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A drop of vitriol: microspherocytosis following sulphuric acid exposure

A 30-year-old man was admitted to hospital following an explosion at the metal foundry where he worked. He had sustained sulphuric acid exposure to 80% of his body, including full thickness skin destruction over 20% of his body surface area. Full blood examination on admission showed haemoglobin 151 g/l, white cell count 24AE3 · 10/l with neutrophil count 20AE4 · 10/l, and platelet count 357 · 10/l. The blood film (illustrated) demonstrated numerous spherocytes and microspherocytes, a number of crenated red cells, occasional red cell fragments and toxic neutrophil granulation. The direct antiglobulin test was negative, and a blood film performed 2 years prior to this presentation had shown no morphological abnormalities. Microspherocytes are a characteristic finding following thermal injury to red cells, such as that resulting from physical burns, but have not to our knowledge been described in association with chemical injury. The mechanism underlying this morphological change is thought to be a decrease in red cell membrane deformability caused by thermal damage to membrane proteins and phospholipids. This may also lead to fragmentation and cell destruction. Microspherocytes and fragments have been implicated in the pathogenesis of renal impairment in the setting of severe burns, through deposition in renal tubules, and may also interfere with automated cell counts. Sulphuric acid (H2SO4), once called oil of vitriol, is a highly corrosive mineral acid. Its destructive properties are enhanced by its exothermic reaction with water, which forms hydronium and sulphate while releasing substantial heat. The chemical injury associated with exposure to sulphuric acid may therefore result in greater damage than that from other acids of similar strength, as local heat and dehydration increase tissue destruction. In this case, it is likely that this secondary thermal damage contributed to the observed morphological changes. This patient was treated with surgical debridement and supportive measures, and made a full recovery. His blood counts and red cell morphology normalized within seven days, with complete resolution of the microspherocytosis.