A 48-year-old male refugee from the Middle East complains of slowly worsening fatigue, sluggishness, and a lack of concentration over a period of three to four years. Careful questioning reveals a history of intermittent vague lower back pain for the same duration.

He has experienced recurrent episodes of urinary frequency and dysuria since childhood. He says that these were 'only treated with pills', and it appears that they were not investigated further, due to his socioeconomic status. He does not drink but has smoked heavily, to a total of 10 pack years.

A complete blood count is significant for a hemoglobin of 9.6 g/dL, with a subsequent blood film demonstrating normocytic normochromic anemia. A tuberculin skin test is found to be negative.