A 39-year-old female with a history of multiple sclerosis, Sjogren's syndrome, and Systemic Lupus erythematosus (SLE) was admitted due to a low-grade fever, dark-colored urine, and fatigue. Lupus nephritis was confirmed through a renal biopsy. Her creatinine level was 5.1 mg/dL. The prednisone dose was increased, and she continued treatment with hydroxychloroquine and Azathioprine. During her hospital course, she experienced hemodynamic instability and altered mental status. Her complete blood count (CBC) revealed the following values: white blood cell count (WBC) of 0 (Reference Range: 4.8-10.8 x 10^3/μL), hemoglobin of 7.8 g/dL (Reference Range: 12 – 15.5 g/dL), hematocrit of 24.3% (Reference Range: 36-46%), and platelet count of 21,000/μL (Reference Range: 150-450 x 10^3/μL).

To investigate the pancytopenia, a bone marrow biopsy was performed, which showed a variably cellular marrow with significant myeloid hypoplasia and numerous fungal elements. Candida tropicalis was identified in the bone marrow cultures. Bone marrow aspirate smears exhibited frequent macrophages containing small lymphocytes and red blood cells, consistent with hemophagocytosis. Other pertinent results included triglyceride levels of 99 mg/dL (Reference Range: <150 mg/dL), ferritin level of 22,449.6 ng/mL (Reference Range: 10.0-150.0 ng/mL), and fibrinogen level of 176 mg/dL (Reference Range: 187–502 mg/dL).