•A 1-day-old early preterm baby boy was admitted in neonatal intensive care unit with low birth weight  and respiratory distress. On examination, the child was afebrile, hypotensive, and deeply jaundiced. Baby’s condition worsened on day 4 of life

• Laboratory tests showed a total bilirubin level of 169.29 µmol/L (9.9 mg/dL) and direct bilirubin of 6.8 µmol/L(0.4md/dL). Hemoglobin was 154 g/L, white cell count 27.3 × 10 9/L, neutrophils 21.4 × 10 9/L, lymphocytes 5.3 × 10 9/L, and monocytes 0.3 × 10 9/L., Platelet count 19x 10 9/L

•There was no blood group incompatibility with mother.

•In the given patient bilirubin levels were not very high but sepsis was present which was confirmed by blood culture positive for Klebsiella pneumonae.

•The child was not maintaining oxygen saturartion, so he was intubated  and given IV fluids, broad-spectrum antibiotics, along with one random donor  platelet transfusion. Blood culture grew Klebsiella pneumoniae; therefore, a diagnosis of klebsiella sepsis was made.

•The baby worsened overnight and succumbed to death on day 6 of life.

•The peripheral blood smears made from EDTA-anticoagulated blood showed golden-yellow refractile crystals in the cytoplasm of neutrophils. Neutrophils also show shift to left with toxic changes.

•The crystals were mostly rectangular to rhomboid in shape (original magnification ×1000, Leishman stain) seen in neutrophils. a. Rectangular bilirubin crystals, b. Rhomboid bilirubin crystal, c. Toxic changes(vacuoles & toxic granules in neutrophil )

•Bilirubin crystals are occasionally seen in neutrophils from neonates and children with marked hyperbilirubinemia.

•These bilirubin crystals are more commonly found in septicemia than with hemolytic disease of the newborn.

• The crystal formation is believed to be an in vitro phenomenon because it is specific to blood samples collected in EDTA.