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A 53-year-old woman was referred to the haematology clinic with neutropenia. She had been diagnosed with seropositive rheumatoid arthritis (RA) in 1985. Treatment with sulphasalazine, penicillamine and hydroxychloroquine, as single agents as well as in combination, was unsuccessful due to inefficacy or the development of side effects. She had previously received treatment with sodium aurothiomalate (gold) between September 1992 and June 2000 in doses varying between 10 mg monthly and 50 mg weekly, with a cumulative dose of 10 440 mg (10·44 g) over this period. This treatment had to be stopped due to the development of a fixed drug reaction, which resolved several weeks after withdrawal. Subsequent treatment with methotrexate at 15 mg weekly and hydroxychloroquine achieved remission of her RA. During 2007 she developed neutropenia, which failed to resolve on withdrawal of methotrexate. Ultrasonography of her abdomen did not reveal splenomegaly. A bone marrow aspirate was performed which showed good overall cellularity with normal maturation in all cellular elements. The trephine biopsy section showed normal cellularity together with several small lymphoid aggregates, within which there was a granular deposit (left). Stains for iron, melanin and CD68 were negative. By a technique of autometallographic silver enhancement it was demonstrated that these were colloidal gold deposits within the bone marrow (right).

Following the bone marrow aspiration, methotrexate was resumed. Fortnightly monitoring of her white cell count facilitated an increase of her methotrexate dose to 20 mg weekly upon which her white cell count improved and entered into the lower end of the normal range.