Yeast-like intraleukocytic inclusions in a peripheral smear.

A 17-year-old male with short gut syndrome secondary to Hirschprung disease presented with a 2-week history of night sweats. He had an indwelling central line for total parental nutrition (TPN) supplementation and a history of multiple line infections with a variety of organisms. After completing a 10-day course of prophylactic fluconazole, and 1 week before the onset of night sweats, he had 4 teeth extracted. Complete blood count showed a leukocyte count of 4.0 103/mL (73% neutrophils) and the peripheral blood smear revealed neutrophils with brilliant blue–colored yeast-like intraleukocytic organisms, 2 to 4 m in diameter (see figure, Wright-Giemsa). The organisms had neither the pseudocapsule or eccentric chromatin suggestive of Histoplasma capsulatum; nor did they produce the “collarettes” indicative of the phialides of Malassezia furfur, a lipid-dependent yeast associated with fungemia in patients requiring TPN. Subsequently, blood cultures grew Candida glabrata. The isolate had a minimum inhibitory concentration of 16 g/mL to fluconazole and 0.015 g/mL to micafungin. Anidulafungin therapy was initiated and the infection cleared.