Repeated infections due to incipient haematological disease

We described a case of a 75 years man. He had a history of past cere-bral ischemic episode,and an acute heart failure and shoulder prote-sis. The first admission in our ward was on 10/2012, with a sintomaticbradiaritmia for persistent AF. We diagnosed a monoclonal gammopa-thy IgAk and a mild macrocitic anemia with folic deficiency. 1 monthlater he reentered in hospital with fever. Radiologic examination,werenegatives. There was a EColi in urine and blood culture. Laboratorytests showed also stable mild anemia,high ESR and PCR with FOB.Because of a high CHA2DS2-VASC risk, we suggest to continueTAO,also because colonscopy was negative. On 1/2013 he came backat our attention for fever,anorexia, vomiting. He had severe pancytopenia (WBC 2500; HB 7,9; Plt 13000)with high INR requiring stop of TAO. Radiologic studies showed a left pneumonia, responding to widespectrum antibiotic therapy (meropenem, teicoplanin, amikacin). Pan-cytopenia was not due to vitamin deficit; autoimmune antibodies,CMV-DNA and antiparvovirus antibodies were negatives, as epatitismarkers(with previous HBV-infection). Blood and urine cultures werenegatives. Direct and indirect antiglobulin test were negatives;coagu-lation test showed persistent alteration. There isn’t schistocytes in the peripheral blood smear, but we observe a cell with megakarioblastic habitus. Bone marrow aspiration was dry and bone biopsy showedmyelodisplasia with severe fibrosis and blast excess,there were some Megakaryocblast suggesting a possible evolution in M7-AML. For co-morbidities (cardiologic, vascular) patient was candidate only to demetilating agents