A 50 year old man presented to the emergency department in a febrile drowsy state. His relatives gave a history of continuous moderate grade fever up to 38^oC for the last 2 months. Occasional chills, cough with scanty mucoid expectoration, anorexia and weight loss were also present. He was a farmer by profession, non-smoker, non-alcoholic. There was no history of drug abuse, intravenous injections, tuberculosis or diabetes mellitus. Sexual history could not be elicited. Physical examination revealed a conscious but drowsy patient, with marked pallor and moderate hepatosplenomegaly. Cyanosis, petechiae and peripheral lymphadenopathy were absent. Respiratory and cardiovascular system were normal on examination. No focal deficit was elicited in the central nervous system. Blood examination revealed a haemoglobin of 6.5 g/dl, total leucocyte count of 1.4 × 10⁹ /l and platelet count of 40 × 10⁹/l. The red cells were normocytic normochromic, no abnormal cells were identified on the peripheral smear. Biochemical profile was within normal limits. Bedside chestx-ray did not show any lesion. A bone marrow aspiration was performed (fig 1 and 2A).

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Figure 1

Photomicrograph of the bone marrow aspirate (Giemsa orig × 40).

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Figure 2

Photomicrograph of (A) bone marrow aspirate smear; (B) splenic aspirate (Giemsa orig × 100).

The patient deteriorated during the 12 hours of hospital stay. Despite supportive therapy, he developed petechial skin rashes all over the body and started bleeding from the site of arterial puncture. He also had upper and lower gastrointestinal bleed, became hypotensive and expired. A postmortem splenic aspiration was also performed (fig2B).