European Journal of Internal Medicine xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine
journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor
Prevalence of thrombocytopenia and thrombocytosis upon acute hospital admission to internal
medicine units. A cross-sectional study in Denmark
A R T I C LE I N FO
Keywords:
Thrombocytopenia
Thrombocytosis
Prevalence
Hospital
Epidemiology
Platelets are involved in primary hemostasis by initiating clot for-
mation. However, they have pleiotropic effects [1]. Due to these mul-
tiple effects and the frequency of stress and inflammation in acutely
hospitalized patients, thrombocytopenia and thrombocytosis may be of
concern in this setting.
However, the frequency of abnormal platelet count upon acute
hospital admission in adults, unselected as regards the reason for hos-
pitalization, is largely unknown. The objective of this study was to as-
sess the prevalence of thrombocytopenia and thrombocytosis upon
admission in acutely hospitalized adults in internal medicine units,
overall and depending on age, sex, primary discharge diagnoses, pre-
sence of malignancy or other comorbidities.
This cross-sectional study was conducted within the Danish
National Patient Registry (DNPR) that records data for all admissions to
Danish non-psychiatric hospitals since 1977 and for all emergency de-
partment and outpatient specialist clinic visits since 1995. At least one
primary diagnosis is recorded at discharge for every inpatient and
outpatient stay or visit. Since 1994, these diagnoses are encoded using
the International Classification of Disease (ICD) version 10 [2].
The inclusion criteria were: i) adult patients (> 15 years); ii) an
acute admission [3] to internal wards of the North and Central Den-
mark Regions between January 1st, 2006 and December 31st, 2012; iii)
no surgical, oncologic, gynecologic or obstetric hospitalizations re-
corded within 30 days prior to the index admission; and v) a mea-
surement of platelet count at the time of admission ± 24 h searched
within the LABKA database [4]. For each identified patient, we only
considered the first acute admission to hospital in the analyses.
Thrombocytopenia was defined as a platelet count < 150 × 10 [9]/L.
We further categorized thrombocytopenia as severe, moderate, and
mild based on platelet counts < 50 × 10 [9]/L, between 50 × 10 [9]/L
and 99 × 10 [9]/L and between 100 × 10 [9]/L and 149 × 10 [9]/L,
respectively. Thrombocytosis was defined as a platelet count > 400
× 10 [9]/L, and > 450 × 10 [9]/L as sensitivity analyses. Mild
thrombocytosis was defined as a platelet count between 401 × 10 [9]/L
and 799 × 10 [9]/L while severe thrombocytosis was defined as a
platelet count ≥800 × 10 [9]/L. If several platelet counts had been
measured during time of admission ± 24 h, we only considered the first
measurement.
https://doi.org/10.1016/j.ejim.2018.08.014
Received 19 August 2018; Accepted 27 August 2018
0953-6205/ © 2018 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
We assessed the prevalence of thrombocytopenia and thrombocy-
tosis at admission to hospital overall, and by age groups (quartiles: <
45, 45–59, 60–75 and ≥ 75 years), sex, categories of primary discharge
diagnoses (ICD-10 codes listed in Supplementary Material, Table S1),
the 19 comorbidities included in the Charlson Comorbidity Index
(identified using inpatient and outpatient specialist clinic diagnoses
recorded in the DNPR prior to the index hospitalization and the asso-
ciated diagnoses of the index hospitalization, see ICD-10 codes in
Supplementary Material, Table S2) [5] and by presence/absence of
recent cancer (defined by at least one in- or outpatient ICD-10 code of
cancer – C00-C97, D00-D09 and D37-D48 – recorded within five years
prior to or during the index hospitalization. Statistical analyses were
performed using SAS V9.4™ software (SAS Institute, Cary, NC, USA).
This study was approved by the National Data Protection Agency for
this study (record no. 2015–57-0002, AU record no. 2016–051-000001/
396).
During the study period, we identified 342,425 adults with acute
admission to hospital. Among them, 274,148 (80.1%) had a platelet
count measurement at admission. Few differences were observed be-
tween patients with and without a platelet count measurement upon
admission (Supplementary Material, Table S3).
Results are indicated in Table 1. Overall, 18,642 (6.8%) patients had
thrombocytopenia at admission to hospital, including 1371 (0.5%) with
severe thrombocytopenia. On the opposite, 21,452 (7.8%) had throm-
bocytosis (4.5% using the cut-off of 450 × 10 [9]/L, see Supplementary
Material Table S4), mostly mild thrombocytosis (n = 20,813; 7.6%).
The prevalence of mild thrombocytopenia and thrombocytosis in-
creased with age. Thrombocytopenia was more frequent in men (9.0%
vs. 4.6%), and thrombocytosis in women (10.1% vs. 5.5%). We ob-
served the highest prevalences of thrombocytopenia in patients ad-
mitted for liver disease (26.1%), sepsis (21.3%), cancer (15.7%), gas-
trointestinal bleeding (11.6%), intracerebral hemorrhage (10.7%),
congestive heart failure (9.6%) and kidney diseases (9.2%). The pre-
valence of thrombocytosis was highest in patients admitted for diges-
tive bleeding (17.9%), other gastrointestinal diseases (16.1%), lower
respiratory tract infection (15.0%), musculoskeletal and connective
tissue diseases (11.6%), kidney diseases (11.5%), respiratory diseases
(10.8%) and sepsis (9.7%). As regards comorbidities, the highest
Letter to the Editor European Journal of Internal Medicine xxx (xxxx) xxx–xxx

