Case Report:
We present the case of a 15-year-old girl with no significant medical history who was admitted to the hospital for 2 weeks with chief complaints of shortness of breath, right-sided chest pain, and sudden dizziness. She mentioned of heavy menstrual loss a day prior to the onset of these symptoms. The patient denied recent sick contacts, travel, or taking medications. On physical examination, she had anicteric sclera, severe conjunctival pallor, normoactive bowel sounds, and a non-tender, non-distended abdomen without hepatosplenomegaly. She was afebrile (38.6 °C), her blood pressure was 80/46 mmHg, her heart rate was 120 beats per minute (bpm), and her respiratory rate was 32 breaths per minute (bpm). The physician suggested the patient get some clinical laboratory tests done and transfused a unit of blood the same day. Investigations showed microcytic hypochromic anemia (possibly due to iron deficiency) with thrombocytopenia in PBF, serum ferritin5.16 ng/ml hemoglobin 7.3 g/dl, ESR 85 mm/1st hr, platelet counts 15000/cu.mm. , RBC  count 3.03 million/cu.mm with HCT/PCV 24%, HBsAg(ICT) negative, HIV 1&2 negative. The patient then gets conservatively managed with 2 units of blood transfusion, tab. prednisolone, Cap. ferrous sulfate + zinc + folic acid, and various symptomatic medical treatments. Her anemia gradually improved and she was discharged after 8 days when her hemoglobin and ESR reached 12.0 g/dl and 15 mm/1st hr, respectively, with a suggestion of regular follow-up.
After eight weeks, the patient experienced the similar symptoms as earlier following heavy menstrual blood loss, and was brought to the hospital. This time, she came up with vesicular skin a rash across her face, neck, and chest, which she had developed two days before admission. Figure 1. Initial laboratory workup showed 5.6 grams/dl hemoglobin, ESR 72 mm/1st hr, with RBC count 2.11 million/cu.mm, HCT/PCV 87%, Total platelet count 47000/cu.mm, and mild leukocytosis, PBF, and bone marrow study illustrated Immune Thrombocytopenic purpura (ITP), ultrasound report of the whole abdomen reveals normal, HBsAg negative, immunological reports (ANA & anti ds DNA), CT report and biochemical study of blood displayed normally. Table 1. Clinically, she was diagnosed with chicken pox and treated with acyclovir, paracetamol, antihistamines, hydration, folic acid +zin, and three units of blood transfusion for severe anemia. Gradually, the patient’s condition improved anemia, symptoms of chickenpox disappeared, and other parameters returned to normal, and she was allowed to go home after 19 days with the advice of regular follow-up.