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Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 74-77

Green discoloration of the serum and influence on analytical variation

Department of Pathology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

Date of Submission11-Apr-2019
Date of Decision28-Jun-2019
Date of Acceptance11-Jul-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
Khalid Sumaily
Department of Pathology, College of Medicine and King Khalid University Hospital, King Saud University, P.O. Box 2925 (30), Riyadh, 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_18_19

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How to cite this article:
Sumaily K. Green discoloration of the serum and influence on analytical variation. J Nat Sci Med 2020;3:74-7

How to cite this URL:
Sumaily K. Green discoloration of the serum and influence on analytical variation. J Nat Sci Med [serial online] 2020 [cited 2022 Nov 27];3:74-7. Available from: https://www.jnsmonline.org/text.asp?2020/3/1/74/269752

  Case Report Top

A 61-year-old female presented with a history of multinodular goiter characterized by chronic lymphocytic thyroiditis and invasive ductal carcinoma of the breast. The patient was admitted to the hospital for total thyroidectomy due to the presence of thyroid nodules and also for right-modified radical mastectomy for breast cancer. A sentinel lymph node (SLN) biopsy was carried out for axillary staging, and she was found to have metastasis to 9 out of the 16 axillary lymph nodes which were positive for the dye uptake. Her vitals readout was steady, with a heart rate of 110 beats/min, blood pressure of 135/80 mmHg, oxygen saturation (SpO2) of 91% on ambient air, and respiratory rate was 16 breaths/min, respectively.

The patient's blood samples were collected in a plain gel tube and sent to the clinical chemistry laboratory for routine chemistry analysis. During the sample preparation, after clotting and centrifugation, the patient's serum was found to be green in color [Figure 1]. This first sample was discarded by the technician, as it was considered to be abnormal and likely due to an error in blood collection or faulty vacationer tubes during the phlebotomy. The sample was not shown to the clinical biochemist for an opinion as the sample was received after working hours, and a repeat sample was requested. The second serum sample after processing was also found to be green in color.
Figure 1: Green-colored serum after the injection of the patent blue dye for sentinel lymph node biopsy

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The second blood sample was taken, and blood analysis was carried out using the automated Siemens Dimension Vista 1500. This clinical chemistry analytical system provides intelligent analytics using advanced chemiluminescence to perform more than a 100 clinical chemistry, toxicology, endocrine, and drug monitoring assays with a high turnaround time. The biochemical analysis results for the patient are mentioned in [Table 1].
Table 1: Effect of patent blue dye on routine biochemical laboratory values of discolored and normal serum on the Siemens Dimension Vista 1500 automated clinicalC chemistry analyzer

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The blood parameters were analyzed before and after the surgery to check for any analytical variations. Although the serum sample was discolored, we found that it had no effect on the results of the biochemical analytical parameters. We could say this confidently as the laboratory values before and after the procedure were found to be within the same range.

  What Is the Diagnosis? Top


Total quality in laboratory diagnostics is multidimensional and challenging, and one that entails standardization and monitoring of a number of activities including checking for variations from the pre-analytical to the analytical phase.[1] The color of the serum is an important preanalytical variable whose variation is known to adversely affect the routine clinical chemistry results. Patent blue dye is an inert dye, used widely with or without its isotope, in diagnostic imaging. It is used, especially during breast cancer surgery to identify the SLN receiving lymphatic drainage from the primary tumor, from the other lymph nodes, by staining them blue after a direct injection into the site of the primary tumor. Although there is widespread perception of the side effects and drug interactions by these compounds, it is unclear whether they impact the sample quality and integrity due to their presence in circulation and by altering the normal straw-colored yellow serum [Figure 2]. No studies have addressed the effect of patent blue dye on biochemical analytical parameters, which made us examine if the change in color leads to variations or interferences within the results of analytical parameters measured with automated Siemens Dimension Vista 1500.
Figure 2: Normal yellow straw-colored serum obtained after clotting and centrifugation

