Friday, December 19, 2008


You do a far-away rotation in Asia where you see a 20 year old woman presenting with shortness of breath, fatigue, and pretibial petechiae that had an insidious onset. She has no significant past medical history, medications, allergies, or family history. However, when you start asking about bad habits, you pause in surprise when she says she "injects gold." Apparently, she thinks it brings fortune and acts as an aphrodisiac. She is afebrile, and all her vital signs are stable. Exam is notable for some petechiae, pallor, and bounding pulses. While some basic labs are cooking, you look at a peripheral blood smear under the microscope:

A bone marrow biopsy is done; hematology describes it as "wet" and "fatty." Here is what they see:

Challenge: What's the diagnosis?

Images shown under fair use.


Stephanie said...

gold poisoning...? her marrow is totally fatty and hypocellular....

Craig Chen said...

good call!

Gold can cause aplastic anemia which should always be suspected with peripheral blood pancytopenia and a hypocellular bone marrow (shown in the images). There is a bimodal age distribution (15-25 and >60) and an unexplained geographical association (more common in Asia). The pathophysiology involves very few hematopoietic progenitor cells. Causes are congenital, idiopathic, irradiation, drugs, viruses, immune disease, paroxysmal nocturnal hemoglobinuria, and pregnancy.

Sources: UpToDate; Hematology (textbook);;