Case Presentation A 70-year-old woman presented with progressive weakness and fatigue.

The symptoms had begun about a month earlier, and she no longer felt well enough to do her housework or take her daily walk. Although her breathing was normal at rest, she was too short of breath to walk more than two or three blocks. The results of the complete blood cell count (CBC) performed in her physician's office were hemoglobin, 5.4 gm/dL; mean corpuscular volume (MCV), 103 m3; red cell distribution width (RDW), 19.8% (normal, 12%-15%), white blood cell count, 3,900/mm3 (48% neutrophils, 43% lymphocytes, 8% monocytes, 1% eosinophils); and platelets, 62,000/mm3. Based on these results, the patient was hospitalized. She had no history of recent bleeding, jaundice, fever, anemia, or heart disease. She had not been exposed to medications (other than occasional vitamins and aspirin) or toxins. She had not abused alcohol and had no previous hospitalizations. Findings on the physical examination were unremarkable except for mild tachycardia at rest (96 bpm), a blood pressure of 146/84 mm Hg recumbent and 142/78 mm Hg standing, pallor, external hemorrhoids, and trace pitting edema of the feet. Neither the liver nor spleen were palpable. The stool was negative for occult blood. A chest x-ray was normal, and an electrocardiogram showed only sinus tachycardia. The blood urea nitrogen (BUN) level was 15 mg/dL; glucose, 108 mg/dL; and total bilirubin, 1.2 mg/dL (normal, <1.2). Electrolyte levels were normal. A sickle cell preparation was negative. Orders were written to monitor vital signs, transfuse three units of packed red blood cells during the night, and arrange for a bone marrow aspiration and biopsy in the morning.