A 58-year-old gentleman was admitted for fever and chills. He complained of anasomia and nausea with vomiting. The past medical history was significant for bronchial asthma for the past 30 years. He was also being treated for diabetes mellitus and hypothyroidism.

He had exposure to COVID-19 through his mother and brother, and subsequently tested positive by RT-PCR testing for SARS-CoV-2

Ultrasound  of the abdomen showed fatty liver, grade-I.

Chest x-ray - Revealed bilateral lung infiltrates.

ABG  -  Revealed respiratory acidosis, hypoxemia, hyperkalemia and type-1 respiratory failure.

Other biomarkers:

1.IL-6  -  202  IU/L (  RR - upto 7.0 IU/L)

2.LDH – 876 IU/L   (RR - upto 450 IU/L)

3.D-DIMER – 4570 ng/ml  ( RR - less than 500ng/ml)

4.CRP  -  194 mg/L   (RR - less than 10 mg/L)

5. Procalcitonin  -   more than 10 ng/ml ( RR - Less than 0.05ng/ml)

6.Fibrinogen  - 162 mg/dl  (RR - 200 -m400 mg/dl)

7.Urea – 72 mg/dl  (RR - 20-40mg/dl)

8. Creatinine – 2.5 mg/dl ( upto 1 mg/dl)

9.Prothrombin time -  29.0 seconds ,  INR- 2.7

CBC & Blood smear study:

There was bicytopenia with leukocytosis, neutrophilia and lymphopenia. The immature granulocytes accounted for 10% of the nucleated cells, while nucleated red cells were present at 2%.

The peripheral blood smear study showed toxic granulation, vacoules and "blue-green crystals" along with Dohle bodies in the neutrophils. RBC shows normocytic cells with polychromatophilia. Platelets shows thrombocytopenia.

The laboratory alerted the physician of the presence of blue-green crystals as a critical value. 

Soon, the patient developed bradycardia and hypotension despite all resuscitative measures and went into cardiac arrest within 24 hours of the critical value call.

Blue-green crystals in neutrophils and monocytes are thought to represent phagocytosed material and lysozomal degradation products. They are associated with hepatic injury and lactic acidosis and often present at times of severe illness, sometimes shortly before death of a patient.