A 72-year-old woman has had increasing fatigue with a 3 kg weight loss over the past 7 months. Her hands become purple and painful upon exposure to cold. On physical examination she has a palpable spleen tip. Laboratory studies show Hgb 10.5 g/dL, Hct 31.7%, MCV 99 fL, platelet count 193,600/microliter, and WBC count 5390/microliter. The direct Coombs test is positive at 4 C and negative at 37 C. Which of the following underlying diseases is this woman most likely to have?

 A Non-Hodgkin lymphoma
 B Systemic lupus erythematosus
 C Pernicious anemia
 D Scleroderma
 E Thalassemia minor

Ans D

Ans D