Phagocytized Candida albicans in the peripheral blood smear of a girl with Crohn disease

A 4-year-old girl with Crohn disease (CD) was repeatedly hospitalized for exacerbation of CD. She was treated with oral tacrolimus, prednisolone, methotrexate, and 6-mercaptopurine. Additionally, total parenteral nutrition was administered through a central venous catheter (CVC). After four months from the CVC was placed, she developed a fever of 39.3 C, hypotension (84/ 42 mmHg), sinus tachycardia (160 beats/min), and tachypnea (40 breaths/min) during hospitalization. Her general appearance was unwell without other remarkable findings. Laboratory data showed a leukocyte count of 4,700/mL (band neutrophils 13%, segmented neutrophils 70%, lymphocytes 12%, monocytes 4.5%, eosinophils 0.5%, and erythroblasts 1.0%), thrombocytopenia (platelet count 100,200/mL), and an increased C-reactive protein level (11.8 mg/dL). Vancomycin and meropenem were empirically administered for sepsis, including a catheter-related bloodstream infection (CRBSI), after two sets of blood cultures were obtained. The next morning, results of a peripheral blood smear (PBS) showed yeast cells phagocytized by leukocytes (Fig. 1). Therefore, micafungin was immediately administered, and the CVC was removed. The blood cultures grew Candida albicans after a two-day incubation, and a culture obtained from the CVC grew C. albicans. A diagnosis of CRBSI due to C. albicans was made. Subsequently, fluconazole was administered instead of micafungin because bilateral endophthalmitis was detected by an ophthalmologist.