A 4-year-old male presented to his primary care physician with easy bruising, fever, malaise, and headache. He was started on amoxicillin for acute otitis media but continued to have fever, and his oral intake was also noted to be decreasing. CBC was obtained and was significant for WBC 1.9 × 109/L, hemoglobin 4.9 g/dL, MCV 88.6 fL, and platelets 6 ×109/L. The patient was admitted for further workup and management, including red blood cell and platelet transfusion. The patient was febrile on admission. Vital signs were otherwise stable. Physical exam showed reticular skin pigmentation and multiple petechiae. The patient had normal height velocity and no skeletal anomalies.

Bilateral bone marrow and aspirate was performed, with initial results revealing marked hypocellularity for age at 5% and no evidence of leukemia. Chest x-ray was performed and was negative for mediastinal mass but was significant for bibasilar lung opacities concerning for multifocal pneumonia.

Based on differential diagnosis, which of the following tests is least likely to lead to the appropriate diagnosis?
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Chandni Dargan, MD, Oluwaseun Olaiya, DO, Erin Hall, MD, and Mukta Sharma, MD
Division of Pediatric Hematology Oncology & BMT
Children’s Mercy Hospital, Kansas City, MO, USA

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