Amino acid sequence homology of thrombopoietin and erythropoietin may explain thrombocytosis in children with iron deficiency anemia

Trace Metals and The Hemostatic System

In this narrative review we report the main relationships between trace metals and the hemostatic system since this aspect has seldom attracted the attention of the scientific community. A basic aspect to be considered is the importance of maintaining the fine control of all trace metals' levels since they have an important impact on the pathophysiology of the hemostatic system. It is worth noting that poor diet habits are responsible for most trace metal deficiencies, while pollution is responsible for dangerous exposure to them with a consequent negative impact on the general population. This appears of paramount importance in planning the implementation of food and nutrient support to ameliorate the hidden hunger and the quality of life of people especially in developing countries and limiting poisons both in the air and food. As it often happens, when damage to certain mechanisms takes a very long time to appear, no attention is paid to the importance of a systematic prevention to avoid late negative outcomes.

A Limited Course of Eculizumab in a Child with the Atypical Hemolytic Uremic Syndrome and Pre-B Acute Lymphoblastic Leukemia on Maintenance Therapy: Case Report and Literature Review

Acute lymphoblastic leukemia (ALL) is considered a possible risk for the occurrence of thrombotic microangiopathies. We present a girl with pre-B ALL successfully treated according to the BFM ALL IC-2009 protocol on maintenance therapy followed by aHUS occurrence. This is the seventh case of HUS/aHUS on ALL maintenance therapy and the first with clearly documented eculizumab use in the early stage of aHUS/secondary TMA. Standard and additional parameters were used in aHUS monitoring alongside the reticulocyte production index adjusted for age (RPI/A) and the aspartate aminotransferase-to-platelet ratio index (APRI) as markers of hemolysis and rapid response following treatment. RPI/A and APRI are markers of bone marrow response to anemia serving as red blood cell vs. platelet recovery markers. Together they mark the exact recovery point of thrombotic microangiopathy and serve as a prognostic marker of eculizumab treatment success. During the 8-month treatment and 6-month follow-up, no recurrence of hemolysis, ALL relapse, or renal damage were observed. A systematic review of the literature revealed 14/312 articles; five children had aHUS before the onset of ALL, and two children had both diseases concurrently. At least 3/7 patients are attributed to aHUS, of whom 2/7 have renal damage. Potential undiagnosed/unpublished cases may be assumed.

Iron Deficiency is Associated With Platelet Count Elevation in Patients With Dialysis-dependent Chronic Kidney Disease

OBJECTIVE

Iron deficiency is common in patients with end-stage renal disease (ESRD). Platelet count changes may reflect iron status, but the relationship between platelet count and iron indices is unclear in patients with ESRD.

METHODS

We conducted a retrospective study in 1,167 patients with ESRD from 2012 to 2017 in West China Hospital. Baseline data were used to analyze the relationship between the platelet count and iron indices. Patients were followed up for 3 years.

RESULTS

Patients with iron deficiency (both absolute and functional) had a higher platelet count than those without iron deficiency (174 ± 61 × 10⁹/L vs. 153 ± 58 × 10⁹/L, P < .001). Receiver operating characteristic analysis showed a weak predictive power of platelet count on absolute iron deficiency (area under curve 0.620; cutoff value > 137 × 10⁹/L, sensitivity 76%, specificity 43%) and functional iron deficiency (area under curve 0.540; cutoff value > 124 × 10⁹/L, sensitivity 77%, specificity 32%). Platelet count was negatively correlated with ferritin (Spearman's rho [ρ] -0.1547, P < .001), transferrin saturation (ρ = -0.1895, P < .001), and serum iron (ρ = -0.1466, P < .001). The abovementioned correlations remained significant in multivariate regression (β -0.7285, 95% confidence interval [CI] -1.0757 to -0.3814; β -.00347, 95% CI -0.0520 to -0.0174; β -0.0097, 95% CI -0.0159 to -0.0035, respectively). In unadjusted and adjusted Cox regression models, neither baseline platelet count nor relative thrombocytosis was associated with 3-year mortality.

CONCLUSION

There was a weak but significant platelet count elevation in patients with ESRD and with iron deficiency.

KEY WORDS

end-stage renal disease; iron deficiency; iron supplement; mortality; platelet count.

Administration of α-Klotho Does Not Rescue Renal Anemia in Mice

Renal anemia is a common complication in chronic kidney disease (CKD), associated with decreased production of erythropoietin (EPO) due to loss of kidney function, and subsequent decreased red blood cell (RBC) production. However, many other factors play a critical role in the development of renal anemia, such as iron deficiency, inflammation, and elevated fibroblast growth factor 23 (FGF23) levels. We previously reported that inhibition of FGF23 signaling rescues anemia in mice with CKD. In the present study we sought to investigate whether α-Klotho deficiency present in CKD also contributes to the development of renal anemia. To address this, we administered α-Klotho to mice with CKD induced by an adenine-rich diet. Mice were sacrificed 24 h after α-Klotho injection, and blood and organs were collected immediately post-mortem. Our data show that α-Klotho administration had no beneficial effect in mice with CKD-associated anemia as it did not increase RBC numbers and hemoglobin levels, and it did not stimulate EPO secretion. Moreover, α-Klotho did not improve iron deficiency and inflammation in CKD as it had no effect on iron levels or inflammatory markers. Interestingly, Klotho supplementation significantly reduced the number of erythroid progenitors in the bone marrow and downregulated renal Epo and Hif2α mRNA in mice fed control diet resulting in reduced circulating EPO levels in these mice. In addition, Klotho significantly decreased intestinal absorption of iron in control mice leading to reduced serum iron and transferrin saturation levels. Our findings demonstrate that α-Klotho does not have a direct role in renal anemia and that FGF23 suppresses erythropoiesis in CKD via a Klotho-independent mechanism. However, in physiological conditions α-Klotho appears to have an inhibitory effect on erythropoiesis and iron regulation.

