A 29-year-old female, with a 3-year history of anemia and iron therapy, admitted for the work-up of refractory anemia. Blood cell counts were: leukocyte counts 3.4×10⁹/L, hemoglobin 7.8 g/dL, and platelet counts 155×10⁹/L. Peripheral blood film showed macrocytosis and severe poikilocytosis (A). Bone marrow (BM) aspirate showed marked erythroid hyperplasia with prominent dyserythropoiesis. Dysplastic changes were not evident in granulocytic and megakaryocytic lineages, and myeloblasts were 0.2% of all nucleated cells (B). Iron stain of BM aspirate revealed abundant ring sideroblasts (45% of the erythroid precursors) (C). Cytogenetic study of marrow cells showed 46,XX[20]. Fluorescent in situ hybridization analyses for myelodysplastic syndromes (MDS) were all negative. Non-clonal causes of sideroblastic anemia were excluded, and the diagnosis of refractory anemia with ring sideroblasts (RARS) was made. MDS mainly occurs in older individuals, and RARS is a rare subtype of MDS. Children and young adults, however, are not spared from the diagnosis of MDS. This case emphasizes that MDS may occur in young individuals.