Jaundice and lethargy in a 26 year old man

A white 26 year old man, who had previously been fit and well, was referred to the on-call medical team by his general practitioner. The general practitioner provided the results of the patient’s blood tests and described breathlessness on climbing stairs, increasing fatigue, and the appearance of jaundice over the previous week. The patient had no history of cough, upper respiratory tract infection, or sore throat. His appetite remained healthy, his weight was stable, and he denied any fever or night sweats. He was not on medication before the illness and he had no relevant travel history.

On examination, he was pale and his skin and sclera were jaundiced. His temperature was 36.7°C, pulse 87 beats/min, blood pressure 144/76 mm Hg, respiratory rate 16 breaths/min, and oxygen saturation 100% on air. Abdominal examination showed an enlarged spleen of 4 cm, but no hepatomegaly or lymphadenopathy. Respiratory, cardiac, and neurological examinations were normal.

Laboratory tests showed haemoglobin 80 g/L (reference range 130-180), red blood cells 2.52×10¹²/L (4.50-6.50), mean cell volume 89.4 fL (80-98), white cell count 15.4×10⁹/L (4.0-11.0), reticulocyte count 315×10⁹/L (20-100), platelets 211×10⁹/L (150-400), bilirubin 44 µmol/L (<17), aspartate transaminase 44 IU/L (5-35), lactate dehydrogenase 722 IU/L (125-243), and haptoglobin <0.08 g/L (0.27-1.39). Urinalysis detected no bilirubin and raised urinary urinobilinogen. A blood film showed lymphocytosis with reactive lymphocytes, spherocytosis, and increased polychromasia.