Reactive Thrombocytosis Related Cerebral Venous Thrombosis: A Rare Complication of Untreated Iron Deficiency Anemia

Thrombocytosis can be either primary or secondary, and it can cause venous pro-thrombotic states like cerebral venous thrombosis. Untreated iron deficiency anemia is postulated to cause reactive (secondary) thrombocytosis due to the proliferation of common progenitor cells. Here we present a case of a middle-aged woman with polycystic ovary syndrome and episodes of menorrhagia. She presented with headache and focal sensory deficits, and her neuroimaging showed evidence of cerebral venous sinus thrombosis (CVST). Laboratory tests showed microcytic hypochromic anemia, low ferritin, high total iron-binding capacity (TIBC), and thrombocytosis with a platelet count of 1,523,000/mm³. A comprehensive workup for hypercoagulable states and primary causes of thrombocytosis was negative. It was concluded that the etiology of her CVST was a reactive thrombocytosis from chronic untreated iron deficiency anemia. Anticoagulation with apixaban and corrective treatment for iron deficiency anemia was initiated. A repeated neuroimaging after four months showed significantly less clot burden in the cerebral venous sinuses, and then apixaban was stopped after six months. Laboratory tests after one year of iron replacement therapy showed improvement in the hemoglobin and hematocrit as well as normalization of platelet count. This case highlights a rare yet potentially dangerous complication of a common untreated condition, i.e., iron deficiency anemia. 

Manifestations and Related Risk Factors of Thrombocyte Abnormalities in HIV-Positive Patients Before and After the Initiation of ART

Background

At present, the thrombocyte abnormality is not well described before and after the initiation of antiretroviral therapy (ART). The purpose of this research is to investigate the dynamic changes and related risk factors of thrombocytopenia and thrombocytosis in HIV-infected individuals.

Methods

We performed a real-world observational study among 6637 HIV patients who started ART from January, 2013 to August, 2020 at the Beijing Ditan Hospital. Hazard indicators linked with thrombocytopenia and thrombocytosis were analyzed by logistic/Cox regression.

Results

The prevalence of thrombocytopenia and thrombocytosis was 2.65% and 5.85% among ART-naïve patients, respectively. Correlated risk factors: (thrombocytopenia) older age, coinfection with HBV, leucopenia, anemia, and CD4 count <350 cells/uL; (thrombocytosis) WBC level ≥4.0 x 10⁹/L, anemia, NLR ≥2.0, and CD4 count ≥350 cells/uL. As for the recovery rate, it was 86.6/54.2, 83.4/46.3, 66.0/35.1, and 65.3/ 33.9 per 100 PYFU in thrombocytopenia/thrombocytosis at different treatment period (12m, 24m, 36m, and 48m). While the new-onset incidence of thrombocytopenia/thrombocytosis at different ART period (12m, 24m, 36m, 48m, 60m, 72m, and 84m) was 0.25/7.2, 0.19/6.31, 0.16/4.74, 0.16/4.55, 0.16/4.48, 0.15/4.41, and 0.15/4.39. And the driving forces of thrombocytosis were antiretroviral treatment, female, overweight, and WBC level ≥ 4.0 x 10⁹/L.

Conclusion

In the medical practice, while paying attention to thrombocytopenia, clinicians should be highly vigilant about the thrombocytosis of HIV/AIDS patients, and related treatment strategies need to be further studied.

Thrombocytopenia in severe iron deficiency anemia in children

AIM

Iron deficiency anemia (IDA) is common in the pediatric population and often accompanied by mild thrombocytosis, but rarely profound thrombocytopenia is seen. We describe the data of children with IDA and thrombocytopenia in two centers and discuss the published data in the literature.

METHODS

In this retrospective case series, the medical records of patients under the age of 19 years old diagnosed with IDA in two tertiary medical centers over the last 10 years, were reviewed. The data were collected and compared to the data published in the medical literature.

RESULTS

All the patients presented with severe IDA and thrombocytopenia improved with iron treatment. Although none of the patients had signs of major bleeding, the thrombocytopenia could mostly be classified as severe (platelet count <50×10E9/L). Due to the severity of the anemia, in about half of the cases, a red blood cell transfusion was given. The peak of the platelet count was seen in the first month after the start of iron treatment. In eight cases of children with IDA, the thrombocytopenia appeared after the supplementation of iron was started.