Table 1
Prevalence of thrombocytopenia and thrombocytosis upon admission to hospital, overall and by age groups, sex, primary discharge diagnoses and comorbidities.
Population Numbers of Thrombocytopenia, n (%) Thrombocytosis, n (%)
patients with
platelet Severe Moderate Mild Any Mild Severe Any
count (< 50 × 109/L) (50–99 × 109/L) (100–149 × 109/L) (< 150 × 109/L) (401–799 × 109/L) (≥800 × 109/L) (> 400 × 109/L)

Overall 274,148 1371 (0.50) 4823 (1.76) 13,819 (5.04) 18,642 (6.80) 20.813 (7.59) 639 (0.23) 21,452 (7.82)
Age groups (years)
< 45 66,078 264 (0.40) 510 (0.77) 2372 (3.59) 3146 (4.76) 3614 (5.47) 63 (0.10) 3677 (5.56)
≥45 and < 60 57,755 373 (0.65) 974 (1.69) 2563 (4.44) 3910 (6.77) 4010 (6.94) 131 (0.23) 4141 (7.17)
≥60 and < 75 76,306 410 (0.54) 1077 (1.41) 4150 (5.44) 5637 (7.39) 6310 (8.27) 212 (0.28) 6522 (8.55)
≥75 74,009 324 (0.44) 891 (1.20) 4735 (6.40) 5949 (8.04) 6879 (9.29) 233 (0.31) 7112 (9.61)
Sex
Males 136,197 783 (0.57) 2269 (1.67) 9230 (6.78) 12,282 (9.02) 7278 (5.34) 248 (0.18) 7526 (5.53)
Females 137,951 588 (0.43) 1183 (0.86) 4589 (3.33) 6360 (4.61) 13,535 (9.81) 391 (0.28) 13,926 (10.09)
Primary discharge
diagnoses
Infections 45,554 228 (0.50) 831 (1.82) 3439 (7.55) 4498 (9.87) 4898 (10.75) 159 (0.35) 5057 (11.10)
Lower respiratory 19,990 68 (0.34) 287 (1.44) 1259 (6.30) 1614 (8.07) 2904 (14.53) 101 (0.51) 3005 (15.03)
tract
Sepsis 3335 75 (2.25) 189 (5.67) 446 (13.37) 710 (21.29) 308 (9.24) 14 (0.42) 322 (9.66)
Other infections 22,229 85 (0.38) 355 (1.60) 1734 (7.80) 2174 (9.78) 1686 (7.58) 44 (0.20) 1730 (7.78)
Cardiovascular 59,422 88 (0.15) 454 (0.76) 3098 (5.21) 3640 (6.13) 2618 (4.41) 69 (0.12) 2687 (4.52)
diseases
Ischemic stroke 9951 5 (0.05) 33 (0.33) 400 (4.02) 438 (4.40) 376 (3.78) 9 (0.09) 385 (3.87)
Intracerebral 925 6 (0.65) 25 (2.70) 68 (7.35) 99 (10.70) 47 (5.08) 2 (0.22) 49 (5.30)
bleeding
Acute ischemic 9135 11 (0.12) 49 (0.54) 423 (4.63) 483 (5.29) 416 (4.55) 9 (0.10) 425 (4.65)
heart disease
Congestive heart 3555 8 (0.23) 57 (1.60) 276 (7.76) 341 (9.59) 201 (5.65) 7 (0.20) 208 (5.85)
failure
Other 35,856 58 (0.16) 290 (0.81) 1931 (5.39) 2279 (6.36) 1578 (4.40) 42 (0.12) 1620 (4.52)
cardiovascular
diseases
Respiratory diseasesa 12,344 23 (0.19) 72 (0.58) 531 (4.30) 626 (5.07) 1304 (10.56) 26 (0.21) 1330 (10.77)
Gastrointestinal 11,386 125 (1.10) 371 (3.26) 725 (6.37) 1221 (10.72) 1510 (13.26) 50 (0.44) 1560 (13.70)
diseases
Digestive bleeding 1010 13 (1.29) 36 (3.56) 68 (6.73) 117 (11.58) 169 (16.73) 12 (1.19) 181 (17.92)
