Hemophagocytic lymphohistiocytosis: macrophages engulfing red cells and neutrophils

A 47-year-old female presented with a 3-day history of high grade fever, myalgia, abdominal discomfort, vomiting, shortness of breath, headache, and altered mental status. She was hypotensive with acute respiratory distress syndrome and multi-organ failure. Laboratory workup was significant for pancytopenia, elevated liver enzymes, acute kidney injury, elevated creatine kinase levels and ferritin level of 10,000 mcg/L.