CONCLUSION

Clinically stable children with severe IDA and thrombocytopenia, where other causes are very unlikely, warrant an empiric monotherapy with iron to prevent unnecessary investigations and treatments.

Rare presentation of iron deficiency anaemia with cerebral venous sinus thrombosis in a middle-aged woman

This is a case of a female patient presented with a mild headache associated with recurrent episodes of nausea and vomiting, confusion and right-sided hemiparesis, diagnosed of haemorrhagic venous infarction from the thrombosis of left transverse and sigmoid sinus and probably the left vein of Labbe. She had severe microcytic hypochromic anaemia due to iron deficiency, without any other risk factors for cerebral venous thrombosis such as trauma history, infections, coagulation disorders or autoimmune diseases. She had a good prognosis after iron supplementation and anticoagulation therapy.

A Review and Assessment of Drug-Induced Thrombocytosis

OBJECTIVES

The purpose of this article is to review the current literature on drug-induced thrombocytosis with the goal of critically assessing causality and providing a comprehensive review of the topic. Thrombopoietic growth factors, such as thrombopoietin-receptor agonists (romiplostim and eltrombopag) and erythropoietin are not included in our review.

DATA SOURCES

The literature search included published articles limited to the English language and humans in MEDLINE, EMBASE, and Web of Science databases. MEDLINE/PubMed (1966 to September 2018) was searched using the MeSH terms thrombocytosis/chemically-induced and thrombocytosis/etiology. EMBASE (1980 to September 2018) was searched using the EMTAGS thrombocytosis/side effect. Web of Science (1970 to September 2018) was searched using the search term thrombocytosis. References of all relevant articles were reviewed for additional citations and information.

STUDY SELECTION AND DATA EXTRACTION

Review articles, clinical trials, background data, case series, and case reports of drug-induced thrombocytosis were collected, and case reports were assessed for causality using a modified Naranjo nomogram.

DATA SYNTHESIS

Drug-induced thrombocytosis, a form of reactive thrombocytosis cannot be easily differentiated from more common etiologies of reactive thrombocytosis. In all, 43 case reports of drug-induced thrombocytosis from a wide variety of drugs and drug classes were reviewed using a modified Naranjo probability scale that included criteria specific for thrombocytosis.

CONCLUSIONS

Drug-induced thrombocytosis is a relatively rare adverse drug reaction. The strongest evidence of causality supports low-molecular-weight heparins and neonatal drug withdrawal. Weaker evidence exists for all-trans retinoic acid, antibiotics, clozapine, epinephrine, gemcitabine, and vinca alkaloids.

Complete blood count reference intervals from a healthy adult urban population in Kenya

BACKGROUND

There are racial, ethnic and geographical differences in complete blood count (CBC) reference intervals (RIs) and therefore it is necessary to establish RIs that are population specific. Several studies have been carried out in Africa to derive CBC RIs but many were not conducted with the rigor recommended for RI studies hence limiting the adoption and generalizability of the results.

METHOD

By use of a Beckman Coulter ACT 5 DIFF CP analyser, we measured CBC parameters in samples collected from 528 healthy black African volunteers in a largely urban population. The latent abnormal values exclusion (LAVE) method was used for secondary exclusion of individuals who may have had sub-clinical diseases. The RIs were derived by both parametric and non-parametric methods with and without LAVE for comparative purposes.

RESULTS

Haemoglobin (Hb) levels were lower while platelet counts were higher in females across the 4 age stratifications. The lower limits for Hb and red blood cell parameters significantly increased after applying the LAVE method which eliminated individuals with latent anemia and inflammation. We adopted RIs by parametric method because 90% confidence intervals of the RI limits were invariably narrower than those by the non-parametric method. The male and female RIs for Hb after applying the LAVE method were 14.5-18.7 g/dL and 12.0-16.5 g/dL respectively while the platelet count RIs were 133-356 and 152-443 x10(3) per μL respectively.

CONCLUSION

Consistent with other studies from Sub-Saharan Africa, Hb and neutrophil counts were lower than Caucasian values. Our finding of higher Hb and lower eosinophil counts compared to other studies conducted in rural Kenya most likely reflects the strict recruitment criteria and healthier reference population after secondary exclusion of individuals with possible sub-clinical diseases.

Thrombocytosis in 715 Dogs (2011-2015)

BACKGROUND

Thrombocytosis is a hematologic abnormality in dogs that has been associated with various neoplastic, metabolic, and inflammatory conditions.

OBJECTIVE

To classify thrombocytosis in dogs based on severity and evaluate whether there are associations between severity and underlying disease processes.

ANIMALS

Seven hundred and fifteen dogs with thrombocytosis and 1,430 dogs with normal numbers of platelets.

METHODS

Retrospective study. Medical records of dogs with increased (>500 × 10³ /μL; thrombocytosis group) and normal (300-500 × 10³ /μL; control group) platelet counts between 2011 and 2015 were reviewed. Dogs were characterized by severity of platelet increase and diagnosis. Diagnostic categories included neoplasia, endocrine disease, inflammatory disease, or miscellaneous.

