Jahanzeb initially presented to local hospital in December 2021 with complaints of fever with chills, headache and joint pain for 15 days. He was managed conservatively there, and became afebrile. In April 2022, he again presented to CMH Bannu with complaints of fever off and on for 3 months. He was managed conservatively. Jahanzeb presented to PEMH on Oct 2022 with history of fever off/on for 1-year, joint pain, headache, undocumented weight loss, anorexia and generalized ill health. His CBC showed leukocytosis with bicytopenia. Peripheral smear was suggestive of MPN. He was referred to AFBMTC for assessment.

At AFBMTC, Blood CP showed WBC-26.6, HB-9.2, Plt-50. Bone marrow examination at AFBMTC was consistent with leukemoid reaction. Flow cytometry from AFIP showed about 3% of total population positive for CD33 and CD34, and about 13 % positive for CD13, CD33, CD117, CD4, HLA-DR and MPO. PCR for JAK2V617F and BCR- ABL1 were negative. Cytogenetics was normal. Patient was admitted at PEMH and was started on cytoreductive therapy (hydroxyurea) and was regularly followed with regular blood counts. He was shifted to AFBMTC in Nov 2022 with suspected diagnosis of CMML. BME done was consistent with CMML-1 (Myo 3). He was planned for Aza + venetoclax followed by allogenic BMT. He received 1x Cycle of Aza+ Veneto. He tolerated chemotherapy well.

He was fully matched with brother. He was transplanted on 27^th, March, 23, with (Bu^12.8 Cy^120, ATG⁵) used as conditioning protocol. Neutrophil engraftment was achieved on Day +17.

Jahanzeb had poor platelet engraftment and slow count recovery after neutrophil engraftment. He was started with Tab Eltrombopag on Day +14. He remained on platelet transfusion. Injection GCSF was also started on Day +14 and stopped on Day +20.