Case of the Month - July 2020 Case of the Month Archive A 66 year old woman was admitted to another hospital in septic shock from pneumonia, with acute respiratory failure requiring intubation with mechanical ventilation. Her medical history was notable for hypertension, diabetes mellitus, end-stage renal disease requiring hemodialysis, anemia requiring blood transfusions, and congestive heart failure. The patient remained in the intensive care unit during a prolonged hospitalization and had a failed extubation attempt two weeks into her hospitalization. Her hospital course was notable for persistent fevers on broad spectrum antibiotics, an increased alkaline phosphatase, and jaundice that was refractory to multiple courses of broad-spectrum antibiotics with an extensive but unrevealing hepatobiliary workup. After two months she was transferred to Montefiore on ventilatory support for further evaluation of her persistent fevers and cholestatic hepatitis. Empiric therapy with piperacillin-tazobactam was initiated, and vancomycin and meropenem were added the following day. After several more days of persistent fevers, micafungin was added. Blood cultures drawn on admission to Montefiore and four consecutive days thereafter were negative. Small budding yeast lacking hyphae or pseudohyphae. grew from a blood culture drawn the next day. The yeast was resistant to fluconazole and voriconazole. It had also grown in a sputum culture performed at the other hospital. (See Figures below.) What is the most likely genus and species for the yeast? Growth on Sabaroud dextrose agar. Calcofluor KOH preparation. Wet mount from Rice-Tween agar.