Liver diseases 2788 95 (3.41) 277 (9.94) 355 (12.73) 727 (26.08) 157 (5.63) 2 (0.07) 159 (5.70)
Other 7588 17 (0.22) 58 (0.76) 302 (3.98) 377 (4.97) 1184 (15.60) 36 (0.47) 1220 (16.08)
gastrointestinal
diseases
Urogenital diseases 8215 18 (0.22) 105 (1.28) 587 (7.15) 710 (8.64) 726 (8.84) 14 (0.17) 740 (9.01)
Kidney diseases 1389 4 (0.29) 27 (1.94) 97 (6.98) 128 (9.22) 157 (11.30) 3 (0.22) 160 (11.52)
Endocrine diseases 6392 7 (0.11) 62 (0.97) 292 (4.57) 361 (5.65) 428 (6.70) 9 (0.14) 437 (6.84)
Diabetes 4320 5 (0.12) 47 (1.09) 208 (4.81) 260 (6.02) 302 (6.99) 7 (0.16) 309 (7.15)
Thyroid diseases 816 0 8 (0.98) 24 (2.94) 32 (3.92) 52 (6.37) 0 52 (6.37)
Other endocrine 1267 2 (0.16) 7 (0.55) 61 (4.81) 70 (5.52) 74 (5.84) 2 (0.16) 76 (6.00)
diseases
Neurologic diseases 12,981 12 (0.09) 65 (0.50) 475 (3.66) 552 (4.25) 556 (4.28) 16 (0.12) 572 (4.41)
Musculoskeletal and 9586 15 (0.16) 41 (0.43) 263 (2.74) 319 (3.33) 1082 (11.29) 29 (0.30) 1111 (11.59)
connective tissue
diseases
Cancer 5911 258 (4.36) 277 (4.69) 392 (6.63) 927 (15.68) 1118 (18.91) 70 (1.18) 1188 (20.10)
Observation for 67,764 171 (0.25) 521 (0.77) 2620 (3.87) 3312 (4.89) 3618 (5.34) 99 (0.15) 3717 (5.49)
suspected diseases
Other 48,267 468 (0.97) 796 (1.65) 2231 (4.62) 3495 (7.24) 3842 (7.96) 120 (0.25) 3962 (8.21)
Charlson Comorbidity
Index score
0 160,817 636 (0.40) 1465 (0.91) 6974 (4.34) 9075 (5.64) 10,491 (6.52) 315 (0.20) 10,806 (6.72)
1–2 82,391 427 (0.52) 1145 (1.39) 4536 (5.50) 6107 (7.41) 7165 (8.70) 221 (0.27) 7386 (8.96)
>2 30,940 308 (1.00) 842 (2.72) 2310 (7.47) 3460 (11.18) 3157 (10.20) 103 (0.33) 3260 (10.54)
Charlson Comorbidity
Index conditions
Myocardial 14,315 64 (0.45) 167 (1.17) 1160 (8.10) 1391 (9.72) 847 (5.92) 25 (0.17) 872 (6.09)
infarction
Congestive heart 11,267 45 (0.40) 171 (1.52) 931 (8.26) 1147 (10.18) 845 (7.50) 32 (0.28) 877 (7.78)
failure
Peripheral vascular 14,329 67 (0.47) 198 (1.38) 911 (6.36) 1176 (8.21) 1413 (9.86) 62 (0.43) 1475 (10.29)
disease
Cerebrovascular 22,980 84 (0.37) 295 (1.28) 1314 (5.72) 1693 (7.37) 2016 (8.77) 63 (0.27) 2079 (9.05)
disease
Dementia 2789 8 (0.29) 38 (1.36) 158 (5.67) 204 (7.31) 311 (11.15) 9 (0.32) 320 (11.47)
Chronic pulmonary 28,040 110 (0.39) 269 (0.96) 1219 (4.35) 1598 (5.70) 2956 (10.54) 87 (0.31) 3043 (10.85)
disease
Connective tissue 9947 87 (0.87) 139 (1.40) 467 (4.68) 692 (6.96) 1083 (10.89) 39 (0.39) 1122 (11.28)
disease
(continued on next page)

