#00063119

A 65-year-old female presented with fever, cough and shortness of breath. Past history was significant for end-stage renal disease and patient underwent renal transplant 19 months ago. Complete blood count on admission showed white blood cell count of 1410/mL; hemoglobin of 12.9 g/dL; and platelets of 163,000/mL. WBC differential was as follows: neutrophils, 55 percent; lymphocytes, including large granular forms, 30 percent; monocytes, 15 percent. Ill-defined patchy opacities were evident in the lungs on chest X-ray. Infectious work-up was positive for SARS-CoV-2 (the virus that causes COVID-19) by reverse transcriptase–polymerase chain reaction. Peripheral blood smear revealed Howell-Jolly body-like inclusions (HJBLIs) in neutrophils.  

HJBLIs are spherical basophilic inclusions in neutrophils and have been found to be associated with HIV, immunosuppression, antiviral medications, and myelodysplastic syndrome. 

HJBLIs in this case were found after onset of respiratory disease and thus are believed to be a response of viral infection rather than immunosuppression. Concomitant presence of toxic granulation in the neutrophils further supports an infectious etiology. Moreover, no inclusion was reported in previous blood smears following immunosuppressive medications for renal transplant.  

Learning points: 

• Round, basophilic inclusions in neutrophils have various differentials including intra-cytoplasmic infectious agents (Ehrlichia and Anaplasma); Howell-Jolly body-like inclusions (HJBLIs) and inclusions of inherited conditions (May-Hegglin anomaly). 

• HJBLIs presumably represent detached nuclear fragments produced from dysplastic granulopoiesis and have morphological and biochemical resemblance to their erythrocytic counterparts. These are rare in occurrence and often go unnoticed. 

• In cases with COVID-19, HJBLIs can be formed as a response to viral infection, as occurs in HIV. 

• Although the prognostic significance of HJBLIs is unclear, accurate identification is important in view of confusing their morphology with other cytoplasmic inclusions. 

Image description: HJBLIs are the spherical, basophilic intra-cytoplasmic inclusions in neutrophils (Black arrow). Note, that these inclusions are completely separate from the main nuclear body differentiating them from a Barr body (Red arrow), which appears as a drumstick-shaped appendage of nuclear lobe. The main nucleus of neutrophils has coarsely condensed chromatin. Additionally, toxic change in secondary granules of neutrophils is seen.