RESULTS

A total of 1,254 complete blood counts with thrombocytosis from 715 dogs were included in the study. Median platelet count in this population was 582 × 10³ /μL (500-1,810 × 10³ /μL). No correlation between severity of thrombocytosis and diagnosis was identified. Causes of secondary thrombocytosis included neoplasia (55.7%), endocrine disease (12.0%), and inflammatory disease (46.6%). Immune-mediated disease was common (22.2%), associated with frequent glucocorticoid administration, and had a significantly higher median platelet count (636 × 10³ /μL [500-1,262 × 10³ /μL] versus 565 × 10³ /μL [500-1,810 × 10³ /μL]) when compared to the other inflammatory processes (P < 0.001). The diagnoses in the thrombocytosis dogs differed significantly from the control population (P < 0.001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Thrombocytosis is commonly associated with carcinoma and immune-mediated disease in dogs.

Erythrocytes and Platelets: A Critical Analysis of their Ontogenic Relationship through Automated Parameters

INTRODUCTION

Erythrocytes and platelets share an intimate development history, due to which special interest is centered on their relationship. Mature Red Blood Cells (RBCs) and platelets show a similar physiological rhythm, and are concurrently involved in numerous pathologic states.

AIM

To identify subtle relationships between various RBC and platelet parameters with an objective to analyse if a linear correlation co-exists between and among them in physiological/pathological states.

MATERIALS AND METHODS

A prospective analysis of 1250 EDTA blood samples was conducted. The five RBC parameters (RBC count, HCT, MCV, RDW, Hb) and four platelet parameters (platelet count, PCT, MPV, PDW) obtained from each case were statistically analysed for linear dependence.

RESULTS

A statistically significant direct linear relationship was found between RDW with platelet count and PCT. A statistically significant inverse linear relationship was noticed between the following parameters: i) HCT with platelet count and PCT; ii) MCV with platelet count and PCT; iii) Haemoglobin and platelet count.

CONCLUSION

A linear correlation, either direct or inverse, was seen among various parallel RBC and platelet parameters.

[Iron deficiency, thrombocytosis and thromboembolism]

Iron deficiency, the most common nutritional deficiency worldwide, is often associated with reactive thrombocytosis. Although secondary thrombocytosis is commonly considered to be harmless, there is accumulating evidence that elevated platelet counts, especially in the setting of iron deficiency, can lead to an increased thromboembolic risk in both arterial and venous systems. Here we present the mechanisms of iron deficiency-induced thrombocytosis and summarize its clinical consequences especially in patients with inflammatory bowel diseases, chronic kidney disease or cancer. We hypothesize that iron deficiency is an underestimated thromboembolic risk factor, and that iron replacement therapy can become an effective preventive strategy in a variety of clinical settings.

The ITPA and C20orf194 Polymorphisms and Hematological Changes During Treatment With Pegylated-Interferon Plus Ribavirin in Patients With Chronic Hepatitis C

BACKGROUND

It has been found that ITPase deficiency is caused by ITPA gene polymorphisms. It was observed that ITPA polymorphisms have impact on hematological changes, including hemoglobin (Hb)-decline during treatment of chronic hepatitis C (CHC) patients with pegylated-interferon (PEG-IFN) plus ribavirin (RBV).

OBJECTIVES

This study aimed to assess the effect of ITPA and C20orf194 polymorphisms on hematological changes at week 4 of treatment with PEG-IFN plus RBV in patients with CHC.

PATIENTS AND METHODS

In this retrospective study, 168 patients with CHC (56% HCV genotype-1 and 44% HCV genotype-3) under the treatment of PEG-IFN plus RBV were genotyped for rs1127354, rs7270101 and rs6051702 polymorphisms by the polymerase chain reaction-restriction fragment length polymorphism. Hematological changes including Hb-, platelet (Plt)- and white blood cell-decline at week 4 of the treatment were assessed.

RESULTS

In univariate analysis, rs1127354 and HCV genotypes were found to influence the Hb-decline at week 4 of the treatment. In multivariate analysis, rs1127354 CA + AA and HCV genotype-3 were found to have a great role on prevention of Hb-decline. Furthermore, rs1127354 and HCV RNA levels were found to influence the Plt-decline at week 4 of the treatment in the univariate analysis. In multivariate analysis, rs1127354 CA + AA and HCV RNA levels less than 600,000 IU/mL were found to be associated with a higher level of Plt-decline.

CONCLUSIONS

In patients with CHC, who were treated with PEG-IFN plus RBV, Hb-decline was affected by rs1127354 and HCV genotypes. However, Plt-decline may be altered by rs1127354 and baseline HCV RNA levels.

Primary thrombocytosis in children

Myeloproliferative neoplasms are uncommon disorders in children, for which we have limited understanding of the pathogenesis and optimal management. JAK2 and MPL mutations, while common drivers of myeloproliferative neoplasms in adult patients, are not clearly linked to pediatric disease. Management and clinical outcomes in adults have been well delineated with defined recommendations for risk stratification and treatment. This is not the case for pediatric patients, for whom there is neither a standard approach to workup nor any consensus regarding management. This review will discuss thrombocytosis in children, including causes of thrombocytosis in children, the limited knowledge we have regarding pediatric primary thrombocytosis, and our thoughts on potential risk stratification and management, and future questions to be answered by laboratory research and collaborative clinical study.

