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患者男,9岁,住院号91-5546。因面色苍白、乏力,鼻衄40天,进行性加重8天,在当地医院用青霉素、中药治疗无效,于1991年6月12日入本院。无特殊嗜好反毒物接触史,家族中亦无类似病史。 查体:T39.1℃,重度贫血貌。皮肤、粘膜无黄染,胸前及双下肢可见散在出血斑点。浅表淋巴不大,胸骨无压痛,双肺正常,心律齐,心率120次/min,心尖区闻及SMⅡ。肝脾(一)。实验室检查:Hb40g/L,BT4.5＇,CT3.5＇,RC0.1％。骨髓像示增生重度减低,全片未见巨核细胞,血小板罕见,淋巴细胞比值相对增高,浆细胞、网状细胞、组织嗜碱等非造血细胞明显增多。骨髓诊断:
Patient male, 9 years old, hospital number 91-5546. Due to pale, weakness, epistaxis 40 days, progressive exacerbations of 8 days in the local hospital with penicillin, traditional Chinese medicine treatment ineffective, June 12, 1991 into our hospital. No special addiction anti-drug exposure history, no similar family history. Physical examination: T39.1 ℃, severe anemia appearance. Skin, mucous membrane without yellow dye, chest and lower limbs visible scattered bleed spots. Superficial lymphatic, sternal no tenderness, normal lungs, heart rate Qi, heart rate 120 beats / min, apex area smell and SM Ⅱ. Liver and spleen (a). Laboratory tests: Hb40g / L, BT4.5 ’, CT3.5’, RC0.1%. Bone marrow showed hyperplasia significantly reduced, the whole piece no megakaryocytes, rare platelets, the relative increase in lymphocyte ratio, plasma cells, reticulocytes, tissue alkaloids and other non-hematopoietic cells increased significantly. Bone marrow diagnosis: