocyte sedimentation rate, 120 mm/h (reference value, 2 to 20 mm/h). Differential count of peripheral blood film (PBF) leukocytes included 79% polymorphonuclear leukocytes (PMNs) and 13% bands. Chemistry data included total serum bilirubin, 11.5 mg/dl (reference value, 0.2 to 1.2 mg/dl); serum glutamic pyruvic transaminase, 84 IU/liter (reference value, 5 to 40 IU/liter); serum creatinine, 0.7 mg/dl (reference value, 0.7 to 1.2 mg/dl); total serum protein level, 2.2 gm/dl (reference value, 6.6 to 8.7 gm/dl); and serum albumin, 1.2 gm/dl (reference value, 3.5 to 5.2 gm/dl). The patient was seronegative for human immunodeficiency virus and hepatitis B surface antigen. PBF study revealed inclusion morphology in 10% of the PMNs (Fig. 1); however, no inclusions were observed in mononuclear cells. PBF also showed microcytic hypochromic red blood cells.

FIG 1.

Inclusions within peripheral blood PMN (Wright stain; ×1,000 total magnification).

For answer and discussion, see https://doi.org/10.1128/JCM.01290-20 in this issue.