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Pseudo-Pelger-Huet Anomaly with Howell-Jolly-like inclusions in Granulocytes

Pseudo-Pelger-Huet Anomaly with Howell-Jolly-like inclusions in Granulocytes
#00064317
Author: Jui Choudhuri, MD,MBBS; Yanan Fang, MD, PhD
Category: Laboratory Hematology > Basic cell morphology > Morphologic variants of white blood cells
Published Date: 03/10/2023

A 49-year-old male with end-stage renal disease secondary to hypertension underwent renal transplant. He presented after two months with nausea and vomiting. His immunosuppression regimen included Tacrolimus, Mycophenolate mofetil and Prednisolone. His blood counts were as follows: white blood cell count of 2.3× 10 9/L, a hemoglobin level of 8.0 g/dL, and a platelet count of 319 × 10 9/L, with an absolute neutrophil count of 1.3 × 10 9/L. Review of the peripheral blood smear showed normocytic normochromic anemia with 20% of neutrophils exhibiting Pseudo-Pelger-Huet anomaly (PPHA). Most Pseudo-Pelger-Huet cells had unilobed nucleus (resembling myelocytes) or indented nucleus (mimicking metamyelocytes) with highly condensed chromatin. Some Pseudo-Pelger-Huet cells as well as rare neutrophils exhibited detached nuclear fragments in the cytoplasm, appearing like round basophilic inclusions, consistent with Howell-Jolly-like inclusions (Images A-D. 100X magnification, A. PPHA with indented nucleus and Howell-Jolly-like bodies. B and C. PPHA with unilobed nucleus and Howell-Jolly-like bodies. D. neutrophil with Howell-Jolly-like bodies). 

PPHA characterized by hyposegmentation of the neutrophil nucleus and clumped chromatin can be seen in patients with myeloid neoplasms, severe infections, or certain drug effects. While Howell-Jolly-like inclusions seen in leukocytes mainly neutrophils are associated with viral infection, immunosuppression, and chemotherapy. Both these findings have previously been described in conditions of immunosuppression associated with Tacrolimus and Mycophenolate, however in this case both were noted together in the same cells.  

Reference:  

  1. Pelger-Huet anomaly and pseudo (acquired) Pelger-Huet. Blood 2006; 107 (9): 3428. 

  2. Eiad Kahwash, Amy S. Gewirtz; Howell-Jolly Body–Like Inclusions in Neutrophils. Arch Pathol Lab Med 1 October 2003; 127 (10): 1389–1390. 

  3. Banerjee R, Halil O, Bain BJ, Cummins D, Banner NR. Neutrophil dysplasia caused by mycophenolate mofetil. Transplantation. 2000 Dec 15;70(11):1608-10.  

 
     
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