A 16-month-old female presented with a 2-week history of fever, nasal congestion and cough progressing to respiratory distress. A chest radiograph revealed hydropneumothorax and complicated pneumonia. Laboratory tests showed macrocytic anemia (hemoglobin 4.8 g/dL), reticulocytosis (immature reticulocyte fraction 74.7%), normal creatinine (0.31 mg/dL), and elevated lactate dehydrogenase (2,242 units/L). The first direct antiglobulin test (DAT) was unable to be performed due to spontaneous agglutination and cold autoantibodies were detected. Repeat DAT was IgG and complement positive. Cold agglutinin screen and titer were performed showing a titer of < 1:2 and it was determined cold autoantibodies were not truly present. The PB smear showed the following findings.