Intravenous iron administration is associated with reduced platelet counts in patients with chronic kidney disease

WHAT IS KNOWN AND OBJECTIVE

In the management of anaemia associated with chronic kidney disease (CKD), optimal use of intravenous (i.v.) iron has a central role. It minimizes reliance on erythropoiesis-stimulating agents (ESAs) and may be beneficial in reducing overall cardiovascular risks through its effects on platelet counts (PLT). We have examined the effects of i.v. iron on PLT in patients with CKD.

METHODS

Two hundred and three patients with CKD, referred to a single teaching hospital in UK for i.v. iron therapy, received low molecular-weight iron dextran at a median dose of 1000 milligrams given over a median time of 2 h and 40 min. PLT at baseline were compared with the measurements taken during a 4-month follow-up period post-infusion.

RESULTS

PLT were checked at various points following i.v. iron treatment. Compared with baseline, mean reduction in PLT ranged between 10.1 and 23.6 (×10(9) /L) during consecutive 15-days intervals post-treatment. At the reference point of 90-days post-infusion, the drop in PLT was statistically significant (P < 0.001).

WHAT IS NEW AND CONCLUSION

Low molecular-weight iron dextran in patients with CKD leads to reduction in PLT. This reduction appears soon after treatment and is maximal after 3 months. Prospective data are required to confirm these findings and examine whether this translates to a reduction in thrombotic episodes.

Alterations of platelet functions in children and adolescents with iron-deficiency anemia and response to therapy

Several changes in platelets have been reported in patients with iron-deficiency anemia (IDA), so a relationship between iron metabolism and thrombopoiesis should be considered. We aimed to study the alterations of platelet functions in patients with IDA by assessment of platelet aggregation with epinephrine, adenosine diphosphate (ADP) and ristocetin and by measuring platelet function analyzer-100 (PFA-100) closure time together with the effect of iron therapy on the same tests. A follow-up study was conducted in Ain Shams University Children's hospital in the period from June 2011 to June 2012 including 20 patients with confirmed IDA and 20 healthy age- and sex-matched control. Bleeding manifestations were reported. Laboratory analysis included complete blood count, assessment of iron status by measuring serum iron, TIBC and ferritin, assessment of platelet functions by PFA-100 closure time and platelet aggregation with collagen, ADP and ristocetin. Patients with IDA were treated by oral iron therapy 6 mg/kg/day of ferrous sulfate and post-therapeutic re-assessment was done. Mean age of IDA patients was 5.7 ± 4.2 years. Bleeding manifestations were more common in patients group. Mean PFA-100 closure times (with epinephrine) were significantly longer in patients (179.1 ± 86.4 seconds) compared to control group (115 ± 28.5 seconds) (p < 0.05). Platelet aggregation by ADP (38.1 ± 22.2%), epinephrine (19.7 ± 14.2%) and ristocetin (58.8 ± 21.4%) were significantly reduced in patients compared to control (62.7 ± 6.2, 63.3 ± 6.9, 73.8 ± 8.3, respectively; p < 0.001). After treatment platelet aggregation tests induced by ADP (64.78 ± 18.25%), and epinephrine (55.47 ± 24%) were significantly increased in patients with IDA compared to before treatment (39.44 ± 21.85%, 20.33 ± 14.58%; p < 0.001). PFA-100 closure time as well showed significant decreased after treatment (118.4 ± 27.242) compared to before treatment (186.2 ± 90.35; p < 0.05). A negative correlation between platelet aggregation induced by ADP and mean values of serum ferritin before treatment (r = 0.042, p < 0.05) was found. A mutual effect is considered between iron deficiency and platelet functions. Subtle bleeding manifestations can occur in patients with IDA with delay in platelet aggregation and prolongation in PFA-100 closure times which can be reversed by iron therapy.

Multipotent role of platelets in inflammatory bowel diseases: A clinical approach

There is evidence that inflammatory bowel diseases (IBD) combine both inflammation and coagulation in their pathogenesis and clinical manifestations. Although platelets (PLT) are well known for their role in hemostasis, there are a rising number of studies supporting their considerable role as inflammatory amplifiers in chronic inflammatory conditions. IBD are associated with several alterations of PLT, including number, shape, and function, and these abnormalities are mainly attributed to the highly activated state of circulating PLT in IBD patients. When PLT activate, they increase in size, release a great variety of bio-active inflammatory and procoagulant molecules/particles, and express a variety of inflammatory receptors. These inflammatory products may represent a part of the missing link between coagulation and inflammation, and can be considered as possible IBD pathogenesis instigators. In clinical practice, thrombocytosis is associated both with disease activity and iron deficiency anemia. Controlling inflammation and iron replacement in anemic patients usually leads to a normalization of PLT count. The aim of this review is to update the role of PLT in IBD and present recent data revealing the possible therapeutic implications of anti-PLT agents in future IBD remedies.

