#00065728

A 14- year-old male with past medical history of dilated cardiomyopathy and limb girdle muscular dystrophy, 6 months post-orthotopic heart transplantation and on immunosuppressive drugs Sirolimus and Tacrolimus, presented to the Emergency Department with fever and dry cough. Laboratory workup was remarkable for positive Rhinovirus by PCR.  Additionally, peripheral blood smear examination revealed neutropenia with Döhle bodies. Interestingly, round deeply basophilic cytoplasmic inclusions were seen in several neutrophils. Basophilic neutrophil inclusions have various differential diagnosis including infections such as Anaplasma, Ehrlichiosis or Howell-Jolly body-like inclusions described in immunosuppressive patients. Given the morphology and in the context of immunosuppression status of this patient, these are most likely Howell-Jolly body-like inclusions, which have been also reported previously in immune compromised patients on Tacrolimus.