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Answers on p 304.
A 16 year boy, resident of Bihar, presented to the emergency department with a history of generalised weakness for one month, and bleeding from his gums for eight days. There was no history of prolonged fever, haematemesis, haematuria, or haemoptysis. The patient had not taken any drug in the recent past. On examination he had severe pallor. Examination of the cardiovascular system revealed an ejection systolic murmur in the pulmonary area. The rest of the physical examination was normal. Laboratory examination showed a haemoglobin concentration of 20 g/l and total leucocyte count of 3.1 × 109/l with differential leucocyte count of 19% neutrophils, 78% lymphocytes, 2% monocytes, and 1% eosinophils. Platelet count was 28 ×109/l. Anaemia was normocytic normochromic. No haemoparasites were seen on peripheral smear examination. All other investigations—biochemical (blood urea, serum creatinine, and liver function tests), chest radiography, and ultrasound of the abdomen—were normal. Bone marrow aspiration revealed cellular marrow smear; myeloid:erythroid ratio was reversed; erythropoiesis was normoblastic to mildly megaloblastic; myeloid cells showed maturation arrest; plasma cells were normal; reticulum cells were increased, and reticular iron grade was II–III with normal sideroblasts. A haemoparasite was seen in bone marrow. No abnormal cells were seen. In view of pancytopenia and relative decrease of myeloid cells and megakaryocytes in bone marrow, the possibility of toxic suppression of marrow was considered.