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Sally Mandour: Can a Blood Smear Diagnose Heatstroke?

Sally Mandour/LinkedIn

Aug 2, 2026, 06:26

Sally Mandour: Can a Blood Smear Diagnose Heatstroke?

Sally Mandour, Associate Professor, Head of Hematology Unit at Clinical Pathology Department of National Liver Institute, Monofeya University, shared a post on LinkedIn:

“Interesting EHA Learning case:

A 68-year-old cyclist with cardiovascular risk factors is brought to the Emergency Room.

He is in cardiopulmonary arrest without pulse after having been found lying on the ground by a 20-meter cliff edge, with multiple burn-like lesions, a Glasgow Coma Scale score of 3 points and fever.

An initial venous blood gas shows severe metabolic acidosis with hyperlacticaemia of 8 mmol/L.

Blood cell counts revealed leukocytosis of 17.96 x10⁹/L with 9.34 x10⁹/L neutrophils and 6.11 x10⁹/L lymphocytes, with normal hemoglobin (143 g/L) and platelet (214 x10⁹/L) counts.

Biochemical tests show multiorgan failure. The peripheral blood smear findings are shown in the picture.

What is the most likely diagnosis?

Vitamin B12 or folate deficiency
Myelodysplastic syndrome
Ethanol overdose
Heatstroke

Answer is Heat stroke

Cells depicted are neutrophils (A-D), lymphocytes (E) and monocytes (F) with botryoid nuclei, characterized by hypersegmented nuclei with a radial arrangement.

These were first seen in 1980 in six patients with heatstroke and were named after the Greek term ‘botrys,’ which translates onto ‘bunch of grapes’ because of their resemblance.

Since then, they have been described in other conditions causing severe hyperthermia, such as cocaine and methamphetamine abuse, autoimmune limbic encephalitis, sepsis, drug rash with eosinophilia and systemic symptoms (DRESS) and neuroleptic malignant syndrome.

These nuclear changes have been hypothesized to be early stages of oncotic (karyolysis) and apoptotic (karyorhexis and pyknosis) cell death because of extreme heat.” Sally Mandour: Can a Blood Smear Diagnose Heatstroke?