Background: Deferiprone is an effective oral iron chelator widely used to treat iron overload in transfusion-dependent thalassemia (TDT). However, its adverse effects, particularly arthropathy, can pose diagnostic challenges, especially in rural settings with limited access to imaging and pediatric hematology consultation. Deferiprone-induced arthropathy is typically reported in older children, with the youngest documented onset around four years of age. We report an unusually early presentation, emphasizing the importance of prompt recognition and appropriate modification of chelation therapy.

Methods: A 3-year-2-month-old boy with TDT developed progressive bilateral knee swelling and pain over three months while receiving long-term high-dose deferiprone therapy (>100 mg/kg/day). The availability of only one type of iron chelating agent in the hospital previously limited dose adjustment and hampered switching to alternative therapies. Clinical assessment, laboratory evaluation, radiographic imaging, and ultrasonography were performed to differentiate deferiprone-induced arthropathy from infectious, autoimmune, and inflammatory conditions.

Results: Physical examination revealed bilateral knee edema without erythema or warmth, with a pain-limited range of motion. Laboratory findings demonstrated normocytic anemia, neutropenia, elevated ferritin (3,203 ng/mL), and mild transaminitis. Radiographs and ultrasonography showed synovial thickening with subchondral irregularities and erosions without joint effusion, consistent with non-inflammatory arthropathy. No infectious or autoimmune features were identified, making juvenile idiopathic arthritis unlikely. Following discontinuation of deferiprone, initiation of deferasirox, administration of nonsteroidal anti-inflammatory drugs, and supportive therapy, the patient showed marked clinical improvement. However, valgus deformity and persistent epiphyseal irregularities were still observed at the 3-month follow-up.

Conclusions: This case highlights an unusually early onset of deferiprone-induced arthropathy, nearly two years earlier than previously reported. High-dose exposure and vulnerability of rapidly growing cartilage may have contributed. Early recognition is critical to prevent irreversible joint damage, particularly in resource-limited settings, to ensure timely diagnosis and appropriate modification of chelation therapy.

Patricia Amanda Widjaja is a medical doctor with a strong interest in pediatric hematology and oncology. She obtained her medical degree from Atma Jaya Catholic University of Indonesia in 2024. She is currently completing her Indonesian medical internship program at Dr. (H.C.) Ir. Soekarno General Hospital in Bangka Belitung is a referral center offering hematology and oncology services. During her studies, she was actively involved in community service initiatives to improve child health and well-being. She has also published research in national medical journals and is currently preparing several case reports and clinical research projects in pediatrics, neonatology, hematology, and oncology. She is eager to further explore these areas and is passionate about advancing pediatric healthcare through clinical research and evidence-based practice.