Ann Hematol DOI 10.1007/s00277-015-2375-2
LETTER TO THE EDITOR
Fulminant pneumococcal bacteraemia revealed by automated digital cell morphology analysis (CellaVision DM96) Maite Serrando i Querol 1 & Cristian Morales-Indiano 2 & Anna Marull i Arnall 1 & Patricia Tejerina Fontaíña 1 & Esperanza Tuset Andujar 3
Received: 20 March 2015 / Accepted: 1 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor, Streptococcus pneumoniae is a common bacterial pathogen in developed countries and is one of the major causes of infection-related death [1, 2]. The severity of pneumococcal infections depends on different pathophysiological conditions (self-limiting mucosal infections, non-invasive pneumonia, invasive disease like bacteraemia and meningitis). The community-acquired pneumonia (CAP) is the main disease related to S. pneumoniae disease. Patients infected with this agent have a greater risk of in-hospital death [3]. Although identifying bacteria on a peripheral blood (PB) smear is a rare finding, this analysis is especially useful for diagnosing some infectious diseases like babesiosis or trypanosomiasis [4, 5]. When it is present, it can lead to an earlier diagnosis before any blood cultures become positive [6, 7]. Manual microscopy is labour intensive and may be subject to differences depending on the observer. CellaVision DM96 is an automated system that acquires digital images of peripheral blood smears; it pre-classifies the cell type and shows red blood cell images on screen [8]. CellaVision DM96
* Cristian Morales-Indiano [email protected] 1
Department of Clinical Laboratory, Hospital Doctor Josep Trueta, Girona, Spain
2
Department of Clinical Laboratory, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain
3
Department of Haematology Laboratory; Institut Català Oncologia (ICO), Hospital Doctor Josep Trueta, Girona, Spain
allows measurement of urgent samples providing early information that can be critical in these kinds of disease. The patient had been splenectomized for a benign tumor of the spleen 14 years ago. He had not been vaccinated. Clinical work-up revealed fever (40 °C), cold skin, cyanosis and hypotension (75/55 mmHg). Arterial blood gas analysis demonstrated severe acidosis (pH 7.09; Lactate:86 mg/dL). Chest Xray was normal. Laboratory tests showed haemoglobin of 15 g/dL, white cell count of 6.88×109/L (left shift was present) and platelet count of 58×109/L. The D-Dimer value was high (11,114 ng/mL) being compatible with a disseminated intravascular coagulation. PB film was stained with MayGrünwald Giemsa and processed with CellaVision DM96 system. The digital images showed intracellular aggregates which seemed to be diplococcic (Fig. 1a). The Gram PB smear was processed as well with digital microscopy obtaining images that suggested Grampositive diplococci in neutrophils in keeping with bacteraemia and sepsis (Fig. 1b). Blood cultures revealed S. pneumoniae growth with penicillin resistance and low minimal inhibitory concentration of second/ third generation cephalosporins. Three days after admission, the patient suffered multiorgan failure and died. The presence of bacteria on PB smears is a rare but extreme situation related in most instances to a fatal prognosis [9, 10]. The microscopical analysis of the PB smear observation is essential in these infectious disease suspects. Automated digital cell morphology analysis is a good tool that allows a quick overall morphological analysis and can detect microorganisms in PB films contributing to an early diagnosis. Primary diagnosis of infectious disease is uncommonly made
Ann Hematol Fig. 1 Digital images (CellaVision) of blood smear with diplococci into neutrophils. a May-Grünwald Giemsa stain and b Gram stain
from morphologic examination of a blood smear, although knowledge of the distinctive morphologic features of various organisms may contribute to an early recognition and diagnosis of several infections. Furthermore, nonspecific manifestations of infection may provide an important clue in guiding a further diagnostic work-up [11, 12].
4.
5.
6. 7.
Conflicts of interest declare.
The authors have no conflicts of interest to
8.
References 9. 1.
2. 3.
