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A two-year-old black African boy was referred to Ga-Rankuwa Hospital with generalized lymphadenopathy, hepatomegaly and multiple non-tender swellings over the head. A whole-body isotope [meta-iodobenzylguanidine (MIBG)] scan (left) was performed, which demonstrated a large primary tumour in the region of the left adrenal gland together with extensive skeletal metastases. A MIBG scan images the adrenal medulla and sympathetic nervous tissue, and these results, therefore, suggested metastatic neuroblastoma.

A bone marrow examination was performed as part of the clinical work-up and showed extensive infiltration by neuroblastoma cells. The patient was classified as stage IV.

Successive full blood counts showed pancytopenia. Microscopic examination of a peripheral blood film showed (on a single occasion) the presence of a group of closely adherent, immature cells with fibrils (right) that were very similar in appearance to the cells infiltrating the marrow.

The presence of cohesive clumps of neuroblastoma cells in the peripheral blood with associated fibrillar material is very rare.