Blue–green cytoplasmic inclusions in monocytes – a rare indicator of fatal outcome in acute liver failure with Glucose-6-phosphate dehydrogenase deficiency

Blue–green cytoplasmic inclusions, also known as “death crystals,” are rare but prognostically significant findings in critically ill patients. We report a 27-year-old male with glucose-6-phosphate dehydrogenase deficiency who developed drug-induced hemolysis, progressing to acute fulminant liver failure and multiorgan dysfunction. Serial peripheral blood smears revealed dense blue–green cytoplasmic inclusions predominantly in monocytes during clinical deterioration. The presence and timing of these inclusions correlated with worsening systemic illness and poor outcomes. This case highlights the clinical relevance of peripheral blood smear examination as a low-cost tool for identifying rare morphological markers of advanced systemic injury and adverse prognosis.