Blot M, Croisier D, Péchinot A, Vagner A, Putot A, Fillion A, Baudouin N, Quenot JP, Charles PE, Bonniaud P, Chavanet P, Piroth L (2014) A leukocyte score to improve clinical outcome predictions in bacteremic pneumococcal pneumonia in adults. Open Forum Infect Dis 1(2):ofu075 Polverino E, Torres MA (2011) Community-acquired pneumonia. Minerva Anestesiol 77(2):196–211 Saraceni C, Schwed-Lustgarten D (2013) Pneumococcal sepsisinduced purpura fulminans in an asplenic adult patient without disseminated intravascular coagulation. Am J Med Sci 346(6):514–516
10.
11. 12.
Blevins SM, Greenfield RA, Bronze MS (2008) Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med 75(7):521–530 Racsa LD, Gander RM, Southern PM, TeKippe E, Doern C, Luus H (2015) Detection of intracellular parasites by use of the CellaVision DM96 analyzer during routine screening of peripheral blood smears. J Clin Microbiol 53(1):167–171 Lancashire J, Crowther M (2012) Blood smear: Fulminant pneumococcal bacteremia. Blood 120(23):4459 Iinuma Y, Hirose Y, Tanaka T, Kumagai K, Miyajima M, Sekiguchi H, Nomoto Y, Yabe M, Imai Y, Yamazaki Y (2007) Rapidly progressive fatal pneumococcal sepsis in adults: a report of two cases. J Infect Chemother 13(5):346–349 Lee LH, Mansoor A, Wood B, Nelson H, Higa D, Naugler C (2013) Performance of CellaVision DM96 in leukocyte classification. J Pathol Inform 4:14 Gérard J, Lebas E, Godon A, Blanchet O, Geneviève F, Mercat A, Zandecki M (2007) Free and intracellular bacteria on peripheral blood smears: an uncommon situation related to an adverse prognosis. Ann Biol Clin 65(1):87–91 Posner MR, Berk SL, Rice PA (1978) Pneumococcal bacteremia diagnosed by peripheral blood smear in multiple myeloma. Arch Intern Med 138(11):1720–1721 Carpenter CT, Kaiser AB (1997) Purpura fulminans in pneumococcal sepsis: case report and review. Scand J Infect Dis 29(5):479–483 Kroft SH (2002) Infectious diseases manifested in the peripheral blood. Clin Lab Med 22(1):253–277
LETTER TO THE EDITOR
Fulminant pneumococcal bacteraemia revealed by automated digital cell morphology analysis (CellaVision DM96) Maite Serrando i Querol 1 & Cristian Morales-Indiano 2 & Anna Marull i Arnall 1 & Patricia Tejerina Fontaíña 1 & Esperanza Tuset Andujar 3
Received: 20 March 2015 / Accepted: 1 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor, Streptococcus pneumoniae is a common bacterial pathogen in developed countries and is one of the major causes of infection-related death [1, 2]. The severity of pneumococcal infections depends on different pathophysiological conditions (self-limiting mucosal infections, non-invasive pneumonia, invasive disease like bacteraemia and meningitis). The community-acquired pneumonia (CAP) is the main disease related to S. pneumoniae disease. Patients infected with this agent have a greater risk of in-hospital death [3]. Although identifying bacteria on a peripheral blood (PB) smear is a rare finding, this analysis is especially useful for diagnosing some infectious diseases like babesiosis or trypanosomiasis [4, 5]. When it is present, it can lead to an earlier diagnosis before any blood cultures become positive [6, 7]. Manual microscopy is labour intensive and may be subject to differences depending on the observer. CellaVision DM96 is an automated system that acquires digital images of peripheral blood smears; it pre-classifies the cell type and shows red blood cell images on screen [8]. CellaVision DM96
* Cristian Morales-Indiano [email protected] 1
Department of Clinical Laboratory, Hospital Doctor Josep Trueta, Girona, Spain
2
Department of Clinical Laboratory, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain
3
Department of Haematology Laboratory; Institut Català Oncologia (ICO), Hospital Doctor Josep Trueta, Girona, Spain
