A 25 year-old otherwise healthy male presents to his primary care doctor after a difficult to control nosebleed, lasting approximately two hours. There is no history of trauma, drug use, or previous episodes of prolonged bleeding. He has not been feeling fatigued lately (able to carry out his usual activities). He does endorse easy bruising over the past 2 months.
- Past Medical History: Denies
- Past Surgical History: Rotator cuff repair
- Allergies: None
- Medications: OTC Multivitamin
- Social History: Engine mechanic. High school graduate. Single, lives alone. No tobacco, social alcohol use.
- Family History: Mother with colorectal cancer (age 32), Maternal Aunt with lymphoma, Maternal Grandmother with squamous cell carcinoma & melanoma
Physical Exam:
- Vitals – Temp 98.7, HR 84, BP 109/53, RR 16 (100% on room air)
- General – alert, age-appropriate overweight white male, not in distress
- HEENT – Atraumatic, pupils equal & reactive to light, no jaundice/icterus; conjunctival pallor is present, scan dried blood in the right nostril; poor dentition; no petechiae or mucosal bleeding; no lymphadenopathy
- CVS – Regular rate & rhythm, without murmur
- Lungs – Clear bilaterally
- Abdomen – normoactive bowel sounds, soft, non-tender, non-distended, spleen & liver nonpalpable
- Skin/Extremities – No rashes/petechiae; several large ecchymoses of various ages on the bilateral upper & lower extremities; no edema or cyanosis; no nail abnormalities
Labs/Studies:
- CBC: WBCs 0.5 / Hemoglobin 6.4 / Platelets 38 / MCV 109 / RDW 17%
- BMP: unremarkable; BUN 18 / Creatinine 1.0 / Calcium 9.5
- LFTs: unremarkable; Total bilirubin 1.0
- Coags: PT 13.9 / PTT 30.9 / INR 1.1
- Rapid HIV testing is negative
A peripheral smear is significant for a paucity of leukocytes, platelets, and a prominent number of dacrocytes.
Click to enlarge. Credit: Ookaboo
The patient is admitted and treatment for the presumptive diagnosis is begun. A bone marrow biopsy the following day is shown below, followed by a smear of the bone marrow aspirate.
Bone marrow core biopsy. Click to enlarge.
Bone marrow aspirate. Click to enlarge.
What is the most likely diagnosis?
A) Hemophagocytic lymphohistiocytosis
B) Viral infection
C) Acute promyelocytic leukemia
D) Severe folate/B12 deficiency
E) Systemic lupus erythematosus
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Abnormal Facies 
Tak
February 2, 2014
C