INVESTIGATIONS
Thoracic radiographs were mostly unremarkable.
Abdominal ultrasound was performed and a moderate volume of free fluid was confirmed. Centesis was performed and a blood-tinged straw-coloured fluid was obtained (Fig. 1).

The liver lobes had rounded margins suggestive of hepatomegaly, but the echotexture was otherwise unremarkable and hepatic vessels were not distended. The spleen was enlarged and isoechoic to the liver.
The splenic capsule was indistinct. Echocardiography was also performed and ruled out a pericardial effusion.

CLINICAL PATHOLOGY
Haematology revealed a mild non-regenerative anaemia and mature neutrophilia.
Biochemistry revealed evidence of hepatocellular damage, although bile acids were not currently suggestive of hepatic dysfunction. Clotting times were unremarkable. D-dimers were increased but were not currently within the thromboembolic range.

Abdominal fluid was moderately cellular consisting of 74% neutrophils. Occasional mast cells were noted. Bacteria were not identified and culture was negative.

Figure 2. Heavily granulated mast cells and eosinophils in a splenic aspirate
(Modified Wrights stain, 500x magnification).

Splenic aspirates were performed under sedation and a large number of granular mast cells were identified (Fig.2).