Clin Chem Lab Med 2016; 54(8): e239–e242
Letter to the Editor
Antonio La Gioia*, Maria Bombara, Fabiana Fiorini, Mariachiara Dell’Amico,
Alessandra Devito, Patrizia Isola, Paola Marelli and Marcello Fiorini
Earlier detection of sepsis by Candida parapsilosis
using three-dimensional cytographic anomalies
on the Mindray BC-6800 hematological analyzer
DOI 10.1515/cclm-2015-1120
Received November 14, 2015; accepted December 9, 2015; previously
published online January 19, 2016
Keywords: BC-6800 hematological analyzer; Candida
­parapsilosis sepsis; phagocytosis.
To the Editor,
Candida parapsilosis sepsis is commonly caused by fungal
surface contamination of medical devices such as central
venous catheters [1].
In case of candidemia, an etiological treatment must
be started only after a positive blood culture.
As microbiological testing requires some days to be
fully performed and sepsis mortality is increased by any
delay in diagnosis and treatment, in some patients the
benefit of starting an early empiric antifungal treatment
based on the available clinical and laboratory data often
outweigh any other risk.
We describe the instrumental information provided
by the BC-6800 hematological analyzer in two cases of
bloodstream infections caused by C. parapsilosis.
Distinctive alterations in the 3D-DIFF cytograms
allowed us to suspect the presence of candidemia, thus
performing a prompt microscopic review that confirmed
the presence of circulating fungal pathogen. Therefore the
clinicians could start an empiric antifungal therapy long
before the blood culture results were available.
*Corresponding author: Antonio La Gioia, UO Patologia Clinica
Ospedale “F. Lotti” di Pontedera, via di Ripoli, 127, 56035 Casciana
Terme, Lari, Italy, E-mail: ant.lagioia@gmail.com; and UO Patologia
Clinica Ospedale “F. Lotti” di Pontedera, Azienda U.S.L. 5, Pisa
Fabiana Fiorini: UO Patologia Clinica Ospedale “F. Lotti” di
Pontedera, Azienda U.S.L. 5, Pisa, Lari, Italy
Maria Bombara, Mariachiara Dell’Amico, Alessandra Devito,
Patrizia Isola, Paola Marelli and Marcello Fiorini: UOC Medicina di
Laboratorio, ASL 6, Livorn, Italy
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The aim of this study is to evaluate the possible corre-
spondence between instrumental cytographic signals and
morphological observations in peripheral blood in case of
C. parapsilosis sepsis.
A complete blood count and white blood cell differen-
tials were performed on BC-6800 hematological analyzer
(Mindray, Shenzhen, China). In this analyzer, the circulat-
ing leukocytes as well as erythroblasts are evaluated by side
and forward laser scatter (SS and FS) and by fluorescence
(FL). The resulting three-dimensional (3D) scattergram can
be rotated to allow a detailed observation of cell popula-
tion clusters, their complexity, size and nucleic acids cell
content [2]. Microscopic review of May-­Grünwald-Giemsa
stained peripheral blood smears was performed by experi-
enced hematologists and microbiologist.
In the first case-study, P.C. was a 74-year-old female
affected by primary ovarian cancer, hospitalized for fever
and pneumonia. The patient had a central intravenous
catheter and was in poor general medical conditions.
The laboratory tests performed on peripheral blood were
consistent for leukocytosis (15.5 × 109/L; normal values
4.0–11.0) with neutrophilia (12.7 × 109/L; normal values
1.8–6.7), anemia (hemoglobin concentration 93.0 g/L;
normal values 114.0–150.0), elevated serum C-reactive
protein (11.60 mg/dL; normal values  < 0.50) and cancer
antigen CA125 (531.3 U/mL; normal values  < 35.0). Body
temperature was 38.7 °C.
In the second case-study, A.G., a 95-year-old female
patient, the clinical and laboratory information were
partial since the blood sample tubes were brought to
our lab by the home hospice care she was resident in.
The patient had a central intravenous catheter, like in
the first case-study. The laboratory results were consist-
ent for anaemia (HGB 85.0 g/L) and for moderate leuko-
cytosis (12.3 × 109/L) with neutrophilia (9.6 × 109/L). Serum
­C-reactive protein was not available.
Two distinct blood samples, one obtained through
the central venous catheter and the other from peripheral
e240      La Gioia et al.: Cytographic anomalies in case of sepsis by Candida parapsilosis

