The patient had attained menopause 3 months earlier, before which she had regular cycles. There was no history of cough with expectoration, headache, arthralgia, and rash, and nor was there a history of recent travel to malaria endemic zone or exposure to any patient of tuberculosis. Examination of the patient revealed pulse rate of 118 per minute, blood pressure of 110/70 mm Hg (supine), and oral temperature of 38.3°C (101°F). She had find more moderate conjunctival pallor and scleral icterus. There was no lymphadenopathy, clubbing, eschar, or skin rashes. Oxygen saturation was 99% on room air, and there were no signs of respiratory Inhibitors,research,lifescience,medical distress in

the patient. Cardiovascular examination revealed a systolic flow murmur in the aortic area. The respiratory and nervous system examinations

were within normal limits. Her chest X-ray and abdomen ultrasound revealed no significant Inhibitors,research,lifescience,medical abnormalities except for mild hepatomegaly. Routine hematological evaluation, on admission, revealed very low hemoglobin (Hb); 22 g/L (120-160), hematocrit; 7.2% (35-45), total leukocyte count (TLC); 3×109/L (4-11), total platelet count (TPC); 64.5×109/L (150-450), absolute neutrophil count; 1.9×109/L (1.5-8×109/L), corrected reticulocyte count; 1.5% (0.5-2), Inhibitors,research,lifescience,medical red cell distribution width; 17.5% (11.5-14.5), mean corpuscular volume (MCV); 114.3 fL (80-98), mean corpuscular hemoglobin (MCH); 34.9 pg (26-32), and mean corpuscular hemoglobin Inhibitors,research,lifescience,medical concentration (MCHC); 30.6% (32-36). Peripheral smear showed pancytopenia

with a moderate degree of anisopoikilocytosis and a good number of macrocytes, macro-ovalocytes, and hypersegmented neutrophils. Bone marrow aspiration and trephine biopsy from the right posterior superior iliac Inhibitors,research,lifescience,medical spine revealed marked hypercellularity for age (70%), florid erythroid hyperplasia with an altered myeloid to erythroid ratio (1:2), megaloblastic dyspoiesis, and numerous giant metamyelocytes. Micromegakaryocytes and/or megakaryocyte clustering were not seen. Perl stain showed DNA ligase adequate marrow iron stores without any ring sideroblasts. There was no evidence of blast prominence (4%), granulomas, hemoparasites, malignancy, or increased reticulin condensation (figures 1 and ​and2).2). The bone marrow morphology was suggestive of megaloblastic anemia, which was confirmed biochemically by low levels of serum vitamin B12 (59.6 pg/mL, reference; 180- 900), low normal folic acid (3.9 ng/mL, reference; 4-24), and markedly elevated serum lactate dehydrogenase (LDH) [10,550 IU/L, reference; 225-420]. The patient’s routine liver and renal function tests were within normal limits except for mild unconjugated hyperbilirubinemia (total bilirubin; 4.8 mg/dL [0.2-1.2]/direct; 0.4 mg/dL [up to 0.3]). Her upper and lower gastrointestinal endoscopy did not show any abnormality.