Clinical case findings at diagnosis and follow-up. (A) Diagnostic bone marrow iron stain (100 × ) showing abundant ring sideroblasts and multilineage dysplasia leading to a diagnosis of MDS with multilineage dysplasia and ring sideroblasts (MDS-MLD-RS). (B) Bone marrow biopsy (40 × ) 2.6 years after diagnosis obtained after initiation of azacytidine showing persistent multilineage dysplasia, erythroid hyperplasia, and new fibrosis (grade 1-2). (C) Clinical and laboratory parameters at diagnosis when the IPSS-M was not in use and at 2.2 years when the IPSS-M was in use upgrading the risk category to high, based on molecular findings. (D) Clinical course as illustrated by the bone marrow blast count, mutation profile obtained at each of the bone marrow biopsies (time 0, 0.8, 2.2, and 2.6 years), and new therapies initiated. ESA, erythropoiesis-stimulating agent; GM-CSF, granulocyte-macrophage colony-stimulating factor; HMA, hypomethylating agent.