Iron deficiency anemia as a risk factor for cerebrovascular events in early childhood: a case-control study

In recent years, iron-deficiency anemia (IDA) has been suggested to have an association with childhood-onset ischemic stroke in otherwise healthy children, but few cases have proven it thus far. In this study, we aimed to investigate whether iron-deficiency anemia is a risk factor for cerebrovascular events and childhood-onset ischemic stroke in previously healthy children. This was a case-control study that included 21 stroke cases with patients who had previously been generally healthy, and matched with age and gender of 100 healthy control subjects. Patients were included if a diagnosis of definite stroke had been made and other known etiologies of childhood onset stroke were excluded. For all subjects, iron parameters including serum iron, ferritin, transferrin, total iron binding capacity, and transferrin saturation were assessed. We screened all case patients for prothrombotic factors including level of hemoglobin S, protein C, protein S, antithrombin III, lupus anticoagulant, factor V Leiden, and prothrombin gene mutation (G20210A). Brain magnetic resonance images (MRI), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) were performed to all case patients. All case patients have normal results regarding functional, immunological, and molecular assay for prothrombotic factors screening. Our results showed that IDA was disclosed in 57.1 % of stroke cases with no identified cause, as compared to 26 % of controls. Our study suggest that previously healthy children who developed stroke are 3.8 times more likely to have IDA than healthy children, who do not develop stroke (OR, 3.8; 95 % CI:1.3-11.2 P = 0.005). In addition, there was significant interaction between IDA and thrombocytosis among studied cases (OR, 10.5; 95 % CI, 1.0-152 P = 0.02). There were nonsignificant differences between stroke patients with IDA and those with normal iron parameters regarding stroke subtype (P > 0.05). Public health messages on the importance of early detection of iron-deficiency anemia in young children, especially in our developing countries so that it can be treated before a life-threatening complication like stroke develops.

Association between thrombocytosis and iron deficiency anemia in inflammatory bowel disease

BACKGROUND

Thrombocytosis and iron deficiency anemia are frequent complications of inflammatory bowel disease (IBD). The aim of this study was to investigate the correlation between iron deficiency anemia and thrombocytosis in IBD patients.

METHODS

A total of 198 consecutive IBD patients and 102 healthy controls participated in the study. The parameters investigated were: platelets (PLT), mean platelet volume, platelet distribution width, plateletcrit, hematocrit (HCT) levels, hemoglobulin (Hb) levels, mean corpuscular volume (MCV), red cell distribution width (RDW), ferritin levels, soluble transferrin receptor (sTfR) levels, the sTfR-F index (sTfR-F=sTfR/log10 ferritin), and vitamin B12 and folate levels. Thrombocytosis was defined as an absolute number of PLT greater than 400k/μl. Disease activity indices (Crohn's Disease Activity Index for Crohn's disease and Simple Clinical Colitis Activity Index for ulcerative colitis) as well as C-reactive protein (CRP) were also correlated with the study parameters.

RESULTS

The IBD patients demonstrated decreased HCT levels, Hb levels, MCV, mean platelet volume, and ferritin levels and an increased absolute PLT count, RDW, platelet distribution width, plateletcrit, sTfR and sTfR-F index (P<0.0001) compared with healthy controls. Twenty-seven patients exhibited thrombocytosis (13.6%). The median value for PLT (interquartile range) was 289 (228-355)k/μl, for Hb levels was 13.4 (12.0-14.7) g/dl, for ferritin levels was 36.6 (19.7-80.7) ng/ml, and for sTfR-F was 0.82 (0.61-1.37) mg/l. The PLT in IBD patients correlated with HCT levels, Hb levels, MCV, RDW, Fe levels, ferritin levels, sTfR, sTfR-F, CRP levels, Simple Clinical Colitis Activity Index, and Crohn's Disease Activity Index (Spearman's ρ correlation). In the multivariate analysis, only Hb levels, RDW, CRP levels, ferritin levels, and sTfR-F remained significant (P<0.05). None of the aforementioned was observed in the control group.

CONCLUSION

The absolute PLT count seems to correlate with iron deficiency anemia parameters and disease activity in IBD patients. Controlling the inflammation and managing iron deficiency could lead to reversal of thrombocytosis in IBD patients.

Idiopathic thrombocytopenia with iron deficiency anemia

We report a rare case of anemia and thrombocytopenia as a result of uterine fibroid and adenomyosis, complicated by immune thrombocytopenic purpura (ITP). Symptoms were presented as menorrhagia and metrorrhagia in a 34-year-old African American woman, who was later treated with blood and platelet transfusion and iron therapy with steroids. Uterine fibroids are commonly found to cause hematologic disturbances such as anemia and reactive thrombocytosis and, less commonly, thrombocytopenia. Moreover, such hematologic disturbances are secondary to heavy and irregular uterine bleeding, which is typically presented. A previous uterine fibroid diagnosis was made and reconfirmed by pelvic and transvaginal ultrasound to exclude other locoregional pathologies. ITP was suggested by Coombs test and several other serologies, leading to confirmation via bone marrow biopsy. In a previous case study, we reported positive responses in hemotecrit and platelet count after the introduction of iron therapy to an iron-depleted middle-aged female presenting severe anemia and thrombocytopenia.1

Anemia and thrombocytosis induced by ribavirin monotherapy in patients with chronic hepatitis C

BACKGROUND

An inosine triphosphatase (ITPA) single-nucleotide polymorphism (SNP) is associated with anemia induced by pegylated interferon and ribavirin (RBV) combination therapy in patients with chronic hepatitis C (CHC). However, there are very few reports on the hematological effects of RBV monotherapy. Here, hematological changes were monitored in patients with CHC who received RBV monotherapy, and the mechanism of these changes was investigated.

