Curious beads for a clinical pearl.

A 42-year-old man was diagnosed with a severe acute respiratory distress syndrome following inhalation of his stomach contents. The previous history revealed liver cirrhosis due to alcoholic liver disease. Seven days later, he presented with a high fever and a painful abdominal distension due to ascites. The blood cell count was as follows: hemoglobin, 10.9 g/dL; white blood cells, 12.2303 10/L (neutrophils, 9.1243 10/L); and platelets, 1243 10/L. The ascitic fluid analysis showed total nucleated cells of 0.242 3 10/L (neutrophils, 29%; lymphocytes, 9%; monocytes, 53%; peritoneal cells, 9%). Microscopic examination showed a mix of isolated, clumped, and budding “pearls” inside or outside the macrophagic cells (panel A). The yeasts had been phagocytized by neutrophils, macrophages, and peritoneal cells and sometimes were arranged as a ring in their cytoplasm (panels B-E). They were identified as Candida albicans, and similar yeasts were identified in the tracheal aspirate. In conjunction with the management of the whole disorder, the patient received fluconazole through an intravenous catheter and recovered after weeks.