#00064962

Case presentation.

A 70-year-old man was transferred to our hospital as a result of right-sided wake-up hemiparesis. In his medical history we note atheromatous disease, Diabetes Mellitus type 2, tabagism and atrial fibrillation for which the patient took edoxaban. Clinical examination showed paresis and hypoesthesia of the right arm and leg and intermittent confusion. MRI of the myelum showed a long-segment T2 hyperintense swelling of the spinal cord with both hyper- and hypo-intense zones present. Described as an epidural hemorrhage or infection. Differential diagnostically we retain: intramedullary hemorrhage or ischemia, myelitis, demyelination or a tumoral process. The abnormalities are too remarkable to explain a degenerative myelomalacia. Furthermore cranial CT was negative, CT-scan of the thorax and abdomen could not demonstrate any malignancies and EEG was slightly delayed.

The physicians performed a lumbar puncture which was hemorrhagic at several levels. It was unclear whether this fluid was hemorrhagic due to an intracerebral hemorrhage or because of multiple traumatic punctures.

Automatic cellular analysis of the cerebrospinal fluid revealed 9760 white blood cells/µL and 1989 red blood cells/µL. Microscopic examination of cytospins stained with May-Grünwald-Giemsa predominantly showed monocytes and macrophages (+/- 70% of the leucocytes).

Numerous erythrophages (A), hemosiderin-laden macrophages (C) as well as multiple clear yellow crystals (B) were observed. These intracytoplasmic rhomboid crystals, so-called hematin or hematoidin crystals, arise because of the breakdown of heme from the hemoglobin in red blood cells. In the presence of bleeding, the phagocytic cells (macrophages and neutrophils) are activated and a 'clearing appearance' is formed with the formation of hemosiderin pigment residues in the macrophages (dark granules in the cytoplasm). Sometimes during this process also hematin crystals are formed.

The presence of multiple siderophages is usually a sign of hemorrhage. But these cells can remain present for months after the hemorrhage. A large number of siderophages and macrophages with hemophagocytosis are a strong morphological sign that there has been a (chronic/long existing/prolonged) hemorrhage.

Williams, M. J., Baughman, B., Shores, A., Gibson, R. M. B., Beasley, M. J., Morgan, T. W., & Williams, M. L. (2022). CSF from a puppy with a cerebral vascular hamartoma. Veterinary Clinical Pathology, 52(1), 97–101. https://doi.org/10.1111/vcp.13153

Benz, R., Züger, M. F., Pung, T., Gallus, E., Weisshaupt, C., & Krause, M. (2009). When a clear crystal makes a case crystal clear. Practical Neurology, 9(6), 345–346. https://doi.org/10.1136/jnnp.2009.193839

Craver, R. (1996b). The Cytology of Cerebrospinal Fluid Associated with Neonatal Intraventricular Hemorrhage. Pediatric Pathology & Laboratory Medicine, 16(5), 713–720. https://doi.org/10.1080/15513819609169298

Kjeldsberg, C. R., & Hussong, J. W. (2015). Body Fluid Analysis. American Society for Clinical Pathology Press.