A 55-year-old previously healthy woman was admitted with fever and cough. Chest X-ray and CT showed features of viral pneumonitis. Her nasopharyngeal swab was positive for severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) by reverse transcription (RT)-PCR. Her complete blood count (CBC) showed leucocytosis with neutrophilia, relative lymphocytopaenia, and monocytopaenia initially with subsequent improvement in the number of monocytes on the fifth day onwards. We report a detailed analysis of the peripheral blood film (PBF) of a patient with COVID-19 during the hospital course which has not been reported hitherto. Some peculiar findings were observed in the neutrophils which were never seen in any other infection. Neutrophils showed heavily clumped chromatin with toxic granules and cytoplasmic vacuoles. Nuclear detachment with elongated nucleoplasm and ring-shaped nuclei were seen with platelet surface attachment. C-shaped, fetus-like nuclei were noted with aberrant nuclear projections, which we named as COVID nuclei ( ). Most of the lymphocytes were seen as large granular lymphocytes (LGL) with round to indented nuclei, condensed chromatin, prominent nucleoli in a few, along with abundant pale blue cytoplasm with distinct variably sized azurophilic granules ( ). Cytoplasmic pod formation and apoptosis were also observed in a few lymphocytes. These might represent natural killer cells or cytotoxic T lymphocytes. Activated monocytes were seen which showed marked anisocytosis with prominent cytoplasmic vacuolisation and few granules. Nuclei were large, having fine chromatin with nuclear blebbing in a few. Nuclear overlapping by vacuoles was observed in some cells ( ). Platelets were adequate, with a few giant forms and focal platelet attachment on the surface of all forms of leucocytes. Her first CBC sample showed normal total leucocyte count (7.4×10 /L) with neutrophilia and relative lymphocytopaenia and monocytopaenia. On the fifth day onwards, her CBC started showing monocytosis, which persisted until day 16. Relative lymphocytopaenia persisted throughout her stay, along with the presence of LGL on PBF. LGL started appearing on PBF on day 7 onwards. These findings clearly indicated that in COVID-19, initial neutrophilia, lymphocytopaenia and monocytopaenia are subsequently accompanied by monocytosis. During the hospital stay, the patient was managed with oral hydroxychloroquine, azithromycin and antipyretics, along with intravenous fluids, bronchodilators and supportive care. The patient was discharged on 8 April 2020 after two negative samples for COVID-19.
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