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Letter to the Editor European Journal of Internal Medicine xxx (xxxx) xxx–xxx

Table 1 (continued)

Population Numbers of Thrombocytopenia, n (%) Thrombocytosis, n (%)

patients with
platelet Severe Moderate Mild Any Mild Severe Any
count (< 50 × 109/L) (50–99 × 109/L) (100–149 × 109/L) (< 150 × 109/L) (401–799 × 109/L) (≥800 × 109/L) (> 400 × 109/L)

Ulcer disease 14,141 104 (0.74) 285 (2.02) 857 (6.06) 1246 (8.81) 1516 (10.72) 35 (0.25) 1551 (10.97)
Mild liver disease 4137 149 (3.60) 517 (12.50) 620 (14.99) 1286 (31.09) 227 (5.49) 7 (0.17) 234 (5.66)
Moderate/severe 1133 83 (7.33) 257 (22.68) 199 (17.56) 539 (47.57) 53 (4.68) 3 (0.26) 56 (4.94)
liver disease
Diabetes without 17,134 83 (0.48) 253 (1.48) 1031 (6.02) 1367 (7.98) 1528 (8.92) 31 (0.18) 1559 (9.10)
complication
Diabetes with 8480 30 (0.35) 107 (1.26) 526 (6.20) 663 (7.82) 778 (9.17) 19 (0.22) 797 (9.40)
complication
Hemiplegia 1224 2 (0.16) 28 (2.29) 52 (4.25) 82 (6.70) 130 (10.62) 4 (0.33) 134 (10.95)
Moderate/severe 5547 23 (0.41) 108 (1.95) 405 (7.30) 536 (9.66) 441 (7.95) 7 (0.13) 448 (8.08)
renal disease
Malignant tumor 27,077 174 (0.64) 453 (1.67) 1690 (6.24) 2317 (8.56) 2981 (11.01) 105 (0.39) 3086 (11.40)
Leukemia 1007 93 (9.24) 130 (12.91) 174 (17.28) 397 (39.42) 42 (4.17) 8 (0.79) 50 (4.97)
Lymphoma 2126 80 (3.76) 181 (8.51) 276 (12.98) 537 (25.26) 126 (5.93) 6 (0.28) 132 (6.21)
Metastatic cancer 4033 49 (1.21) 127 (3.15) 302 (7.49) 478 (11.85) 599 (14.85) 25 (0.62) 624 (15.47)
HIV infection 270 2 (0.74) 9 (3.33) 32 (11.85) 43 (15.93) 14 (5.19) 1 (0.37) 15 (5.56)
Recent cancerb
Yes 24,668 447 (1.81) 827 (3.35) 1813 (7.35) 3087 (12.51) 3240 (13.13) 185 (0.75) 3425 (13.88)
No 249,480 924 (0.37) 2625 (1.05) 12,006 (4.81) 15,555 (6.23) 17,573 (7.04) 454 (0.18) 18,027 (7.23)

