December 2010 - Presented by Melissa Rodgers-Ohlau, M.D.

Clinical history:

The patient is a 15-month-old female with a 1-week history of fever, fatigue, and maculopapular rash which had recently resolved. Shotty bilateral cervical and inguinal lymph nodes, as well as heptosplenomegaly, were noted on physical exam. Initial lab results were as follows:


Red cell count 3.15 (4.1-5.3 m/mm3)
Hgb 8.4 (9.5-13.5 gm/dl)
Hct 23.3 (29-41%)
Platelet Count 52 (130-400 k/mm3)
AST 351 (15-43 U/ml)
ALT 276 (5-54 U/ml)

The patient developed cough, coryza and worsening of previous symptoms.  As a viral illness was initially suspected, specimens were sent for serological testing which ultimately revealed recent Epstein Barr virus (EBV) and cytomegalovirus (CMV) infections.  Follow-up lab work revealed more marked thrombocytopenia (platelet count – 37) and further elevation of liver transaminases (AST – 530; ALT – 572).

A bone marrow was performed and additional lab work for triglyceride, ferritin and fibrinogen levels was ordered.


Microscopic Photographs of Bone Marrow: