A 10-year-old boy presented with tiredness and pallor. Symptoms began about 6 months before presentation, when easy bruising was noted. Episodic bone pain in the lower extremities, hips, and shoulders had been present for 4 months. The patient had no relevant family history.
Results of physical examination were within normal limits except for marked pallor, numerous bruises, and a spleen that was palpable 6 cm below the left costal margin. The liver was palpable 2 cm below the right costal margin. Tendon reflexes were 4+ and symmetrical.
Results of laboratory studies revealed the following values: hemoglobin, 60 g/L; white blood cell count, 3.2×109/L (polymorphonuclear cells, 0.24; lymphocytes, 0.62; monocytes, 0.12; and eosinophils, 0.02); platelets, 60× 109/L; and reticulocyte count, 80 × 10−3. Roentgenograms were obtained (Fig 1), and a bone marrow biopsy was performed (Figs 2 and 3).
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