You have a patient awaiting a two week wait appointment for weight loss, fever and pancytopenia. He is rather obese so examination is difficult.  He has a history of diffuse large B cell non-Hodgkin lymphoma treated to complete remission ten years ago and splenectomy.

Differential diagnosis includes:

• B12 and folate deficiency
• Therapy-related myeloid neoplasm (encompassing secondary myelodysplasia and secondary acute myeloid leukaemia as a result of previous chemotherapy)
• Bone marrow infiltration due to malignancy, including relapse of his original lymphoma
• Viral infection/sepsis, including HIV
• Haemophagocytic lymphohistiocytosis
• Autoimmune
• Chemical/medication
• Environmental factors

The day of his haematology he is admitted with abdominal pain and the A&E doctor thinks he has marked heptomegaly.

Questions:

• What imaging would you like?
• What viral tests are appropriate?

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