Abstract
A 27-year-old woman had a 4-week history of progressive dyspnea on exertion, palpitations, light-headedness during activity, and frontal headache. She denied having fever, cough, chest pain, or vertigo. Hematologic studies showed a hemoglobin concentration of 5.0 g/dL, a mean corpuscular volume of 102.9 fL, a total leukocyte count of 4.3 x 109/L (differential: neutrophils, 1.35 x 109; lymphocytes, 2.54 x 109; mononuclear cells, 0.39 x 109; eosinophils, 0.01 X 109; and basophils, 0.01 X 109),and a platelet count of 115 X 109/ L. She was hospitalized for further assessment. The patient's past medical history was remarkable for a chronic generalized seizure disorder; the last tonic-clonic seizure had occurred 3 months before the current admission. She experienced absence seizures daily. One episode of streptococcal pharyngitis was treated with orally administered penicillin 4 months before the current examination. Medications included valproic acid, 1 g/day in divided doses (a regimen that had been used for 7 years), and felbamate, 1,200 mg three times daily (therapy that had been initiated 7 months before hospitalization). She used nonprescription aspirin preparations for headaches. The patient had no family history of hematologic disorders, and a complete blood cell count performed 8 months previously had shown normal results. Menses were normal, and no other overt source of blood loss was identified. The patient had never received chemotherapy or radiation treatment, and no exposure to toxins was elicited. Physical examination revealed a resting tachycardia of 110 beats/min and a normal blood pressure, respiratory rate, and temperature. Pallor was noted. A grade 2 (on the basis of 1 to 6) systolic murmur was heard over the precordium. No adenopathy, splenomegaly, or neurologic deficit was detected. Two painless ecchymoses, each less than 5 em in diameter, were seen over the left deltoid muscle and anterior aspect of the thigh. On admission, an electrolyte panel, liver
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