INVESTIGATIONS
A brain computed tomography (CT) revealed diffuse swelling. A contrast-enhanced CT scan of the chest showed marked enlargement of the right-sided heart, patchy ground-glass appearance in the bilateral lung field, and consolidation in the S6 region of the right lung. However, there was no thrombus in the pulmonary artery. Petechiae were prominent on his skin of the anterior thorax, and his blood test disclosed thrombocytopenia with a platelet count of 75 × 103/μl, anaemia with a haemoglobin level of 7.5 g/dl and coagulopathy with an activated partial thromboplastin time of 79.6 (reference range: 25-35) s, prothrombin time-international normalized ratio of 2.31 and d-dimer level of 73.7 μg/ml.
Based on all these findings, we made a diagnosis of FES according to Gurd and Wilson criteria2. Retrospectively, we examined fat globules in peripheral blood by Giemsa staining using his whole blood samples preserved in our laboratory. Our findings showed a few white round bodies representing fat globules in blood in the sample collected on the 4th day (Figure 1a.). However, the number of fat globules with various sizes increased dramatically after the first collapse on the 6th day (Figure 1b.). Thereafter, they almost disappeared from the sample collected on the 7th day (Figure 1c.) but again increased in the sample collected 1 h before the cardiac arrest on the 8th day (Figure 1d.); all these findings corresponded to his clinical deterioration. Using fat-specific Sudan Black staining, we further confirmed that the white round bodies were definitely fat globules (Figure 1e.). Figure 2 shows serial changes of fraction of the area occupied by fat globules in microscopic fields shown as Figure 1a-d.