METHODS

Patients with CHC (n = 30) received RBV monotherapy for 4 weeks. The RBV dose was determined on the basis of body weight. Complete blood count, and serum erythropoietin (EPO) and thrombopoietin (TPO) levels were assessed. The associations between these parameters and the ITPA SNP (rs1127354) were analyzed.

RESULTS

Over the 4 weeks, the median hemoglobin level of all patients decreased significantly, from 13.6 (10.5-16.6) to 11.7 (9.4-14.9) g/dl (P < 0.001), and the platelet counts increased, from 14.0 × 10(4) (8.9-37.4 × 10(4)) to 15.8 × 10(4) (10.2-40.6 × 10(4)) /mm(3) (P = 0.003). At week 4, hemoglobin levels differed between patients with the ITPA CC genotype and those with the AA or AC genotypes [11.1 (9.4-13.5) vs. 12.9 (12.5-14.9) g/dl, P = 0.001]. The platelet change ratio (i.e., platelet count at week 4/platelet count at baseline) in the patients with developing anemia was correlated with the increase in the serum EPO level over 4 weeks (r = 0.88, P = 0.002), but not with the increase in the serum TPO level over 4 weeks.

CONCLUSIONS

RBV monotherapy induced anemia and affected thrombocytosis in patients with CHC. Elevated endogenous EPO may stimulate platelet production.

Thrombocytosis: diagnostic evaluation, thrombotic risk stratification, and risk-based management strategies

Thrombocytosis is a commonly encountered clinical scenario, with a large proportion of cases discovered incidentally. The differential diagnosis for thrombocytosis is broad and the diagnostic process can be challenging. Thrombocytosis can be spurious, attributed to a reactive process or due to clonal disorder. This distinction is important as it carries implications for evaluation, prognosis, and treatment. Clonal thrombocytosis associated with the myeloproliferative neoplasms, especially essential thrombocythemia and polycythemia vera, carries a unique prognostic profile, with a markedly increased risk of thrombosis. This risk is the driving factor behind treatment strategies in these disorders. Clinical trials utilizing targeted therapies in thrombocytosis are ongoing with new therapeutic targets waiting to be explored. This paper will outline the mechanisms underlying thrombocytosis, the diagnostic evaluation of thrombocytosis, complications of thrombocytosis with a special focus on thrombotic risk as well as treatment options for clonal processes leading to thrombocytosis, including essential thrombocythemia and polycythemia vera.

Iron deficiency: beyond anemia

Iron deficiency is the most common nutritional disorder affecting at least one third of world's population. Though anemia is common manifestation of iron deficiency, other effects of iron deficiency on various tissues, organs and systems are usually under recognized. Impaired brain development and cognitive, behavioural and psychomotor impairment are most worrisome manifestations of iron deficiency. Studies have demonstrated that some of these changes occurring during period of brain growth spurt (<2 years age) may be irreversible. Association of iron deficiency with febrile seizures, pica, breath holding spells, restless leg syndrome and thrombosis is increasingly being recognized. Impaired cell-mediated immunity and bactericidal function are generally noted in iron-deficient persons; however, the findings are inconsistent. Despite proven reversible functional immunological defects in vitro studies, a clinically important relationship between states of iron deficiency and susceptibility to infections remains controversial. Studies from malaria endemic regions have reported increased incidence of malaria in association with iron supplementation. These and some other aspects of iron deficiency are reviewed in this article.

Severe thrombocytopenia with iron deficiency anemia

Although severe thrombocytopenia has been reported among children with iron deficiency anemia, the presence of both anemia and thrombocytopenia can suggest serious or malignant bone marrow dysfunction, requiring further work-up. This paper reviews the management and outcomes of patients with the diagnosis of iron deficiency anemia presenting with severe thrombocytopenia. The authors present 4 pediatric patients with iron deficiency anemia and severe thrombocytopenia at initial presentation. Charts were reviewed after approval by the institutional review boards at both St. Jude Children's Research Hospital and LeBonheur Children's Medical Center in Memphis, Tennessee. All 4 patients' hemoglobin concentrations and platelet counts normalized within 1 to 3 weeks of initiating iron supplementation, suggesting that in such patients iron supplementation can obviate the need for invasive diagnostic procedures. In addition, these patients all had a platelet "overshoot" phenomenon during iron therapy prior to normalization of platelet counts, the mechanism of which is still unknown. The literature exploring the mechanism behind the current clinical findings is reviewed.

