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A 21-year-old male with ileal Crohn's disease on maintenance with azathioprine presented with fevers and pancytopenia. Erythrocyte 6-thioguanine nucleotide level was therapeutic. CT excluded an abscess and showed thickening of the rectum, sigmoid and terminal ileum. His condition failed to respond to azathioprine withdrawal, intravenous piperacillin/tazobactam and granulocyte colony-stimulating factor. Blood tests showed hyperbilirubinemia, transaminitis, marked hyperferritinemia (>7000 μg/l), hypofibrinogenemia and hypertriglyceridaemia. Bone marrow aspirate microscopy is shown in figure 1.
The patient developed rectal bleeding, refractory to blood product support …