Case 89 – update 1

Thanks for everyones contributions so far. Further information now available as requested by yourselves:

Patient decline over past 6 months – 0.5 stone weight loss, no night sweats / fevers. Marked lethargy and generally feeling ‘achey’. Poor appetite but no early saiety and previously unremarkable diet. Constipated. No bleeding / bruising. No symptoms suggestive of autoimmune disease. No medications.

Positive findings on examination:

  • Pale. Spleen palpable 2cm below the costal margin.
  • Hb 95, MCV 103, Plts 90, WCC 17, Neuts 14, basophils 0.04
  • Mild AKI ( Ur 12, Cr 105). CRP 10.
  • Ferritin 35, B12 / folate NAD
  • HIV and hepatitis screen negative. Serum electrophoresis in progress.

Blood film:




  • What is your current differential diagnosis?
  • What further investigations would you now perform?

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