Critical green inclusion
|Critical green inclusions|
|Other names||Green neutrophilic inclusions, death crystals, crystals of death|
|Critical green inclusions in a neutrophil|
Critical green inclusions, also known as green neutrophilic inclusions and informally, death crystals or crystals of death, are amorphous blue-green cytoplasmic inclusions found in neutrophils and occasionally in monocytes. They appear brightly coloured and refractile when stained with Wright-Giemsa stain. These inclusions are most commonly found in critically ill patients, particularly those with liver disease, and their presence on the peripheral blood smear is associated with a high short-term mortality rate.
Critical green inclusions are a rare finding, and when found they are suggestive of a poor prognosis, hence the colloquial term death crystals. A 2018 review found that 56% of patients died shortly after the inclusions were first identified (usually within two weeks). However, critical green inclusions are of limited utility for predicting mortality because they are usually found in severely ill patients whose poor prognosis is already evident for other reasons by the time the crystals are detected.
The inclusions are strongly associated with damage to liver tissue: they are most frequently seen in cases of acute hypoxic and ischaemic hepatitis and have been observed after uncomplicated liver transplantation. They are also associated with lactic acidosis.
The composition of the inclusions is not well understood, but transmission electron microscopy has shown that they are rich in lipids and possibly related to lipofuscin. Microscopic examination of liver tissue in patients with critical green inclusions has demonstrated prominent deposition of lipofuscin, suggesting that the white blood cell inclusions represent phagocytosis of this substance following severe injury to the liver.
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