Case Report: First report of blue-green neutrophilic inclusions in Epstein-Barr virus-related hemophagocytic lymphohistiocytosis: a fatal pediatric case and literature review.

BACKGROUND

Green neutrophilic inclusions (GNIs) are rare cytoplasmic inclusions in peripheral blood smears, historically associated with acute liver failure and high mortality. Recent evidence suggests that GNIs may also occur in other critical illnesses; however, reports in pediatric populations remain scarce. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome, but GNIs have not been previously described in patients with HLH.

CASE PRESENTATION: We report a 9-year-and-5-month-old female with Epstein-Barr virus-related hemophagocytic lymphohistiocytosis (EBV-HLH) in whom GNIs were identified in peripheral blood neutrophils during her clinical course. The patient presented with persistent fever, progressive cytopenias, hyperferritinemia, hemophagocytosis on bone marrow aspirate, and markedly elevated cytokines. Despite intensive supportive care, including continuous renal replacement therapy and plasma exchange, her condition deteriorated rapidly. On hospital day 6, GNIs were identified in her peripheral blood neutrophils. She died of multiorgan dysfunction on hospital day 8.

CONCLUSION

This is the first report of GNIs in a patient with EBV-HLH. GNIs expand the clinical spectrum of EBV-HLH and may serve as an ominous prognostic marker in pediatric patients.