A 12-year-old boy presents to the pediatric clinic with fatigue, recurrent nosebleeds, and easy bruising over the past month. His parents report he has been less active recently and noticed pale skin. There is no history of recent illness, medication use, or significant environmental exposures. His family history reveals a maternal uncle who died of bone marrow failure in his teens. You suspect aplastic anemia in this boy. As you prepare for a physical examination, you wonder about possible positive findings in this patient. Which of the following is not seen in aplastic anemia and its presence should suggest an alternative diagnosis?
