Teaching Cases from the Royal Marsden Hospital Case 4: fever, hepatic dysfunction and cytopenia

Abstract

CASE A 67 year old English male presented with a six month history of shortness of breath, malaise, lethargy, fever, and night sweats. He had not suffered pruritus or alcohol-induced pain. There was no history of recent travel. He had no hepatomegaly, lymphadenopathy, splenomegaly or abnormal findings in the chest. Results of laboratory tests were: Hb 10 g/dl, MCV 89 fl, WBC 3.8 × 10⁹/1, neutrophil count 2.5 × 10⁹/1, lymphocyte count 1.1 × 10⁹/1, monocyte count 0.04 × 10⁹/1, platelet count 269 × 10⁹/1, ESR 116 mm/hr, aspartate transferase 44IU/1 (NR<41), alanine transferase 39 IU/1 (NR < 45), alkaline phosphatase 458 IU/1 (NR 30-115), γGT 637 IU/1 (NR < 65), bilirubin 29 μm/1 (NR 3-20), albumin 28 g/1 (NR 34-50), serum iron 4μm (NR 10-30), TIBC 43.8 μm (NR 45-70), iron saturation 9%. Normal results included urea, creatinine, serum B₁₂, red cell and serum folate, immunoglobulin concentrations and serum electrophoretic pattern. No Bence Jones protein was detected. Serology for hepatitis A and B was negative. Culture of blood, urine, and sputum yielded no pathogens. A Ziehl-Nielsen (ZN)/auramine stain of sputum was negative as was a Mantoux test. A CT scan of the abdomen showed the liver and spleen to be normal in texture; there was no lymphadenopathy. Chest radiography and a skeletal survey were normal. The peripheral blood film showed rouleaux and occasional abnormal cells. Bone marrow aspirate was difficult and yielded a poor aspirate containing cells such as are shown in Figure 1. A trephine biopsy was markedly abnormal (Figure 2). A further diagnostic procedure was performed.

Key Words:

• Hairy cell leukaemia
• tuberculosis
• miliary tuberculosis