An 88-year-old African American man was evaluated for altered mental status and was found to have a urinary tract infection. He developed septic shock with a positive blood culture for Escherichia coli, confirmed as extended spectrum beta-lactamase. During the course of infection, the aspartate aminotransferase and alanine aminotransferase increased rapidly from 50 U/L and 22 U/L to 348 U/L and 116 U/L, respectively. The bilirubin increased from 3.4 mg/dL to 4.4 mg/dL (direct: 3.2 mg/dL) with increased international normalized ratio, prolonged prothrombin time and activated partial thromboplastin time, and elevated creatinine. The peripheral blood smear showed normocytic normochromic anemia with acanthocytes and neutrophilic leukocytosis (white blood cells: 21.8 × 10⁹/L). Variable-sized, ill-defined, bright-green cytoplasmic inclusions (panels A and B) were seen in a subset of the patient’s neutrophils (15% of total neutrophils). Associated reactive changes, including toxic granulation, cytoplasmic vacuoles, and Döhle bodies, were noted in some of these neutrophils, as well as others. The green inclusions were negative for iron, myeloperoxidase, and bilirubin special stains. The platelets were 117 × 10⁹/L with normal morphology. The patient’s condition deteriorated rapidly, and he expired 2 days after admission.

Similar neutrophilic inclusions have been reported (Harris VN, Malysz J, Smith MD. Green neutrophilic inclusions in liver disease. J Clin Pathol. 2009;62[9]:853-854) in 2 patients with fatal acute hepatic failure just prior to death; we support the suggestion in this report that the presence of such inclusions may serve as a prognostic indicator of impending death.