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Green refractile inclusions in neutrophils are a very rare peripheral smear finding with few reported cases in literature. They were thought to be a marker of impending death with a very high mortality rate in the immediate hospitalization period. They were often seen in critically ill patients and often related to liver injury. Clinical and pathophysiologic characterizations of these inclusions are limited due to the rarity of this finding. We describe the case of a 42-year-old woman with tuberous sclerosis and recent renal transplantation who was critically ill due to pneumonia and had elevation of liver enzymes. She was found to have green refractile inclusions on peripheral blood smear on the third day of hospitalization. The patient improved rapidly with treatment and was discharged in 5 days. It appears that prognostic value of these inclusion bodies is doubtful. We also highlight the need to conduct further studies to clarify the link between hepatic injury and the presence of these inclusions.

This case illustrates the diagnostic and therapeutic challenges posed by neoplasms with plasmablastic features. Even though differentiating between plasmablastic lymphoma (PL) and plasma cell neoplasms can be difficult and somewhat arbitrary, the implications for the therapeutic regimen are significant. In this case, the lesion was identified in the nasal cavity of a previously healthy 37-year-old man, HIV negative. While the neoplasm had all the features of PL, including positivity for Epstein–Barr virus, it also showed sheets of monotypic kappa cells alternating with sheets of monotypic lambda cells. Molecular studies showed a population with clonally rearranged IGH and peaks corresponding to IGK VJ and IGK VKdel. The patient was treated with 3 cycles of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone, with excellent results. The patient is free of disease more than 20 months later. In the absence of randomized trials investigating the effectiveness of therapeutic protocols for PL, currently aggressive regimens are recommended. This case shows that at least in a subset of the patients with PL, a less aggressive approach may be considered. It is also the first case of PL expressing both light chains.