A 34-year-old gentleman presented with reduced effort tolerance and palpitation for one-week duration. He had underlying thalassemia intermedia diagnosed at the age of 7 years old. Clinically, he was pale with frontal bossing, nasal bridge depression, prominent maxillary bones and hepatosplenomegaly. His hemoglobin level was 4.5g/dl and he required an admission for transfusion. A chest radiograph showed multiple ribs expansion bilaterally, indicates features of extramedullary hematopoiesis. The computed tomography of thorax showed diffuse bony changes with medullary expansion, cortical thinning and coarse trabeculation involved the ribs and paravertebral consistent with extramedullary hematopoiesis. His average hemoglobin level for the past few years were between 4g - 7g/dl indicating that he had been under-transfused contributing to his prominent extramedullary hematopoiesis features.