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A 67-year-old Caucasian female presented with abdominal pain, elevated lipase (970 U/L), and abdominal CT concerning for acute interstitial pancreatitis and infectious colitis. Within two days of admission to the medical ICU, liver transaminase levels rose from 8 U/L to 219 U/L (ALT) and 34 to 1,810 U/L (AST), while coagulation laboratory testing showed increased prothrombin time, increased activated partial thromboplastin time, and decreased fibrinogen, consistent with disseminated intravascular coagulation. Peripheral blood smear demonstrated rare schistocytes (2-4 per high power field) as well as abundant neutrophils and monocytes (15-20%) containing blue-green refractile cytoplasmic inclusions (see panel images A, B, C, D). Additionally, the patient showed neutrophilic leukocytosis (17.9 x 103/µL WBCC, 14.6 x 103 absolute neutrophil count), thrombocytopenia (15 x 103/µL), and numerous Burr cells. The patient deteriorated quickly, expiring 4 days after admission. 

Blue-green neutrophilic and/or monocytic inclusions are a rare finding previously reported as dire prognostic indicators of impending deterioration in critical patients, especially in settings of acute liver failure, multiorgan failure, and sepsis (Soos et al., 2019). The finding of blue-green neutrophilic and monocytic inclusions conveys a dire prognosis which may be valuable to clinicians and should be reported in official hematological reports.