Platelet counts in adults with iron deficiency anemia

In adults with iron deficiency anemia (IDA), abnormal platelet counts were seen in several studies. However we retrospectively examined the clinical records of a larger number of adults with IDA to assess abnormal platelet counts. From November 2006 to April 2008, 615 consecutive adults (73 men and 542 women; age range, 16-88 years) with IDA were included in this study. The mean initial hemoglobin was 9.0 +/- 1.8 g/dL (range 2.7-12.8 g/dL), and the mean initial platelet count was 304 x 10(3)/microL +/- 92.3 (range, 105-700 x 10(3)/microL). The initial platelet counts were normal in 520 (84.6%) adults with IDA. Thrombocytosis (>400 x 10(3)/microL) and thrombocytopenia (<150 x 10(3)/microL) were detected in 82 (13.3%) and 13 (2.1%) adults with IDA, respectively. In conclusion, thrombocytosis was seen at lower rates in our study. Furthermore, this study shows that mild thrombocytopenia is not so rare in adults with IDA.

Clinicohematological study of thrombocytosis

OBJECTIVE

To find out etiology and clinical course of thrombocytosis in Indian pediatric population.

METHODS

A total of 250 patients having thrombocytosis (defined as platelet count >500 x 10(9)/L) on haematological investigations were studied over one yr period. All patients were evaluated clinically and were subjected to investigations, including complete blood counts (CBC) with peripheral smear examination. To elucidate the possible role of inflammatory cytokines in pathogenesis of RT, levels of Interleukin-6 (IL-6) and C - reactive protein (CRP) were estimated.

RESULTS

Infants and young children (<2 yr age) were most common group, contributing 60% of total cases. Out of total 250 cases, only 3 (1.2%) cases were found to have primary thrombocytosis and remaining 98.8% cases were having RT. Among RT patients, infections (alone or in association with iron deficiency anemia) were most common cause, accounting for 65% cases, while iron deficiency anemia (IDA) was second most common cause accounting for 41.3% cases (12.6% IDA alone and 28.7 % in association with infections). Other causes included nutritional dimorphic anemia and patients on treatment for megaloblastic anemia, acute lymphoblastic leukemia (during treatment) and lymphoma. Among various groups of RT, IL-6 and CRP levels were higher in patients with infection with or without IDA than IDA alone. One child with essential thrombocytosis and one child with RT had thrombotic complications. On follow up, platelet counts normalized in most of the patients with treatment of underlying conditions.

CONCLUSIONS

Results of this study suggest that essential thrombocytosis is extremely rare in children. Infections and IDA (alone or in association with infections) are common causes of RT. IL-6 and CRP levels are increased in patients with RT, to a higher level in patients with infections than in patients with IDA. Most patients with RT have uneventful recovery of platelet counts to normal range with treatment for underlying condition.

Severe thrombocytosis and anemia associated with celiac disease in a young female patient: a case report

INTRODUCTION

Platelet counts exceeding 1.000 x 103/microl are usually considered secondary to another cause, particularly to chronic myeloproliferative disease (CMPD). Reactive thrombocytosis due to iron deficiency rarely exceeds platelet counts of 700 x 103/microl.

CASE PRESENTATION

Here we report the case of a young woman presenting with clinical signs of severe anemia. Laboratory findings confirmed an iron-deficiency anemia associated with severe thrombocytosis of 1703 x 103/microl. Macroscopic gastrointestinal and genitourinary tract bleeding was excluded. The excessive elevation of platelets, slightly elevated lactate dehydrogenase and slightly elevated leukocytes along with the absence of other inflammation parameters raised the suspicion of an underlying hematological disease. However, bone marrow evaluation could not prove the suspected diagnosis of a CMPD, especially essential thrombocythemia (ET). In the further clinical course the platelet count returned to normal after raising the hemoglobin to a level close to normal range with erythrocyte transfusion, and normalization of serum iron and decline of erythropoietin. Finally, following small bowel biopsy, despite the absence of typical clinical signs, celiac disease was diagnosed. After discharge from hospital the patient was commenced on a gluten-free diet and her hemoglobin almost completely normalized in the further follow-up period.

CONCLUSION

This case illustrates the rare constellation of an extreme thrombocytosis most likely secondary to iron deficiency due to celiac disease. This represents, to the best of the authors' knowledge, the highest reported platelet count coincident with iron deficiency. A potential mechanism for the association of iron-deficiency anemia and thrombocytosis is discussed. Even in the presence of 'atypically' high platelets one should consider the possibility of reactive thrombocytosis. Extreme thrombocytosis could emerge in the case of iron deficiency secondary to celiac disease.

Iron and thrombosis

Although essential for cell physiology, an increase or depletion of body iron has harmful effects on health. Apart from iron deficiency anemia and iron overload-related organ tissue damage, there are increasing evidences that body iron status is implicated in atherosclerotic cardiovascular diseases. The hypothesis formulated in 1981 that iron depletion may protect against cardiovascular events is intriguing and has generated a significant debate in the last two decades. Indeed, to study this phenomenon, several investigators have tried to design appropriate experimental and clinical studies and to identify useful biochemical and genetic markers of iron status. The results of the literature on the effect of iron deficiency and overload on vascular health are critically reviewed in this study from a pathogenic and clinical point of view.