International J.

of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 43-
46

Case Report:
Iron deficiency anemia with thrombocytosis: a diagnostic challenge
1Abha Chandna, 2Jyoti Sharma, 3Ashok Sangwaiya,4 Swagatika Samal, 5Manoj Sankala, 6Shilpa Garg
1Senior Resident, Deptt of Pathology, PGIMS, Rohtak , Haryana (India)
2Senior Resident, Deptt of Pathology, PGIMS, Rohtak , Haryana (India)
3Senior Resident, Deptt of Pathology, PGIMS, Rohtak , Haryana (India)
4Junior Resident, Deptt of Pathology, PGIMS Rohtak, Haryana
5Junior Resident, Deptt of Pathology, PGIMS Rohtak, Haryana
6Assistant Professor, Deptt of pathology, PGIMS Rohtak, Haryana
Corresponding Author: Dr Jyoti Sharma

Abstract:
Thrombocytosis,a common hematologic finding can present as incidental finding and pose a great
diagnostic challenge. Thrombocytosis can be due to reactive process or due to clonal disorder. Platelet
count more than
3 3
1,000x10 /mm is usually caused by clonal disorder. Reactive causes like Iron deficiency anemia rarely lead to
3 3
platelet counts more than 700x10 /mm . Here we report a case of a young woman presenting with iron
3 3
deficiency anemia associated with thrombocytosis with platelet count 1,308x10 /mm .
Keywords: Thrombocytosis, Iron deficiency anemia

Introduction Case Report

Thrombocytosis is commonly encountered in clinical A 23 year old female presented with pain abdomen,
setting with majority of cases discovered fatigue and shortness of breath since 1 month.
incidentally. Thrombocytosis can be attributed to She had history of heavy menstrual bleeding since 6
autonomous (neoplastic) overproduction or as a months.There was no history of bleeding from other
reactive overproduction secondary to infections, sites. On examination pallor was present, no icterus,
1
iron deficiency anemia, malignancies. Iron petechiae, ecchymosis or purpuric lesions were
deficiency anemia usually results in mild to noted. Her haemoglobin was 7.4g/dl (Normal
2
moderate degree of reactive thrombocytosis. The range
mechanism leading to secondary or reactive 12-15g/dl), platelet count was
3 3
1,308x10 /mm (normal
thrombocytosis is not completely understood. The
3 3
range 150-450x10 /mm ).Total leucocyte count and
accelerated megakaryopoiesis may result due to
differential leucocyte count were within
elevated megakaryocytic growth factors such as
3 normal range. Total leucocyte count- 6700
thrombopoietin, Interleukin (IL)-6 or IL-11. But
(Normal 4-
despite many efforts exact cause behind enhanced 3 3
11x10 /mm , differential leucocyte count-
megakaryopoiesis is vaguely known and further
neutrophils
investigation is required.
65%, lymphocyte 30%, monocyte 3%,
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 International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 01, October 2014, Pages 43-
46
eosinophil
2%, basophil 0%. Mean corpuscular volume was
62.8 fl (Normal range 80-100 fl), Mean corpuscular
haemoglobin was 16.3pg (Normal range 27-32 pg),
Mean corpuscular haemoglobin concentration
was