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Normally, the serum is pale yellow due to the presence of the carotenoids, mainly ceruloplasmin, pigments bilirubin, hemoglobin, and iron transferrin. Any variation in the color is considered as an artifact and a cause for concern, as it leads to variation in the biochemical parameters. Green-colored plasma has been mentioned in a few case reports and is considered as a rare finding. The incidence of green plasma was reported by Elkassabany et al. in their study and was estimated to be 0.3% of their inventory of fresh frozen plasma.[2] While the earlier reports had placed this number at 1%.[3] Its presence was most recently documented by Raghuwanshi and Pehlajani who described it in two female patients on oral contraceptives.[1] The other causes of discoloration of plasma units were related to increased ceruloplasmin levels in pregnant women, or due to the administration of estrogen components such as ethinyloestradiol or mestranol, rheumatoid arthritis, presence of Gram-negative cryophilic contaminants such as the Pseudomonas species or use of medications such as sulfonamides.[3],[4],[5],[6]

Our case did not fit any of these criteria, as demonstrated by the patient's history. She was of postmenopausal age and was neither pregnant nor on contraceptive pills. On looking further into the literature, we identified only a few reports that have mentioned the presence of green serum with the use of patent blue dye or its isomers. These include studies by Meng et al.[7] and Houseworth et al.[8] who demonstrated the change in serum color after the use of isosulfan blue dye and by Bailey and Wu after using a fluorescent dye.[9] While Randell[10] and Berglund et al.[11] showed the presence of green plasma after injection of patent blue V dye and patent blue dye, respectively. The lack of knowledge of the occurrence of greenish discoloration of plasma or serum has frequently resulted in them getting discarded or removed from the donor pool in the blood bank, purely based on its appearance.[12]

The main issue of concern regarding the change in the serum's color is due to the possibility of any analytical interferences that can arise due to this change in color. Many of the analytical devices in the clinical chemistry are directly or indirectly dependent on the spectrophotometric techniques, and it is not clear whether this green color will add or subtract from the optical density measurements. This is also seen in the cases of hemolysis or an icteric sample where the values need to be corrected or in cases where the serum is high colored or when the patient is has consumed colored carotenoids. Another example of interference due to a change in the color of the serum is in the lipemic sample. Imaging dyes could theoretically interfere with test results, depending on the detection system used (colorimetric, fluorescence, or luminescence) which are the mainstay for all the automated clinical chemistry instruments.

In our case, the green color of the serum was found to be due to the use of the patent blue dye. Many cancers metastasize via the lymphatic system and are used to accurately determine the nodal involvement, which is critical for prognosis and treatment. The clinical method for determining the first draining lymph node or SLN, used for clinical staging of melanoma and breast cancers, involves injection of the patent blue dye proximal to the primary tumor before imaging or clinical examination. Patent blue V belongs to the group of triarylmethan dyes along with isosulfan blue, its isomer. In general, approximately 5% of the total dye diffused from the injection site is retained by the lymphatics, while the remaining enters the bloodstream.[13] It is known to have a low protein-binding affinity, binds weakly to serum albumin to form a complex that has a slow rate of renal excretion, which may account for the green-colored discoloration.[14]

Injection of patent blue dye briefly gives serum a green color by adding blue to the normal yellow color of the serum. Scherer et al.[15] described a biphasic course for the reaction of the dyes that may also contribute to the slow release of the dye from the subcutaneous tissue or the lymphatic tissue and the half-life of the dye in the body of several hours leading to a blue or green serum, urine, or skin discoloration for up to 24 h. Thevarajah et al. in their study have also documented the side effects of the blue dyes in general and mentioned that the dye temporarily changes the color of the plasma to green.[16] In a previous report on intraoperative SLN mapping, patent blue aside from the green color resulted in a turquoise discoloration of the plasma demonstrating that the hue of the green color may vary in intensities.[17] Besides this seemingly innocuous discoloration, severe allergic reactions and interferences with the assessment of oxygen saturation by peripheral pulse oximetry based on red or infrared light absorption have also been noted. Burgoyne et al.[18] reported that the green discoloration caused a shift in the absorption spectra during pulse oximetry, from 640 nm (peak absorbance of the patent blue) to that similar to methemoglobin, thereby giving a factitious methemoglobinemia result. It also resulted in mimicking a true intraoperative hypoxia[19]-like picture or showed the false presence of sulfhemoglobin.[20] Aside from the reports that indicated a shift in pulse oximetry, no reports were found to indicate whether or not this discoloration interfered with pathology tests.[10]

Ours is the first report that evaluates the interferences of the green discoloration with biochemical tests and reports that this change did not affect the routine biochemical analyses. The finding that at this level, there is no interference observed in any of the analyses assessed is very reassuring.

