Sepsis - Bactaraemia in a patient on intensive care

This patient is on intensive care with severe sepsis. There are changes throughout the myeloid series reflecting this. The neutrophils are left shifted with circulating myeloid precursors. Overall, the picture is leucoerythroblastic with nucleared red blood cells present.. The other white cells are also reactive - including monocytes and lymphocytes.

The red cells show some evidence of organ dysfunction with frequent stomatocytes which fits with the clinical picture of a patient on ITU. Stomatocytes and anisocytosis in this context are seen most frequently with liver impairment and to a lesser degree with renal impairment. 

The neutrophils show toxic granulation but we can't see any intracellular bacteria - this is important to look for as if they are present then this confirms bacteraemia. Intracellular diplococci can occsionally be seen in neisseria septicaemia (see slide CW034 for an example of this). There are some apoptotic neutrophils. Some morphology texts suggest these are suggestive of EBV infection, however they are seen in any patient where the neutrophils are highly activated. It is true that the presence of frequent apoptoci neutrophils in the absence of other rective change would suggest a viral infection, particularly EBV.

Platelets are increased as part of a reactive picture, and there are also occasional clumps. This is relevant if the patient develops thrombocytopenia as the platelet count may be underestimated.