a
Excluding lower respiratory tract infections.
b
Within the 5 years prior to the index hospitalization.

prevalence of thrombocytopenia and thrombocytosis were observed for
patients with mild and moderate/severe liver diseases and metastatic
cancer, respectively (Table 1).
Of note, 795 patients had a new diagnosis of hematological disease
at the index hospitalization (lymphoid malignancies, n = 580; immune
thrombocytopenia, n = 103; myeloid disorders, n = 83; myelodys-
plastic syndromes, n = 29). Most of them had abnormal platelet counts
upon admission (Supplementary Material, Table S5).
Our overall prevalence of thrombocytopenia and thrombocytosis
upon acute admission were higher than the prevalence of 2.9% and
1.8%, respectively, found in the general population of adults aged
≥35 years in the Italian MOLI-SANI study [6], suggesting the role of
additional disease-related underlying mechanisms of platelet count
abnormalities in hospitalized patients. Variations of prevalence by age,
sex, and Charlson Comorbidity Index score in this study have been
previously suggested in the general population [7,8]. Cancer is highly
associated with thrombocytopenia and thrombocytosis, as supported by
the decreasing prevalences from the patients admitted for cancer, those
with a recent cancer, and those with any previous cancer as listed
among the Charlson Comorbidity Index comorbidities.
This study suffers from limitations. First, only 80.1% of the patients
had a platelet count measurement at admission. However, only slight
differences were observed between the included and excluded patients.
Second, diagnoses rely on codes. Albeit most of them have been pre-
viously validated in the DNPR [2], we cannot rule out miscoding:
congestive heart failure [9] and sepsis may have been underestimated.
Lastly, since we only included patients admitted to medical wards, the
number of patients with digestive bleeding was relatively low.
In conclusion, thrombocytopenia and thrombocytosis were frequent
upon acute admission to internal medicine wards. This study helps in
identifying patients who would necessitate a platelet count screening
and prompts further studies regarding the association of platelet counts
with clinical outcomes.
1. Learning points
• This study assessed the prevalences of thrombocytopenia and
thrombocytosis upon acute hospital admission in internal medicine
wards.
• These prevalences were 6.8% and 7.8%, respectively. The
prevalence of severe thrombocytopenia (< 50 × 10 [9]/L) was
0.5%.
• The prevalence of thrombocytopenia and thrombocytosis increased
with age, the presence of cancer and the number of comorbidities.
Thrombocytopenia was more frequent in men.
• The primary discharge diagnoses associated with a high rate of
thrombocytopenia were sepsis, liver diseases, cancer, gastro-
intestinal bleeds, hemorrhagic stroke, congestive heart failure and
moderate to severe chronic kidney disease.
• The primary discharge diagnoses associated with a high rate of
thrombocytosis were gastro-intestinal bleeds, other gastro-intestinal
diseases, lower respiratory tract infection, musculoskeletal, kidney,
respiratory diseases and sepsis.
Conflict of interests
The authors report having no conflict of interest related to this
study.
Funding source
To conduct this study, GM received grants from the Foundation for
the Development of Internal Medicine in Europe (FDIME, linked to the
European Federation of Internal Medicine), from the Institut Servier and
from Toulouse University Hospital (CHU de Toulouse).
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ejim.2018.08.014.
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⁎
Corresponding author.