An 18-year-old, previously healthy woman was admitted for urgent evaluation and management of symptomatic anemia after presenting to her primary care physician with fatigue and shortness of breath. The initial outpatient evaluation was remarkable for hypochromic, microcytic anemia with a hemoglobin level of 6.7 gm/dl. Three months prior to her admission, the patient developed a persistent cough without wheezing or other symptoms of a preceding upper respiratory infection. Her respiratory symptoms progressed to include dyspnea and gradually worsened despite treatment with amoxicillin and bronchodilators. There was no chest pain. In addition, she reported fatigue that began one month prior to presentation to her physician while she was showing swine at a local livestock competition and rodeo. Her mother recalled the patient having a pale appearance upon returning from the rodeo, though the patient was able to attend school and carry out her afterschool activities.

In the week prior to admission, the patient had noticed her urine was dark but dismissed this as a side effect of the iron tablets she was taking. The day prior to admission, she noticed that both feet appeared swollen and were aching. She reported no previous instances of joint swelling or any fevers, night sweats, rashes, oral or nasal ulcers, alopecia, Raynaud’s phenomenon, photosensitivity, epistaxis, hearing loss, dysphagia, or numbness.