Drug induced megaloblastic anaemia with abnormal skin pigmentation

A 19-year old boy with cervical lymphadenopathy, no constitutional symptoms, a positive lymph node biopsy and high levels of IgG for toxoplasma had a 6-week course of cotrimoxazole and pyrimethamine. He developed vomiting, abdominal pain, diarrhoea, loss of appetite, loss of weight and a grey discolouration of his face, axillae, hands and feet. Addison’s disease had been excluded by appropriate laboratory investigation at this hospital. As there was worsening of his condition even after three weeks of treatment the patient sought admission to our unit.