METHODS Male, 20 FINAL DIAGNOSIS: Sickle cell anemia Symptoms: Bone marrow necrosis • bone pain • fever • hepatomegaly • icterus • splenomegaly • weakness METHODS - Clinical Procedure: - Specialty: Hematology. OBJECTIVE Unusual clinical course. BACKGROUND In sickle cell disease, bone involvement is the commonest clinical presentation in the acute as well as chronic setting presenting as painful vaso-occlusive crisis and avascular necrosis, respectively. Other complications include bone marrow necrosis and infarction. METHODS We report a case of a 20-year-old male who was referred for bone marrow evaluation due to symptoms of fever, weakness, and repeated episodes of bone pains. Bone trephine biopsy revealed multiple areas of central necrosis surrounded by fibroblasts. CONCLUSIONS Recognition of necrosis through bone trephine biopsy is important for early initiation of therapy.