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A woman in her 60s had a 10-day history of a dry cough and thoracic back pain associated with a chest X-ray demonstrating an acute T9 compression fracture and a minor band of atelectasis in the right lower zone. She had been started on amoxicillin and tapentadol analgesia. Over the 24 hours prior to presentation, she had developed episodic visual changes and dizziness. On examination, there was mild confusion, normal oxygen saturations and a moderate sized left retinal haemorrhage The white cell count (WCC) at presentation was 351×10 9/L (reference interval 4.0–11.0) compared with a routine test performed 1 week prior to this presentation showing a WCC of 5.1×109/L indicating the highly proliferative nature of her disease at presentation.