This is a good example of how the differential plots must be reviewed when interpreting Full Blood Count results.
The X axis on the Sysmex XNs shows an increase in cell complexity from left to right ( i.e granules and nuclear lobulation). Eosinophils are therefore far right because of their heavy granulation and nuclear lobulation and neutrophils are just left of these. The monocytes are to the left of the neutrophils as they are less complex , but higher up on the Y axis due to an increased DNA/ RNA content. Lymphocytes are far left.
Look at this plot. The neutrophil population is partly too far left illustrating that whatever these cells are, they are far less complex. My thinking was that there could be dysplasia, either dysplastic nuclei or hypogranular neutrophils which both make the neutrophils less complex and therefore appear left of the expected plot position.
The blood film did indeed show some hypogranular netrophils. Other neutrophils however showed toxic granulation The clinical details were bilary sepsis so features of infection/ inflammation would be consistent
Reading up on the mechanism behind neutrophils lacking granules, it could be defective granule formation or excessive degranulation during development.
The significance of this feature could be that this is a myelodysplasia or myeloproliferative disorder.
The Full Blood Count results were not remarkable and the film would not have been made if the plot wasn't viewed. Therefore very important!