FIGURE1 patient picture, he had features of thalassemia.

3-EXAMINATION

Examination revealed a fully conscious patient (GCS=15), puls 124 beats per minute, and blood pressure was 100/70mmhg. He was pale and his face shows features of thalassemia. His cardiac examination revealed normal first and second heart sound with a humic murmur all over the pericardium. Other systems were clear on examination.

4-INVESTIGATION

On presentation his blood test showed hemoglobin=6.7 g/dl, mean corpuscular volume =87.5 fl, platelets=319 x 10^3/Cmm, and WBCs = 8.8 x 10^3. urine analysis the pus cells count was 18-20/HPF, RBCs count (was 5-7)/HPF. renal function test was normal, electrolyte showed hyponatremia, hypokalemia, and hypocalcemia. The widal test for brucella was insignificant. No malaria parasites have been seen in the blood film. TSH= 2.69, LFT showed AST 21, ALT 15, ALP 159. Abdominal X-ray showed distended large bowel with an air-fluid level. upper GI endoscopy was done showing several 2mm red spots in the upper body of the stomach. Abdomino-pelvic U/S was done and was normal apart from hepatomegaly. echocardiography was done and was normal. hormonal analysis was done and showed features of hypo gonads ( LH, FSH, and testosterone were low), MRI brain was done and showed pituitary macro adenoma. analysis for somatomedin c was done and was on the lower limit of normal, prolactin level done and was normal.

Investigation done regarding his long-standning problems of recurrent anemia, and bloody diarrhea: hemoglobin electrophoresis done was normal, upper GI endoscopy done show mild lower-end esophagitis with incompetent cardia, Colonoscopy was done showed inflamed internal piles, serum amylase = 2064 U/L. Bone marrow aspiration was done and showed hypercellular bone marrow with no abnormal infiltration. CT’s Chest and abdomen did and were normal. bilirubin, LDH, serum ferritin, and serum iron were low, B12 level was high, and BUN/crt was normal. reticulocyte count was low, the direct coombs test was negative and the viral screen was negative, the folate level was negative, and the gliadin screen was less than 0.6.

The last upper GI endoscopy show mild erosion in the stomach and duodenum, and a colonoscopy was done and showed multiple erosive and skip lesions, and biopsy was taken and the result showed lymphocytic infiltration.