  Clinicopathological Pearls Top

Although green serum has been reported in the literature, its occurrence is not commonly known. Specimens contaminated with patent blue are occasionally received in the chemistry laboratories, and it is, however, crucial that laboratory personnel, technicians, and students alike should know of these variations in the physical properties of blood products. This is important so as to be aware of this artifact, because receipt of such a specimen may lead to false rejection of the samples and possible delay in analyses of the requested investigations. It should also be kept in mind that the change in color due to the patent blue dye does not interfere with any biochemical investigations and does not impact the results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Raghuwanshi B, Pehlajani NK. Green colour donor plasma. Indian J Anaesth 2016;60:778-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
Elkassabany NM, Meny GM, Doria RR, Marcucci C. Green plasma-revisited. Anesthesiology 2008;108:764-5.  Back to cited text no. 2
Wolf P, Enlander D, Dalziel J, Swanson J. Green plasma in blood donors. N Engl J Med 1969;281:205.  Back to cited text no. 3
Gorlin JB, Engblom A, Janzen M. Transfusion medicine illustrated. Green plasma in female blood donors on estrogen-containing birth control pills. Transfusion 2013;53:2122.  Back to cited text no. 4
Swinburne K, Losowsky MS, Hall DA. pigmentation of serum in rheumatoid arthritis. Proc R Soc Med 1963;56:818-20.  Back to cited text no. 5
Tovey LA, Lathe GH. Caeruloplasmin and green plasma in women taking oral contraceptives, in pregnant women, and in patients with rheumatoid arthritis. Lancet 1968;2:596-600.  Back to cited text no. 6
Meng QH, Handy B, Wagar E. A case of green blood. Clin Chem 2014;60:695-6.  Back to cited text no. 7
Houseworth JL, Parks JA, Miguel EA, McCarthy LJ, Danielson CF. Transfusion medicine illustrated. Iatrogenic green plasma. Transfusion 2005;45:1047.  Back to cited text no. 8
Randell P. Green serum: Should the laboratory be worried. Biomed Sci 2011;55. p. 402  Back to cited text no. 9
Bailey H, Wu AH. Images in clinical medicine. Bright green serum. N Engl J Med 2007;356:e10.  Back to cited text no. 10
Berglund D, Lindvall P, Lubenow N. Green plasma. Transfusion 2015;55:245.  Back to cited text no. 11
Visual Inspection Reference Guide, American National Red Cross, American Red Cross Biomedical Services; 2006. p. 6-26.  Back to cited text no. 12
Bagby TR, Cai S, Duan S, Thati S, Aires DJ, Forrest L. Impact of molecular weight on lymphatic drainage of a biopolymer-based imaging agent. Pharmaceutics 2012;4:276-95.  Back to cited text no. 13
Tsopelas C, Sutton R. Why certain dyes are useful for localizing the sentinel lymph node. J Nucl Med 2002;43:1377-82.  Back to cited text no. 14
Scherer K, Studer W, Figueiredo V, Bircher AJ. Anaphylaxis to isosulfan blue and cross-reactivity to patent blue V: Case report and review of the nomenclature of vital blue dyes. Ann Allergy Asthma Immunol 2006;96:497-500.  Back to cited text no. 15
Thevarajah S, Huston TL, Simmons RM. A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer. Am J Surg 2005;189:236-9.  Back to cited text no. 16
Guignard J, Tissot JD, Canellini G. Unusual colours of plasma. Br J Haematol 2012;156:419.  Back to cited text no. 17
Burgoyne LL, Jay DW, Bikhazi GB, De Armendi AJ. Isosulfan blue causes factitious methemoglobinemia in an infant. Paediatr Anaesth 2005;15:1116-9.  Back to cited text no. 18
Sagadai S, Umakanth P. Colour coding prefilled syringes. Anaesthesia 2005;60:628.  Back to cited text no. 19
Flexman AM, Del Vicario G, Schwarz SK. Dark green blood in the operating theatre. Lancet 2007;369:1972.  Back to cited text no. 20


  [Figure 1], [Figure 2]

  [Table 1]


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