So… we have a leucoerythroblastic film (left shifted granulopoiesis and nucleated red cells) along with tear drop cells.

The main differentials the team came up with were:

• Myelofibrosis (primary or secondary – he did have a haematology past)
• Metastatic carcinoma
• Beta thalassaemia
• Iron deficiency

As us haematologists are keen we saw him for a marrow biopsy. We found out that he indeed previously had polycythaemia vera with the JAK2 V617F mutation. The initial marrow was a dry tap as expected… but we did see these  cells after looking around for a while:

Here is part of the trephine:

The marrow infiltration was patchy and in other areas it was heavily fibrotic with no evidence of carcinoma. His ferritin was low and had iron deficiency.

Final diagnosis

• Metastatic adenocarcinoma – colonic
• Secondary (post polycythaemia) myelofibrosis
• Iron deficiency