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A 53-year-old man with Crohn's disease, short-bowel syndrome that required total parenteral nutrition, a history of recurrent catheter infections, hypertension, chronic renal insufficiency, and mitral regurgitation presented with fevers of 2 weeks' duration. He had elevated liver enzyme levels (aspartate aminotransferase, 45 U per liter; alanine aminotransferase, 97 U per liter; alkaline phosphatase, 679 U per liter; and total bilirubin, 7.3 mg per deciliter [125 µmol per liter]). Abdominal ultrasonography and endoscopic retrograde cholangiopancreatography showed no abnormalities. Blood was obtained for culture, and the patient was discharged while receiving intravenous levofloxacin. He returned after 5 days because of continued fevers, with temperatures as high as 102°F (39°C). A peripheral-blood smear showed intracellular and extracellular budding yeasts that were 2 to 4 µm in diameter with Wright's stain (Panel A, arrows) and Gram's stain (Panel B, arrow), some with collarettes, along with cocci that were gram-positive (Panel B, arrowhead). Although initial blood cultures grew only coagulase-negative staphylococci, the fungus Malassezia furfur grew on subculture with lipid supplementation. The patient was subsequently treated with amphotericin B, daptomycin, and vancomycin with clinical improvement. Repeat lipid-supplemented fungal cultures 2 months later were negative. Infection with M. furfur is associated with the use of intravenous lipid supplementation, and the diagnostic evaluation requires such supplementation as well. As seen in this case, the peripheral-blood smear remains a valuable diagnostic tool.
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