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J. clin. Path. (1955), 8, 324.

DHLE BODIES IN THE LEUCOCYTES OF PATIENTS


WITH BURNS
BY
W. WEINER AND ELIZABETH TOPLEY
From the Birmingham Regional Blood Transfusin Service and the Medical Research Council Industrial
Injuries and Burns Research Unit, Birmingham Accident Hospital

(RECEIVED FOR PUBLICATION APRIL 20, 1955)

When working in a hospital for infectious described by Kolmer (1912) in a case of scarlet
diseases, Dhle (1911, 1912a and b) noticed round, fever complicating burns.
blue-staining bodies in the cytoplasm of neutrophil The more modern staining techniques have so
leucocytes of patients suffering from scarlet fever. far added little to what Dhle clearly described.
As these bodies were occasionally reminiscent of The bodies (Fig. 1) are usually round or oval
spirochaetes, Dhle first assumed them to be the shaped and have a diameter from just visible size
cause of scarlet fever. This is not surprising if one to approximately 1 to 2 p. They are found most
remembers that only a short time before a spiro- often at the periphery of the cell. With Leishman-
chaete had been discovered as the cause of syphilis. Giemsa, or any other of the usual Romanowsky
However, the same bodies, which carne to be stains, they are a sky blue to grey blue colour and
known as Dhle bodies, were observed also in are easily distinguished from the pinkish stained
erysipelas (Kolmer, 1912 ; MacEwen, 1913-14), in cytoplasm of the neutrophil leucocytes. Some of the
diphtheria on about the third day (Kolmer, 1912), cells contain one Dhle body, others may contain
in typhus (MacEwen, 1913-14 ; Rehder, 1942), and up to three or even four. They are always discrete
possibly in tuberculosis (Bachman and Lucke, and clearly separated by normal stained cytoplasm.
1918). In measles Kolmer (1912) found them Their staining properties, shape, and position in
absent, while MacEwen (1913-14)-considered their the cell distinguish them clearly from normal or
presence in 12 out of 35 cases as possibly asso- pathological granulation occurring in neutrophil
ciated with oral sepsis. Dhle bodies were leucocytes.
The discovery of Dhle bodies in the neutrophil
leucocytes of patients with burns was due to a
chance observation when a blood film from a
patient was examined for a quite different reason.
In view of this finding, repeated blood films were
taken from patients with burns of different severity
in order to ascertain the frequency and timing of
their occurrence and any possible association
between the presence of Dhle bodies and other
features such as the size of the burn, bacterial
colonization, anaemia, or leucocytosis.

Material and Methods


Blood films were taken from 19 consecutive patients
admitted to the Burns Unit of the Birmingham Acci-
dent Hospital between June 29 and August 15, 1953,
and from nine patients with burns involving more than
13% of the body surface admitted later. Numerous
cases have been investigated since then, but are not
included in Tables I and II.
Blood films were prepared from capillary blood in
Doble bodies the usual way about three times a week for the first
FIG. 1.A blood film from a patient suffering from burns. three weeks and then weekly. They were stained by
DOHLE BODIES IN LEUCOCYTES OF PATIENTS WITH BURNS

325

Leishman-Giemsa. To avoid bias one of us was re- excised on the day of admission, and the grafts
sponsible for the collection of the clinical data and took almost perfectly. No Dhle bodies appeared
for the making of the films. The films were coded in the leucocytes of these patients.
with serial numbers and examined by the other Inspection of Table I also suggests that there is
without knowledge of the origin of the film. At the
end of the investigations the results were compared. a relationship between the incidence of Dhle
Differential counts of at least 300 white cells were bodies, pyrexia, bacterial colonization, and mor-
performed on a number of films. All other films were tality. A direct association between the area of
carefully examined for the presence of Dhle bodies. the burn and such clinical and pathological find-
Structures found in the cytoplasm of the cells were ings is already well recognized. This means that
counted as Dhle bodies, only if they conformed fully in order to seek for a positive association between
with all the characteristics given in the introduction. Dhle bodies and a certain pathological finding,
No note was made of their single or mltiple occur- e.g., bacterial colonization, it is necessary to allow
rence in one or the same cell. for the severity of the burn. The present evidence
Results shows that Dhle bodies are more common in
Of the 19 consecutive patients admitted between more extensive burns.
the dates given above, 11 showed Dhle bodies at Dhle bodies have been found in patients whose
some time after their admission. The clinical burns were not colonized by group A streptococci,
details of these cases are shown in Table I. Of coagulase-positive staphylococci, coliform bacilli,
the 14 burns patients with 2% or less full-thickness or Ps. pyocyanea, and in patients who had not
skin loss, only six showed Dhle bodies: all received any blood transfusions, plasma, or dex-
five patients with more than 2% full-thickness tran. None of these factors alone would therefore
skin loss showed Dhle bodies. Table I also in- appear to be essential by itself for the appearance
cludes nine patients admitted later, all with more of Dhle bodies.
than 13% full-thickness skin loss. All of these Table II and Fig. 2 show the incidence of Dhle
showed Dhle bodies. In two patients admitted to bodies at different times after burning. They have
this hospital in 1955 the burns involving 10 to rarely been seen on the day of the burn, and the
14% full-thickness skin loss were primarily many abnormalities observed during the first hour
after a severe burn, though on occasion somewhat

