Many years ago I was invited to play the CPC game at a university hospital. The pea-beneath-a-walnut-shell arrangement was unusual. I was not required to guess the diagnosis; it was given to me (Evans' syndrome1). I was expected to explain the pathologist's report.
See also p 287.
The patient was a 35-year-old man who, during the six months before admission, had a nosebleed that persisted in spite of many office visits, many a cautery and packing of his nose. He came to the hospital emergency room at night because of syncope. He was pale and had a large spleen, copious epistaxis, and extensive purpura. Blood testing found 6 g of hemoglobin, a low leukocyte count, and thrombocytopenia. A midnight marrow aspiration was thought to confirm a suspicion of acute leukemia but, by dawn's early light, the abundant blasts were identified as erythroblasts; a profusion of megakaryocytes was present, and