1 case of hyperthermia-cold hemoglobinuria patients with peripheral blood smears of granulocytes and single-core cells

There are many reasons for swallowing blood cells in bone marrow morphological tests, and there are more types of cells that are swallowedHowever, the appearance of peripheral blood medium granulocytes, mononucleocygolate red blood cells is a very rare phenomenonIn the bed work, the author found 1 exception of the weekly blood middle granulocytes, mononucleic cells to eat red blood cells phenomenon, is reported as follows1 clinical datapatient, female, 78-year-old farmerMain complaint: intermittent fever for 1 month, plus heavy limb pumping 1d into Shahe City People's HospitalThe patient had no obvious cause of intermittent fever and body temperature of 380 degrees C, no obvious cough cough sputum, chest pain, unconscious disorder, repeated seizures, in the local infusion treatment, symptoms no significant improvement, 1d before the patient appeared limb pumping obvious, still fever, body temperature in 38At about 5 degrees C, ask no answer, there have been urinating incontinence, poor, fatigue, for further diagnosis and treatment on April 11, 2019 into the Shahe City People's HospitalCT examination: the skull sweeps the elderly brain flat, the lungs sweep the small nodules on the upper leaves of the right lung, the enlarged lymph nodes of the lobe and the armpitsA small amount of fluid in the two-sided chest cavityUpper and lower abdominal spleen CT flat sweep: spleen slightly larger, colon dilating gas, gallbladder largeB super display: two-tip valve off incomplete (light), three-tip flap off incomplete (light, double renal cortex echo enhancementThe gallbladder is larger than normalPatients considerdiagnosis are: (1) multiple organ failure; (2) lung infection ; (3) hypertension 3, high risk; (4) electrolyte disorder, hyponatremia, hypochloremia; (5) abnormal liver function; (6) abnormal kidney function; (7) hypothermia; (8) Parkinson's disease After admission to give oxygen absorption, CCJ monitoring, to the pyrethlintazine batan, hot toxicnin, but also prototype glutathione to fight infection, liver protection, support for the disease and other comprehensive treatment, hospital 1d, the patient is in critical condition, should continue to be hospitalized, to tell him that discharge may be at any time death, but the persuasion is not effective, the patient's family insisted on discharge 2 laboratory examination white blood cells 21 83 x 10 9/L, red blood cell 2 74 x 1012/L, hemoglobin 89g/L, neutrophils percentage 84 90%, platelets 160 x 10 9/L, net red blood cells 0 006, potassium ion 3 94mmol /L, sodium ion 125 3mmol /L, chloride ion 86 60 mmol /L, calcium ion s2 30 mmol /L, total egg white 67 34g/L, egg white 26 19g/L, egg white 48 29g/L, protein-globulin ratio is 0 54, total bilirubin 53 49 smol/L, direct bilirubin 21 41 smol /L, indirect bilirubin 32 08 smol /L, alanine amino transferase 17 85U/L, Tianmen Dinine amino transferase 216 50U/L, glutamate amine transferase 41 60U/L, alkaline phosphatase 170 13 U/L, urea nitrogen 14 58 mmol /L, creatine 251 11 smol /L, autoantibodies (anti-nuclear antibodies, anti-U1RBNP/anti-Sm, anti-Sm, anti-SSA, SSB, anti-Sc1-70, anti-Jo-1, anti-ribosome P egg White) negative, syphilis spiral (syphilis screw-specific antibody qualitative test, syphilis luxamine red non-heating test semi-quantitative) are negative, anti-human ball egg white test card test direct resistance test and free, release test are positive The results of blood cell count trigger editthele rules of blood analyzers, and then blood smear staining mirrors can detect the phenomenon of neutrophil sacphyding red blood cells (Figure 1A-C) and single-core cells gobbling red blood cells (Figure 1D) And can be seen red blood cells vary in size or into serrated red cells, spherical red blood cells Note: A-C indicates the phenomenon of middle granulocytes swallowing red blood cells, and D for single-core cells eating red blood cells Figure 1 Blood smear staining mirror test results (4 x 100) 3 the patient showed positive signs such as poor blood, jaundice, slightly largeer spleen, serum appearance is brownred, urine is soy sauce color, anti-human globulin test direct anti-test and free, release test are positive, suggesting that the patient may be self-
immune hemolytic anemia (AIHA) Serum total bilirubin, direct bilirubin, indirect bilirubin is the detection index of high bilirubinemia, although according to the 8th edition of Diagnostics provided by hemolytic jaundice, direct bilirubin/ indirect bilirubin ratio of 20%, total bilirubin general s85 00 smol /L, but supports a patient as AIHA according to the literature, and mature red blood cell size and morphology also support a diagnosis of AIHA AIHA is anthropostatic anemia caused by autoantibodies of red blood cell membrane components, which are classified as warm antibody type and cold antibody type according to the most appropriate temperature of antibody reaction, which is divided into condensation syndrome and burst cold hemoglobinuria (PCH) According to the literature, the most likely diagnosis for this case is PCH PCH is a rare cold-reactive autoantibodies in AIHA immuno
hemolytic anemia characterized by a large number of blood vessels intravascular and blood-red egg white urine that occurs suddenly after a total or local cold Neutral granulocytes have been reported as a prominent feature of PCH, and studies have clarified the immune mechanism of mid-granulocytes and mononucleosis of red blood cells, the most common of which is PCH It should be noted that most of the literature refers to the increase of net-woven red blood cells in patients during hemolytic blood, as one of the test items for the diagnosis of hemolytic blood In this case, the percentage of net-woven red blood cells is normal, and the cause may be chronic kidney disease In this case, urea nitrogen and creatinine both increased, suggesting that the accumulation of chronic kidney disease caused substantial damage to the patient's kidneys, resulting in a reduction in the production of red blood cell production in the patient, mesh red blood cell rise is not obvious or not elevated According to the literature, observing the phenomenon of mid-sex granulocytes devouring red blood cells can provide diagnostic clues to PCH and improve the accuracy of diagnosis At the same time, it is recommended that blood routine testing, do not rely on blood analyzers, in the test results trigger the retest rules, should be timely blood smear examination, to prevent missed and misdiagnosis, improve the accuracy and compliance rate of routine blood testing references