TABLE I
INCIDENCE OF DHLE BODIES IN 28 BURNS
Total Films Area of Burn* Mximu
Blood Bacterial Colonization of Burn
Films with m First 2 Weeks in Hospital
Pat dur- Dhl Full- Tot Pyrexia Di Coagul
ient e al (F.) ed Ps. Colifor
ing First thicknes Partial Group ase m
Bodi s Skin First A +ve Pyoc
Two y- Bacil
Weeks es Skin Loss 2 Weeks H. S. Staphy
Loss - anea li
A 2' 0 0 5 5 104 0 + lococci
+ 0 0
B 2 0 0 5 5 99 0 0 0 0 0
C 6 1 0 17 1 102 0 0 + + +
D 6 0 <i 0 <i 99 0 0 0 0 0
E 5 0 i 0 i 99 0 0 + 0 0
F 2 0 03 0 0-3 100 0 0 0 + +
G 1 0 f 6i 7 102 0 + 0 + +
H 4 4 i 0 i 100 0 0 + 0 ~r
19 consecutive I 4 3 i n 1 101 0 0 + + +
cases J 3 1 <1 13 + 1 100 0 0 + 0 +
K 6 0 1 4 5 102 0 + 0 0
L 5 3 1 2 3 103 0 .*+ + + +
M 5 4 1 14 1 103 0 0 + + +
N 1 0 2 4i 6i 104 0 .+ + 0 +
O 4 3 4 6 1 100 0 0 + + +
P 5 3 5 15 2 100 0 0 + + +
Q 6 2 7 13 2 103 0 0 + + +
R 6 4 12 13 2 103 0 0 + + +
S 5 5 14 0 1 +103 + 0 0 + +
4
T 5 4 14 21 3 104 0 0 + + +
U 8 7 20 5 25 104 0 0 + + +
9 further cases V 6 5 20 5 2 106 0 + + + +
selected beca W 3 2 25 2 2 104 0 0 + 0 +
of large area X 2 2 27 16 4 103 0 0 + + +
of burn Y 5 4 40 10 5 102 0 + + 0 +
Z 3 3 Not known 6 103 + 0 + + +
A 3 2 Not known 7 104 + 0 + 0 +
B
Z
4 4 70 | 5 7
5 101
+
0
+ + +

* ach group ranked in order of area of full-thickness skin loss


W. WEINER and EL1ZABETH TOPLEY
TABLE 13
INCIDENCE OF DHLE BODIES AT DIFFERENT PERIODS AFTER THE BURN
Blood Films - Weeks
Patients (see Table I) with Dhle Days
Bodies 3 4 5 7 3& 5& >6
1 2 6 2 4 6
19 consecutive cases + 0 2 1 5 2 2 2 14 4 0 0
0 1 9 1 5 2 7 0 23 2 9 8
Total 1 11 2 1 4 9 2 37 2 9 8
0 4
9 further cases selected + 2 2 4 6 4 2 3 9 9 3 2
because
of large area of burn 0 4 1 0 0 0 0 0 1 2 2 11
Total 6 3 4 6 4 2 3 1 1 5 13
0 1
Total 28 cases .. .. .. Proportio 5 3/14 2/21
n 2/ / 11/1 6/ 4/11 5/ 23/4 13/3
7 4/14 6 8 5 7 5
positive l 6

obscuring the picture, were certainly not obscuring A typical blood count in a fairly severely burned
the presence of Dhle bodies. Somewhat more patient (25% of body surface) gave the following
frequently than on the day of the burn, they were vales on the third day after injury:
Myelocyte containing Dhle bodies but no toxic granulation 0-3%
seen 24 hours afterwards and usually reached their Metamyelocyte with no toxic granulation or Dhle bodies 5-7'
highest incidence by the third day.
,,
toxic granulation but no Dhle bodies
Dhle bodies but no toxic
Repeated blood films have been taken during granulation 2-7%
toxic granulation and Dhle bodies 0-3%
the first 12 hours in a very extensive burn (80% Polymorphs with no toxic granulation or Dhle 11-7%
of the body surface). Dhle bodies were not bodies
toxic granulation but no Dhle bodies
7%
70%
definitely seen until the twelfth hour, although Dhle bodies but no toxic granulation 3%
toxic granulation and Dhle bodies 11-3%
there was a primary leucocytosis of 47,000 white Staff forms with no toxic granulation or Dhle bodies 7%
cells per cubic millimetre by the sixth hour.



