Dear Editor, Previous studies suggested that the presence of green inclusion bodies in blood neutrophils may be due to the phagocytosis of damaged liver cells by neutrophils1 and was associated with increased transaminase, lactic acidosis, liver failure, and higher early mortality rates. An 82-year-old male with residual gastric malignancy was admitted to the hospital for radical gastrectomy and partial hepatectomy via laparoscopy. His medical history included 46 years after gastrectomy, cerebral infarction, prostate hyperplasia, and chronic obstructive pulmonary disease. The preoperative physical examination showed no special abnormalities. Gastroscopy at another hospital indicated (anastomosis) moderately to poorly differentiated adenocarcinoma. Interestingly, during the acute phase, microscopic examination of the drainage fluid revealed that 0.8% of neutrophils contained green inclusion bodies Figure 1a and b, which were absent in mononuclear macrophages. Meanwhile, no green inclusion bodies were observed in the peripheral blood smears. The laboratory results of the drainage fluid were shown in Table 1. In addition, there were no special abnormalities in coagulation and liver function, except for a slight increase in aspartate aminotransferase (AST) (104 U/L).Figure 1: The arrow shows neutrophils with green inclusion bodies (a and b) in the ascites smear of a patient in the initial convalescence after laparoscopic partial hepatectomy (×1000, Wright–Giemsa staining)Table 1: Ascites laboratory with green inclusion bodies observed during admissionDuring the postoperative recovery period, the proportion of neutrophils with green inclusion bodies in the drainage fluid decreased, but increased in mononuclear macrophages Figure 2a and b. However, no such cells were found in peripheral blood smears. The relevant laboratory tests showed no abnormalities, and AST levels also returned to normal (30 U/L). During the acute phase and the postoperative recovery period, the Rivalta test did not corroborate the presence of protein in ascitic fluid, but the presence of mucoprotein. Meanwhile, the ascitic fluid microbial culture report showed no bacterial growth in both periods.Figure 2: The arrow shows neutrophils and mononuclear macrophages with green inclusion bodies (a and b) in the ascites smear of a patient in the late convalescence after laparoscopic partial hepatectomy (×1000, Wright–Giemsa staining)The green inclusion bodies are also called “death bodies.” The discovery of green inclusion bodies in peripheral blood smears needs to be reported to the clinic.2-4 In the present case, the inclusion bodies appeared in the drainage fluid, but not in peripheral blood, and the patient did not exhibit liver failure and other clinical manifestations. This phenomenon might relate to the damage of liver cells caused by laparoscopic partial hepatectomy; hence, the inclusion bodies in neutrophils decreased in the later stage of the recovery period.5 Our case report provides further evidence that green inclusion bodies in neutrophils result from phagocytosis of damaged liver cells. The presence of these bodies in drainage fluid has different clinical implications than their presence in peripheral blood. Interestingly, these inclusion bodies appeared first in neutrophils and later in mononuclear macrophages, and no such cells were found in the peripheral blood, suggesting that examination of surgical drainage fluid may be a potential indicator for early monitoring of liver damage. Declaration of patient consent Written informed consent was obtained from the patient’s relatives for the publication of this case report and accompanying images. Author contributions ZW: conceived the idea. ZC: wrote the original draft. ZC, XL, and ZW: collected the literature data. All authors approved the final version of the manuscript to be published. Ethical policy and Institutional Review Board statement All procedures performed in this study were in accordance with the ethical standards of The Central Hospital of Zhuji. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Chen et al. (Wed,) studied this question.