#00063561

A 17 year old young male presented with fever, headache, vomiting and fluctuating alertness. He was immunocompromised from HIV infection with CD4 count was 10 cells/uL.  His blood work showed pancytopenia. (WBC count 2.34 ×109 cells/L, Hb: 7.8gms/ dl, Platelet count: 48000/ cmm)

Examination of the feathered edge of the peripheral blood film revealed intact, well-preserved, large (50- to 60-um diameter) abnormal large, atypical cells (Images A, B, C and E). These cells had abundant basophilic cytoplasm, with a central zone of eosinophilic granules that displaced the nuclei. The nuclei were eccentric, oval, and occasionally slightly concave. Nuclei had a granular appearance, and nuclear inclusions were seen (Images: B, C, and E).

Paraffin-embedded sections of buffy coat preparations from peripheral blood revealed enlarged cell having intranuclear inclusions characteristic for cytomegalovirus (CMV) infection ( Image D). Polymerase chain reaction analysis indicated the presence of CMV DNA in his cerebrospinal fluid (CSF).

Although the appearance of these cells is distinctive, lack of familiarity may lead to their misidentification as other cell types like megakaryocytes or other large cells such as malignant cells, both of which may be seen in peripheral blood. 

Circulating CMV-infected endothelial cells in routinely processed peripheral blood films is an uncommon phenomenon. The presence of circulating cytomegalic cells may correlate with particularly severe infection, and rarely may represent the earliest evidence of CMV infection, potentially leading to more timely institution of antiviral therapy. 

Reference:

Pooley R, Peterson L, Finn W, et al. Cytomegalovirus-lnfected Cells in Routinely Prepared Peripheral Blood Films of Immunosuppressed Patients. Am J Clin Pathol. 1999;112:108-112