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Case history

An 86 year old man was referred from a community hospital for further investigation of his anaemia. On examination he was alert, oriented, and haemodynamically stable. He was pale with extensive ecchymoses over his trunk and upper limbs. He had a tender swollen left arm (see figure). There were no other relevant findings.

Investigations showed a haemoglobin concentration of 59g/l with a mean corpuscular volume of 101fl, platelets 319×109/l, and white cell count of 9.1×109/l. Blood film showed no evidence of haemolysis; there were no target cells or hypersegmented neutrophils, but the film confirmed a macrocytic anaemia. Concentrations of vitamin B-12 and folate were normal, as were results of thyroid and liver function …