venipuncture, were simultaneously collected for each
patient. Microbiological cultures were performed whit
Bactec 9240 system (Becton Dickinson, USA). The catheters
tips were cultured on: chocolate, blood and ­MacConkey
agar plates. The study received formal approval by the
hospital board’s ethical committee and was carried out
in accordance with the Declaration of Helsinki under the
terms of all relevant local legislation.
The BC-6800 3D-DIFF cytogram (i.e. differential sepa-
ration of leukocytes) showed for both patients the neu-
trophils population subdivided in two clusters formed by
cells with normal and reduced complexity. An extension
toward the area of the immature granulocytes (IG) was
also present. When rotating the DIFF cytogram, both neu-
trophils clusters showed an extended flare along the FS
axis due to their increased cell size. Moreover, on the lower
face of the rotational 3D-cytogram cube (i.e. the “floor”),
an increased number of cell debris formed an even layer,
like a “blue carpet”. In the erythroblasts channel (NRBC) a
cell cluster showed a different shape and placement with
respect to the normal pattern (Figure 1).
The microscopic review performed on peripheral
blood smears displayed normal neutrophils as well as
the presence of a number of granulocytes engulfing one
or more Candida cells. Many of these showed cellular
autolysis and a deconstructed nuclear chromatin. IG as
well as NRBC were not found. Numerous Candida blasto-
spores and pseudo-hyphae were found outside of neu-
trophils (Figure 2). The microbial cultures performed on
venous central catheters as well as on both P.C. and A.G.
peripheral blood samples tested positive for C. ­parapsilosis
three days later.
It is well known that some infectious agents as plas-
modium or yeasts do interfere in automated blood cell
counts performed by hematology analyzers [3, 4]. The
overall effect on the accuracy of the automated count
depends both on the infectious agent and its concentra-
tion in blood as well as on the analyzer’s technology.
Detection of Candida sepsis by automated hematology
analyzers or by peripheral blood smear examination has
often been described as a quite uncommon finding, since
the threshold of yeast concentration detectable by the two
above-described methods usually ranges between 1–5 × 105
and 1–5 × 108 CFU/mL, respectively, which is rare to find in
clinical practice [4].
However, there are two main interferences that can
be observed and evaluated easily by the BC-6800 3D-DIFF
scattergram: the first is due to morphological changes in
neutrophils engulfed with yeasts, and the second is due
the presence of Candida bodies outside them.

Figure 1: Patient P.C. BC-6800 cytograms after a small right to left rotation.
On the left DIFF cytogram: the neutrophils cluster extends along SS and FL axes because the phagocytosis of Candida increase their size
(light blue cluster) and, respectively their nucleic acid content (gray cluster on the top). On the right NRBC cytogram: although the fuchsia
cluster is classified as an erythroblastic cluster, their shape and their positioning is different than normal. Based on the lower size, com-
plexity and nucleic content as well as on the absence of erythroblasts on peripheral blood smears, the fuchsia cluster could be formed by
blastospores of Candida outside of neutrophils.

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 La Gioia et al.: Cytographic anomalies in case of sepsis by Candida parapsilosis      e241

Figure 2: Peripheral blood smear.

MGG stain 1000 ×  magnification. On the left: phagocytic activity of a neutrophil engulfing five Candidas’ blastospores. The nucleous is
pushed to the periphery and cellular size is increased. On the right: blastospores outside of neutrophils (blue arrow). In some cases they
are surrended by destroyed cellular material (red arrow).

In our cases we were lucky enough to find both
extra- and intracellular Candida induced morphological
changes in 3D-DIFF cytograms on BC-6800. There seems
to be some correlation between instrumental changes
and microscopic features in peripheral blood smears.
Indeed, neutrophils phagocytosis of one or few Candida
may determine a cluster formed by cells with increased
size but normal internal complexity. On the opposite,
the phagocytosis of many Candida cells may cause in
neutrophils an increase in their nucleic acid content. As
a result of this, a variable amount of neutrophils may
have been falsely classified as immature granulocytes
(Figures 1 and 2). As for the two neutrophils clusters,
we can argue that the one with minor cell complexity
could be formed by damaged neuthrophils with cellular
autolysis and deconstructed nuclear chromatin. Simi-
larly, in the NRBC channel, Candida cells are ostensibly
identified as erythroblast by the instrument, but the
shape and position of this cluster is significantly differ-
ent with respect to the normal one. And as proof of that,
no erythroblast was found microscopically in peripheral
blood smears.
Candida infections are a relevant and increasing
problem in debilitated and immunosuppressed patients,
that can evolve from a superficial non-life-threatening
disease to a clinical picture of severe sepsis with multi-
organ dissemination, especially those of C. parapsilosis in
nosocomial settings.
An etiological diagnosis of catheter-related candi-
demia requires the yeasts isolation from both peripheral
and catheter blood samples and takes 3 or more days in
obtaining definite culture results, so the average time
before an etiological therapy can be administered usually
involves waiting more than 98.0 h, depending on the
species of Candida [5, 6].
Our observations suggest that in presence of Candida
sepsis, morphological changes induced in 3D-DIFF cyto-
grams on BC-6800 hematology analyzer may be related
with the pathophysiological events involved in the neutro-
philic phagocytic activity. Even if our experimental results
are in agreement with such theory, further observations
are needed to confirm these hypotheses.
Author contributions: All the authors have accepted
responsibility for the entire content of this submitted
manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played
no role in the study design; in the collection, analysis, and
interpretation of data; in the writing of the report; or in the
decision to submit the report for publication.
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e242      La Gioia et al.: Cytographic anomalies in case of sepsis by Candida parapsilosis

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