toxic granulation but no Dhle bodies
Dhle bodies but no toxic granulation
7-3%
In many cases Dhle bodies have disappeared toxic granulation and Dhle bodies 15 0^
Lymphocytes N1
by the third week, but in more extensive burns Eosinophils Nil
they may persist for six weeks or more (Fig. 2, Basophils
Monocytes
Table II). Dhle bodies frequently disappear at Plasma cells
about the time of near complete skin cover and Dhle bodies were not recognized in monocytes
clinical convalescence of the patient. or lymphocytes. This does not necessarily mean
that they are absent, but, if
they do occur, they
will no doubt be very
difficult to recognize owing
FIG. 2.Graph of Dhle
to their more or less identical
bodies seen in leuco- staining properties
cytes after reviewing with the cytoplasm of these
185 blood films from
28 bumed patients. cells. From the above
count, which was typical of a
number of other
counts performed, it can be
seen that Dhle bodies
occur together with and also
independently of
toxic granulation so common
in burned patients.
They also occur in young
immature cells (myelo-
cytes or metamyelocytes, but
see also below) and
were more frequent in staff
forms than in the
polysegmented cells.
The significantly greater
frequency of Dhle
WEEKS AFTER
bodies in staff forms than in polymorphs is shown punctures on these
in Table III, which summarizes counts of 15 films patients, as some
from patients with of them were too
burns. ill and most of
We did not feel them were chil-
justified in per- dren. We had,
forming marrow
DOHLE BODIES IN LEUCOCYTES OF PATIENTS WITH BURNS 327
TABLE ni
DIFFERENTIAL COUNTS (300 CELLS) OF 15 FILMS FROM SEVEN PATIENTS WITH BURNS INVOLVING 5-25% OF THE BODY
AREA SHOWING INCIDENCE OF DHLE BODIES IN STAFF FORMS AND POLYMORPHONUCLEAR LEUCOCYTES
Days Polymorpho Polymorphs % of Dhle All Staff % of Dhle Higher
Patient after - with Dhle Bodies in Staff Forms Bodies in Incidence of
Burn nuclear Bodies Polymorphs Forms with Dhle Staff Dhle Bodies in
Leucocytes Bodies Forms
A 7 250 100 400 9-3 50 53-8 Staff forms
O 75-9 03 04 7-6 03 40 99 99
O 3 64-3 1-3 20 59 03 51 99 99
P 3 67-4 110 16-4 16-9 56 33 1 99 99
P 6 55-9 16-6 29-7 24-7 110 44-5 99 99
P 8 51-6 4-3 8-3 20-3 30 14-8
Q 10 441 2-7 61 14-1 07 50 Polymorphs
Q 12 25 0 13 0 520 28 1 18-9 67-3 Staff forms
R 3 61 0 90 14-8 180 7-3 40 6 >
R 5 600 30-7 511 15 8 8-4 531 *
R 7 49-3 15 3 31 0 32-9 14 3 43-5 * >
S 1 78-7 07 09 96 03 ! 31
S 3 24-7 10 3 41-7 33-5 129 38-5 Polymorphs
S 5 28-4 23-7 83-4 34-7 331 95-4 Staff forms
Not in Table 35 22-6 4-4 0-3 15 0
I 10 20
2
The x distribution of Dhle bodies between staff and polymorphonuclear leucocytes shows a highly significant preponderance in the staff
forms (P= < 0 001)

