Case 148: update 1

The gastroenterology team have kindly organised further investigations. B12 and folate are normal, viral serology (including HIV, CMV, EBV and parvovirus) are all negative. Autoantibody screen was also negative. LDH is normal and there is no evidence of haemolysis. Peripheral blood smear confirmed pancytopenia but did not identify any dysplasia or primitive cells. Examination did not identify any lymphadenopathy or hepatosplenomegaly. He has no significant PMH or family history and is not taking any regular medications. He denies any recreational drug use. He is referred to the haematology clinic and is seen two weeks later. He now feels breathless and is pyrexial. Repeat FBC is as follows:

Hb                      69  (130-180)
Platelets             43  (150-450)
WCC                 1.0 (4-11)
Neut                   0.2 (2-7)
Lymphocytes     0.4 (1-4.5)
Monocytes         0.3 (0.2-0.8)

What would you do now?
What further investigations are required?

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