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A 17-year-old woman of Afro-Caribbean origin presented with a 1 month history of abdominal pain associated with vomiting and weight loss. Symptoms had gradually become more frequent and persistent. She had previously been well and had no previous hospital attendances or illnesses.
Vital signs and physical examination was normal with the exception of tenderness in the epigastrium on palpation.
Initial bloods tests revealed the following abnormalities only; platelets 520, alkaline phosphatase 169, C-reactive protein 73, international normalised ratio 1.3.
An x-ray of her chest was abnormal with bilateral reticular nodular shadowing and CT of her chest, abdomen and …