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25.9g/dl (Normal range 32-37g/dl), Red cell Platelets (thrombocytes) are produced by mature
distribution width (RDW) was 27.2% (Normal megakaryocytes. Adult humans produce about 100
4
range billion thrombocytes per day. The major
11%-15%). Iron studies revealed serum iron 20µg/dl
(Normal range 50-170 µg/dl), serum ferritin was 5.56
ng/dl (Normal range 12-150 ng/dl), serum
transferring binding capacity was 416.8 mg/dl (
Normal range 204-360 mg/dl), percent saturation
was
6% (Normal range 16-45%). Results of iron studies
were consistent with iron deficiency anemia. The
peripheral blood smear showed microcytic
hypochromic cells with increased number of
platelets. Bone marrow aspiration study revealed
erythroid hyperplasia with micronormoblastic
erythropoiesis and megakaryocytic hyperplasia.
Overall bone marrow picture doesnot support
diagnosis of Essential thrombocythemia.
Megakaryotes were normal in morphology, giant
megakaryocytes were absent and megakaryocytes
donot show clustering. Prussian blue stain revealed
decreased storage iron. Ultrasound of pelvis showed
anteverted uterus with heterogenous thickening of
endometrium with thickness of 14 mm .Histological
examination of endometrial biopsy revealed
irregularly cystically dilated glands with minimal
atypia consistent with diagnosis of simple
endometrial hyperplasia without atypia. Her
coagulation parameters were normal. Patient was
administered one unit of packed red cells and was
advised to take oral iron supplements along with
progesterone therapy.5 weeks after iron
supplementation her haemoglobin was increased
to
11.2g/dl and platelet count decreased to
3 3
480x10 /mm .
Discussion
pathophysiologic cuses of thrombocytosis i.e. an amino acid sequence homology between
elevated platelet count are 1)clonal including thrombopoietin and
14
erythropoietin. In iron
essential(or primary) thrombocythemia and other deficiency anemia erythropoietin level gets increased
myeloproliferative disorders like polycythemia which explains thrombocytosis in Iron
vera,chronic myelogenous leukemia, idiopathic deficiency
myelofibrosis, myelodysplastic syndrome with 5q
abnormality 2)reactive in which
thrombocytosis occurs secondary to variety of acute
and chronic clinical conditions like acute
infection, Iron deficiency anemia, malignancies,
5
inflammatory bowel disease. Studies had shown
that reactive thrombocytosis is more common
than primary or
6
clonal thrombocytosis. Iron deficiency anemia
is
shown to be associated with reactive
7,8
thrombocytosis but platelet count rarely
exceeds
3 3
700x10 /mm as was depicted by Sanchez
and
9
Ewton. Platelet counts exceeding
3 3
1000x10 /mm was observed in few reports
10,11
only. In our patient keeping in view of severe
thrombocytosis haematological malignancy was
suspected initially. However bone marrow smear
examination did not
support the diagnosis of Essential
thrombocythemia or other myeloproliferative
disorders and iron studies further establishes the
diagnosis of iron deficiency anemia. Moreover
normalisation of platelet counts after correction of
iron status of the patient rules out the diagnosis of
essential thrombocythemia.The mechanisms behind
secondary thrombocytosis are not well defined
and seems to be complex and diverse.
Thrombopoietin is the key hormone which regulates
megakaryocyte differentiation and proliferation in
association with various cytokines like IL-1,IL-
12 13
6 ,IL-11. It has been shown that there is an
anemia. However few reports suggested that reactive marrow smears showed megakaryocytic
thrombocytosis and iron deficiency relationship is hyperplasia.Till now only few reports mentioned the
more complex as few patients with iron deficiency elevated megakaryocyte counts in iron deficiency
anemia and elevated erythropoietin levels donot anemia thereby resulting in increased platelet
15 10,16
present with thrombocytosis pointing towards production. In general reactive thrombocytosis
the possibility of involvement of some additional even when extremely high doesnot cause
factor present in some iron deficient patients which thrombotic or bleeding complications and hence
support doesnot require
the stimulatory potential of erythropoietin on treatment. Thrombotic complications were
thrombopoesis.Tefferi A et al reported elevated IL-6 occasionally reported in iron deficiency anemia.
16,17

levels in patients with reactive thrombocytosis or Conclusion

clonal thrombocytosis with reactive This case establishes the association of an extreme
thrombocytosis thereby supporting the possible thrombocytosis secondary to iron deficiency
pathogenic role of anemia. The fact to be stressed is that even in the
elevated IL-6 levels in reactive presence of an extremely high platelet count
6
thrombocytosis. But
possibility of reactive thrombocytosis should be
contrasting findings were reported by Akan et al
considered and underlying cause should be
whereby none of these cytokines had any effect on
investigated because in secondary thrombocytosis
reactive thrombocytosis in Iron deficiency
16 treatment of an underlying cause normalises the
anemia. So to establish the etiology of
platelet count.
thrombocytosis in iron deficiency anemia further
investigations needs to be performed.In our case
bone

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