Going forward , we test and rule out other underlying problems :
- Genetic mutation for primary HLH is negative
- Workup for organic acidemias and inborn errors are negative
- Extended viral panel and AFB does not help
- There is no evidence of double negative T cells
- Workup for immune deficiency is negative
Meanwhile Ferritin continues to rise and there is ongoing monocytosis with cytopenias.
So there is HLH which is driving the fever, but what is the primary problem ?
Out of the blue we receive a call from the molecular lab :
- The bone marrow sample which was tested is positive for k-RAS !!
What do you think now ? Does it tie everything into a neat bow ?
Can we fit everything into one diagnosis?