Acquired Pelger-Huët anomaly associated with ibuprofen therapy.

Pelger–Huët anomaly (PHA) is a benign inherited condition characterized by hyposegmentation of the neutrophils nucleus and excessive chromatin clumping [1]. An acquired neutrophils dysplasia similar to PHA has been already described in hematological diseases [2,3] and in some clinical conditions, especially under certain drugs effect [4–9]. It has been known as acquired or pseudo Pelger–Huët anomaly. A previous report of our group showed that the incidence of acquired PHA in kidney transplanted patients under immunosuppressive therapy in a local BrazilianHospitalwas 5.3% (9 out of 170 patients) [10]. In March 2008, a healthy 7-year old child was punctioned in a small laboratory in Mateus Leme/MG for a routine hemogram analysis. Her blood cells showed to be normal under quantitative and qualitative points of view. Two months later, this child had fever, without other symptoms and 17 drops of ibuprofen was given to her, from 4 to 4 h during 1 day and night. Next day, as the girl's condition became worse, she was conducted to the same laboratory for another routine blood analysis. This dose (510 mg/24 h) was >12 times higher than that recommended (40 mg/24 h). The leukocytes count was 12,500/μL with 22% band form neutrophils, 50% segmented neutrophils, 20% lymphocytes and 8% monocytes, erythrocyte sedimentation rate (60 min.) was 6 mm and Reactive C Protein was negative. However, blood film revealed that segmented neutrophils nucleus had a poor segmentation, with only bilobular nuclear form or peanut shaped and the chromatin was excessively clumped (Fig. 1 a, b, c and d). Later on a more experienced observer has diagnosed the child as a carrier of PHA. Since there was a normal blood analysis reported 2 months ago, the hypothesis of benign inherited PHA was discharged. The apparent neutrophils' shift left (22% band forms) was not coherent with the child's symptoms, she only had fever once,with no infection symptoms. Five days later, a new blood analysis was done and the total leukocytes were 5300/μL persisting 21% of band neutrophils. Six months later, the child had fever again and other blood analysis was required. The leukocytes count was 17,700/μL and 5% band neutrophils (without alterations), 54% segmented neutrophils, 32% lymphocytes, 2% monocytes and 7% eosinophils (Fig. 1e) was found, which confirm the transitory character of neutrophil abnormalities observed when the child was under ibuprofen use. All data are shown in Table 1. It was not suspected that this case of transitory neutrophil abnormalities was caused by ibuprofen, since it was the only drug that the child had received. Only one report on ibuprofen use and pseudo PHA has previously been described [11]. Although some hypotheses were raised to explain this phenomen, themechanism of nuclear change is still unclear. Thefirst hyphothesis is related to abnormalities in the sequence of lamin B receptor (LBR) gene resulting in a lack of LBR protein. This protein is essential for chromatin binding to nuclear membrane. In the absence of LBR, neutrophils and also erythroblasts, monocytes, lymphocytes, plasma cells, eosinophils