however, occasion to examine marrows from two Dhle bodies have been seen in patients with burns
patients shortly after their death. On examination of too small an area for the haemoglobin to fall
of the films obtained, one gained the impression below 11.8 g. %. However, still more data
that the myeloid series showed a fairly gross dis- are required to establish the significance of the
turbance of maturation. Otherwise typical myelo- association between Dhle bodies and area of re-
cytes showed a blue cytoplasm in spite of the fact maining full-thickness skin loss or degree of anaemia.
that their granulation and nuclei were already fully The appearance of Dhle bodies on the second
mature. Some metamyelocytes showed big patches or third day does not coincide with the height of
of blue cytoplasm on many occasions. It is con- the total neutrophil leucocyte count in the peri-
ceivable that Dhle bodies as found in the more pheral blood, but it is possible that it does coincide
mature cells are the remains of these patches of with the first rapid new formation of leucocytes.
blue cytoplasm. However, the films had been Leucocytes disappear into the burned area within
taken after death and, as it is well known that very the first few hours, but dense polymorphonuclear
rapid changes occur in the marrow cells after the leucocyte infiltration may take one or two days to
death of the patient, it would not appear to be safe form in the burn area (Gordon, Hall, Heggie, and
to base any conclusions on these observations. Horne, 1946 ; Moritz, 1947), and massive purulent
exdate (present even in burns from which no
Discussion bacteria were cultivated) is usually not seen on the
The finding of Dhle bodies in burned patients burned surface until the third day. It is possible,
was unexpected. They had been seen previously, therefore, that the fall in the total polymorpho-
as already pointed out, in scarlet fever, other nuclear leucocyte count often seen in the peri-
streptococcal infections, diphtheria, typhus, and pheral count on the second or third day (Van
tuberculosis. Kolmer (1912) has described the Duyn, 1945 ; Sevitt, 1951) is associated with an
occurrence of Dhle bodies in scarlet fever which increased rate of formation of leucocytes and an
complicated burns, but he regards their occur- even more increased rate of loss of leucocytes into
rence as due to the scarlet fever and does not dis- the burned area. This is the time of the appear-
cuss any connexion with the burn. Morpho- ance of Dhle bodies in the leucocytes of the peri-
logically, the bodies seen in the films taken from pheral blood.
burned patients were identical with those obtained A common cause of the occurrence of these
in scarlet fever. They were more common in marked changes in the cytoplasm of leucocytes has
patients with extensive full-thickness skin loss. not been found in the diseases in which Dhle
They appeared during the first few days and per- bodies have already been reported, although most
sisted for two or more weeks after burning, often were associated with a polymorphonuclear leuco-
until near complete skin cover had been obtained. cytosis. Any n e w morphological change
This timing is very similar to the acute anaemia noticed always poses the questions, What is it,
of burns which is due largely to an unexplained what is the cause underlying it, and what is its
disappearance of red cells ; but scanty numbers of clinical and pathological significance ? None of
328 W. WEINER and ELIZABETH TOPLEY
these questions can be answered with the present look out for them regularly in conditions where
evidence, but it is hoped that our observation may their occurrence has not been described or
lead to further investigaron into the problem. suspected.
It may be that the presence of Dhle bodies
reflects one of the many changes in biochemistry Sumiiiary
of the neutrophil leucocytes taking part in an acute Dhle bodies have been found to be frequently
reticulo-endothelial response. In all cases reported present in the neutrophil leucocytes of patients
so far (with the possible exception of typhus fever) with burns involving more than 2% of full-thick-
the appearance of Dhle bodies coincided more or ness skin loss. They appear during the first day
less with the appearance of a polymorphonuclear or two after the burn and often disappear when
leucocytosis. Histochemical and biochemical in- complete or nearly complete skin cover is obtained.
vestigations on these leucocytes may possibly give Their clinical and pathological significance is as
results which would clarify the problem of their yet unknown. It is suggested that a more precise
causation. From the morphological point of view, knowledge of their incidence in different diseases
a very precise knowledge of their incidence in might add to our knowledge of their pathological
different diseases might increase our knowledge of significance.
their pathological significance. For example, it is
We wish to thank Dr. E. Lowbury for the use of his
not known whether they always occur in bacterial bacterial records and Mrs. M. G. Evans and her
infections which produce a leucocytosis or whether colleagues for technical assistance; Mr. Gil for the
they may on occasion also appear in leucopenic pie- photograph and Miss P. Young for secretarial assistance.
tures. It is not known how often there is an associated
unexplained disappearance of red cells. On occasion REFERENCES

it has been claimed that leukaemic leucocytes have Bachman, R. W., and Lucke, B. H. (1918). N.Y. med. 107, 492.
Dhle, P. (1911). Zbl. Bakt., 7. Abt. Orig., 61, 63.
never shown Dhle bodies, whereas other observers ------(1912a). Mnch. med. Wschr., 59, 1688.
------(1912b). Zbl. Bakt., I. Abt. Orig., 65, 57.
have described Dhle bodies occurring in myelo- Gordon, J., Hall, R. A., Heggie, R. M., and Hcrne, E. A. (1946).
genous leukaemia. They have, to our knowledge, J. Path. Bact., 58, 51.
Kolmer, J. A. (1912). Amer. J. Dis. Child., 4, 1.
not been described in pernicious anaemia or MacEwen, W. (1913-14). J. Path. Bact., 18, 456.
Moritz, A. R. (1947). Amer. J. Path., 23, 915.
haemolytic anaemias and nothing is known of their Rehder, H. (1942). Mnch. med. Wschr., 89, 495.
appearance in the reticuloses. As Dhle bodies are Sevitt, S. (1951). Brit. med. /., 1, 976.
Van Duyn, J. (1945). Arch. Surg., Chicago, 50, 242.
easily overlooked, it may perhaps be rewarding to
Dhle Bodies in the Leucocytes
of Patients with Burns
W. Weiner and Elizabeth Topley
J Clin Pathol 1955 8: 324-328
doi: 10.1136/jcp.8.4.324

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