# Flower shaped nuclei and blue-green inclusions in heatstroke

Emeline Tourret, Joévin Besombes

► To cite this version:

Emeline Tourret, Joévin Besombes. Flower shaped nuclei and blue-green inclusions in heatstroke. British Journal of Haematology, 2023, 204 (1), pp.7-8. 10.1111/bjh.19187. hal-04956361

HAL Id: hal-04956361

https://hal.science/hal-04956361v1

Submitted on 5 Mar 2025

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Distributed under a Creative Commons Attribution 4.0 International License
Flower shaped nuclei and blue-green inclusions in heatstroke

Emeline Tourret
Joévin Besombes

An 84-year-old woman was found unresponsive in her garden on a sunny July day. Her temperature was 40.6°C, heart rate was 138 beats per minute, and the Glasgow Coma Scale score was 3 (i.e. severe consciousness impairment). Full blood count revealed haemoglobin level of 136 g/L, white cell count of 7.4 x 10⁹/L and platelet count of 155 x 10⁹/L. Peripheral blood films displayed hypersegmented flower shaped nuclei, called botryoid nuclei, in 65% of neutrophils (A and B, 63x objective; Wright-Giemsa stain), 23% of monocytes (C and D) and 15% of lymphocytes (E). Toxicology screening ruled out drug abuse. After 16 hours, botryoid nuclei had disappeared on blood smears, but rare neutrophils (1%) exhibited critical blue-green inclusions ("green crystals of death", F). The patient's condition rapidly deteriorated, and she died 3 days after admission.

Botryoid nuclei are a consequence of hyperthermia and especially heatstroke, often associated to drug abuse, which was not found in our case. Their precise pathogenesis remains poorly understood but they might indicate early-stage apoptosis. This abnormality is most commonly seen in eutrophils but can also affect monocytes and lymphocytes. Botryoid nuclei should not be confused with other pathological conditions in which nuclear hypersegmentation may be seen, such as megaloblastic anaemia or, less commonly, dysmyelopoiesis. In megaloblastic anaemia, nuclei are hypersegmented (more than 6 lobes) but do not have this typical flower shape and are often accompanied by macroovalocytes. In dysmyelopoiesis, neutrophil nuclei may appear hypersegmented with chromatin condensation defects and degranulation. In our case, the patient presented with multiple organ dysfunction syndrome secondary to heatstroke, which could explain the blue-green inclusions in neutrophils. These inclusions have been identified in acute liver failure and are thought to be derived from lipofuscin. Their presence should alert clinicians to the increased risk of mortality in these patients.

The authors thank the Anipath histology platform (GRED Institute, Clermont-Ferrand) for providing
the imaging equipment.

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A

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B

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C

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D

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E

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F