images in clinical medicine
The new england journal of medicine
n engl j med 368;17 nejm.org april 25, 2013
and a score of 4 on the Glasgow Coma Scale (eyes 1, verbal 2, motor 1; total scores
range from 3 to 15, with lower scores indicating reduced levels of consciousness).
He was intubated, resuscitated, and cooled. Laboratory tests showed a hemoglobin
level of 14 g per deciliter, a white-cell count of 13,700 per cubic millimeter (neutro-
phils, 8200 per cubic millimeter, with a myeloid left shift), and a platelet count of
172,000 per cubic millimeter. A blood film showed that 90% of neutrophils (Panels
A and B), 98% of monocytes (Panel C), and 22% of lymphocytes (Panel D) had un-
usual nuclear morphologic features. The nuclei showed hypersegmentation, with the
segments connected by thin filaments and arranged radially. These morphologic char-
acteristics have been previously described as botryoid nuclei. After obtaining a medi-
cal history and a drug screen, we gave the patient a diagnosis of methamphetamine-
induced hyperthermia. Botryoid white-cell nuclei are unusual and have been found in
patients with hyperthermia. Other causes of hyperthermia in such cases have in-
cluded heatstroke, hemorrhagic shock and encephalopathy syndrome, autoimmune
encephalitis, malignant hyperthermia of anesthesia, and cocaine overdose. The
patient had multiorgan failure and required treatment in the intensive care unit, but
he ultimately survived his acute illness and was discharged from the hospital.
26-year-old man was found unresponsive at work. When exam-
ined by emergency medical service responders, he had a temperature of
41.9°C, a heart rate of 150 beats per minute, unrecordable blood pressure,
Copyright © 2013 Massachusetts Medical Society.
Botryoid White-Cell Nuclei
Edward Chew, M.D.
Surender Juneja, M.D.
Royal Melbourne Hospital
Melbourne, VIC, Australia
The New England Journal of Medicine
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