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CASE REPORT
An 83-year-old Dutch woman with a history of atrial fibrillation, bronchitis, and methotrexate use for rheumatoid arthritis and psoriasis, presented to the outpatient clinic of internal medicine with progressive fatigue and pancytopenia. She had been living in Spain for the past three years in Sant Jordi and Vinaros, and was visiting the Netherlands for the holidays. Blood results showed: haemoglobin 6.0 mmol/l, mean corpuscular volume 94 fl, thrombocytes 66 x 10⁹/l, leucocytes 1.0 x 10⁹/l, neutrophils 0.5 x 10⁹/l (with 2% myelocytes), lymphocytes 0.3 x 10⁹/l, and haptoglobin concentration of 1.31 g/l. Vitamin B12 and folic acid levels were normal. Normal renal and liver function tests were found, whereas a splenomegaly of 14 cm was noted on ultrasound examination. Methotrexate was stopped, as this was the presumed cause of her pancytopenia. One month later, the patient was admitted to the hospital with fever and persistent pancytopenia. Peripheral blood smear showed one particular monocyte with cytoplasmic inclusions (figure 1).
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