PMC6563395_01
Representative ultrasound image of variably organized hyperechoic and anechoic debris within the gall bladder (GB) lumen
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Initial abdominal ultrasonography was performed within 24 h of admission and revealed variably organized anechoic-to-hyperechoic material within the gall bladder lumen (Figure 1). Repeat abdominal ultrasound revealed mostly hyperechoic, organized material against an interface of anechoic content within the gall bladder lumen (Figure 1).
Representative image of a direct smear of fluid obtained from a cholecystocentesis. (a) Mildly degenerate neutrophil with two extracellular round-to-oval, approximately 2 x 5-7 microm, deep-blue yeast organisms with a thin clear halo. (b) Mildly degenerate neutrophil containing a phagocytized yeast organism. The morphologic appearance of the yeast organisms was suggestive of Candida species, which was later confirmed on fungal culture. (c) Non-degenerate neutrophil containing phagocytized amorphous blue material, suggestive of mucin. Wright's stain, X 100 objective, bar = 20 microm
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Low numbers of round-to-oval, approximately 2 x 5-7 microm, deep-blue yeast organisms with a thin clear halo were present extracellularly and rarely phagocytized within neutrophils (Figure 2a,b). Rare neutrophils appeared to contain phagocytized blue material, suggestive of mucin (Figure 2c).
Representative image from a fine-needle aspirate of the liver. A single uniform cluster of cuboidal-to-low columnar epithelial cells, interpreted as biliary in origin. Note the amorphous, pale-blue material, interpreted as mucin, within the cytoplasm of the cells. This material is not a normal finding in biliary epithelium seen as an incidental finding in liver aspirates, and is suggestive of excessive mucus production and/or inspissation. Wright's stain, X 50 objective, bar = 50 microm
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The Wright's stained smears of the liver aspirate were moderately cellular consisting of predominantly hepatocyte clusters, moderate numbers of small to moderately sized clusters of cuboidal-to-low columnar epithelial cells, interpreted as biliary in origin (Figure 3), and moderate numbers of inflammatory cells. The biliary epithelial cells frequently contained small-to-moderate amounts of pale blue cytoplasmic material, suggestive of mucin (Figure 3).
Representative image from a fine-needle aspirate of the liver. Hepatocytes and increased numbers of non-degenerate neutrophils are caught up within loose streams and tight spirals of pale-to-dark-blue mucinous material. This mucin material is an abnormal finding in liver aspirates and was suggestive of 'white bile', as can be seen with gall bladder mucoceles. The hepatocytes are noted to display moderate anisocytosis and anisokaryosis and increased cytoplasmic basophilia, interpreted as a regenerative response to the inflammation. Low numbers of clear discrete vacuoles, consistent with lipid, are also visible within hepatocytes. Wright's stain, X 50 objective, bar = 50 microm
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Elsewhere on the smear, there were loose streams and tight spirals of pale-to-dark-blue mucinous material, which occasionally contained entrapped hepatocytes and non-degenerate neutrophils (Figure 4).