allows measurement of urgent samples providing early information that can be critical in these kinds of disease. The patient had been splenectomized for a benign tumor of the spleen 14 years ago. He had not been vaccinated. Clinical work-up revealed fever (40 °C), cold skin, cyanosis and hypotension (75/55 mmHg). Arterial blood gas analysis demonstrated severe acidosis (pH 7.09; Lactate:86 mg/dL). Chest Xray was normal. Laboratory tests showed haemoglobin of 15 g/dL, white cell count of 6.88×109/L (left shift was present) and platelet count of 58×109/L. The D-Dimer value was high (11,114 ng/mL) being compatible with a disseminated intravascular coagulation. PB film was stained with MayGrünwald Giemsa and processed with CellaVision DM96 system. The digital images showed intracellular aggregates which seemed to be diplococcic (Fig. 1a). The Gram PB smear was processed as well with digital microscopy obtaining images that suggested Grampositive diplococci in neutrophils in keeping with bacteraemia and sepsis (Fig. 1b). Blood cultures revealed S. pneumoniae growth with penicillin resistance and low minimal inhibitory concentration of second/ third generation cephalosporins. Three days after admission, the patient suffered multiorgan failure and died. The presence of bacteria on PB smears is a rare but extreme situation related in most instances to a fatal prognosis [9, 10]. The microscopical analysis of the PB smear observation is essential in these infectious disease suspects. Automated digital cell morphology analysis is a good tool that allows a quick overall morphological analysis and can detect microorganisms in PB films contributing to an early diagnosis. Primary diagnosis of infectious disease is uncommonly made
Ann Hematol Fig. 1 Digital images (CellaVision) of blood smear with diplococci into neutrophils. a May-Grünwald Giemsa stain and b Gram stain
from morphologic examination of a blood smear, although knowledge of the distinctive morphologic features of various organisms may contribute to an early recognition and diagnosis of several infections. Furthermore, nonspecific manifestations of infection may provide an important clue in guiding a further diagnostic work-up [11, 12].
4.
5.
6. 7.
Conflicts of interest declare.
The authors have no conflicts of interest to
8.
References 9. 1.
2. 3.
Blot M, Croisier D, Péchinot A, Vagner A, Putot A, Fillion A, Baudouin N, Quenot JP, Charles PE, Bonniaud P, Chavanet P, Piroth L (2014) A leukocyte score to improve clinical outcome predictions in bacteremic pneumococcal pneumonia in adults. Open Forum Infect Dis 1(2):ofu075 Polverino E, Torres MA (2011) Community-acquired pneumonia. Minerva Anestesiol 77(2):196–211 Saraceni C, Schwed-Lustgarten D (2013) Pneumococcal sepsisinduced purpura fulminans in an asplenic adult patient without disseminated intravascular coagulation. Am J Med Sci 346(6):514–516
10.
11. 12.
Blevins SM, Greenfield RA, Bronze MS (2008) Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med 75(7):521–530 Racsa LD, Gander RM, Southern PM, TeKippe E, Doern C, Luus H (2015) Detection of intracellular parasites by use of the CellaVision DM96 analyzer during routine screening of peripheral blood smears. J Clin Microbiol 53(1):167–171 Lancashire J, Crowther M (2012) Blood smear: Fulminant pneumococcal bacteremia. Blood 120(23):4459 Iinuma Y, Hirose Y, Tanaka T, Kumagai K, Miyajima M, Sekiguchi H, Nomoto Y, Yabe M, Imai Y, Yamazaki Y (2007) Rapidly progressive fatal pneumococcal sepsis in adults: a report of two cases. J Infect Chemother 13(5):346–349 Lee LH, Mansoor A, Wood B, Nelson H, Higa D, Naugler C (2013) Performance of CellaVision DM96 in leukocyte classification. J Pathol Inform 4:14 Gérard J, Lebas E, Godon A, Blanchet O, Geneviève F, Mercat A, Zandecki M (2007) Free and intracellular bacteria on peripheral blood smears: an uncommon situation related to an adverse prognosis. Ann Biol Clin 65(1):87–91 Posner MR, Berk SL, Rice PA (1978) Pneumococcal bacteremia diagnosed by peripheral blood smear in multiple myeloma. Arch Intern Med 138(11):1720–1721 Carpenter CT, Kaiser AB (1997) Purpura fulminans in pneumococcal sepsis: case report and review. Scand J Infect Dis 29(5):479–483 Kroft SH (2002) Infectious diseases manifested in the peripheral blood. Clin Lab Med 22(1):253–277
