Neutrophils and monocytes with enlarged azurophilic granules resembling toxic changes in mucopolysaccharidosis type VI.
A 2-year-old girl had a history of macrocephaly and short stature. Examination revealed camptodactyly and stiffness in the elbow and knee joints. Skeletal examination showed a J-shaped sella turcica and multiple dysostosis multiplex rings, indicative of a metabolic genetic disease. Review of the peripheral blood smear showed normal numbers of granulocytes (top panel, ×100 objective and ×1000 total magnification) and monocytes (bottom panel, ×100 objective and ×1000 total magnification) with enlarged coarse azurophilic granules resembling toxic granulations. Additional testing showed low arylsulfatase B (ARSB) activity in leukocytes and elevated urinary glycosaminoglycans (GAG), consistent with mucopolysaccharidosis type VI (MPS VI). Genetic testing revealed 2 pathogenic variants, c.1449A>T. MPS VI is a rare autosomal recessive metabolic disorder caused by mutations in the ARSB gene, leading to a deficiency of the lysosomal enzyme ARSB, which is part of the GAG breakdown process in lysosomes. Onset and clinical manifestations can vary widely. Symptoms include decreased growth rate, coarse facial features, skeletal deformities, frequent upper respiratory tract infections, hearing loss, joint stiffness, cardiac valve abnormalities, spinal cord compression, and hepatosplenomegaly. This case highlights the association of toxic granulation-like changes in MPS VI, affecting all granulocytes and monocytes.
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