Thrombocythemia is a condition of high platelet thrombocyte count in the blood. Normal count is in the range of , to , platelets per microlitre of blood. When the cause is unknown, the term thrombocythemia is used, as either primary thrombocythyemia or essential thrombocythemia. The condition arises from a fault in the bone marrow cells that overproduce the platelets.
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The differential includes spurious, reactive secondary or autonomous primary thrombocytosis. Always confirm by repeat testing of the platelet count and peripheral smear and exclude false or spurious causes of thrombocytosis. Causes of spurious thrombocytosis include cell fragments which are increased in the case of leukemia , red cell inclusions such as Pappenheimer bodies or schistocytes, as seen in the setting of hemolysis or severe burns. In cryoglobulinemia, platelet counts and white blood cells rise when samples are prepared at cool temperatures.
Causes of secondary thrombocytosis include infection, inflammatory states for example, inflammatory bowel disease , physical stress including the post-operative state , acute blood loss, iron deficiency anemia, post-splenectomy and underlying malignancy.
Primary or autonomous thrombocytosis is a clonal bone marrow process. Disorders include essential thrombocythemia ET , polycythemia vera, primary myelofibrosis and chronic myeloid leukemia.
If confirmed, review the duration of thrombocytosis and perform a thorough history and physical to evaluate for causes of reactive thrombocytosis. Take note of whether the patient had recent trauma, surgery, infection, or inflammatory disease, history of splenectomy, history of iron deficiency, thrombosis or bleeding, weight loss, fatigue or night sweats suggestive of malignancy. Check ferritin to evaluate for iron deficiency anemia. Consider an autonomous disorder once reactive processes have been excluded.
A bone marrow biopsy with aspiration and cytogenetic testing is required to confirm the diagnosis. Consider evaluating for occult malignancy with review of prior imaging and further testing and imaging as indicated by systemic and localizing signs and symptoms.
Note that the degree of thrombocytosis is not indicative of its etiology. In reactive thrombocytosis, platelets are typically small in size and with a normal mean platelet volume. The peripheral smear may provide evidence of an underlying infective or inflammatory process. Bone marrow aspirate or trephine is not required; if it is performed, megakaryocytic hyperplasia with normal mature and left shifted megakaryocyte morphology. Reactive causes must be excluded, and iron stores are normal.
Peripheral smear may be significant for thrombocytosis with platelet anisocytosis varying size. Evidence of iron deficiency anemia may be present where erythrocytes are hypochromic and microcytic.
Leukoerythroblastosis and poikilocytosis are not seen. Polycythemia vera, chronic myeloid leukemia, primary myelofibrosis and myelodysplastic syndrome must be ruled out. Bone marrow biopsy is typically required for diagnosis. If a clonal abnormality is detected in an elderly patient and features of myelodysplastic syndrome or primary myelofibrosis are not present, bone marrow biopsy may not be required. Bone marrow is normocellular for age; the number of megakaryocytes is increased but normal in morphology.
Many large megakaryocytes with hyperlobulated nuclei are present. Erythropoeisis and granulopoesis are normal. Avoid obtaining CRP or ESR if patient has an apparent underlying infectious or inflammatory disorder, as they will be elevated.
Rule out etiologies of reactive thrombocytosis. If etiology is identified, then treat underlying disease or remove inciting process. However, this causes no symptoms as plasma levels of potassium are unaffected. You can confirm by checking a plasma potassium level. Extreme thrombocytosis is sometimes associated with an acquired type II von Willebrand disease vWD ; in this setting, rapid reduction of platelet count with platelet apheresis along with aspirin is required.
If the patient is bleeding, stop antiplatelet agents including aspirin and nonsteroidal anti-inflammatory drugs NSAIDs. May require fresh frozen plasma FFP or platelet transfusion if actively bleeding and hemodynamically unstable. Patients with vasomotor symptoms headache, flushing may benefit from aspirin 81 milligram mg daily.
Consider platelet cytoreductive therapy with hydroxyurea or megakaryocyte inhibitor with anagrelide in patients with essential thrombocytosis and platelets greater than 1. Rapid reduction of platelets with platelet apheresis is performed for patients with acute cerebrovascular complications or digital ischemia. If suspect acquired VWF deficiency, consider emergent platelet apheresis and aspirin 81mg by mouth po daily. BMJ Case Rep. I think this is an important clinical laboratory finding for hospitalists to be aware of, because not only is treatment unnecessary for pseudohyperkalemia but it can also result in symptomatic hypokalemia.
Schafer, A. This is a recent case report and summary of literature on how to approach a new diagnosis of thrombocytosis in a clinical scenario. Tefferi, A, Barbui, T. This is an updated guideline for treatment of PV and ET. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. Login Register. We want you to take advantage of everything Cancer Therapy Advisor has to offer. To view unlimited content, log in or register for free.
Register now at no charge to access unlimited clinical news, full-length features, case studies, conference coverage, and more. Thrombocytosis I. Diagnostic Approach. What is the differential diagnosis for this problem? Powered By Decision Support in Medicine. Jump to Section Thrombocytosis I. Historical information important in the diagnosis of this problem. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem. Management while the Diagnostic Process is Proceeding. Management of Clinical Problem Thrombocytosis. Popular Emailed Recent Loading Please login or register first to view this content. Open Next post in Hospital Medicine Close. Close more info about Thrombocytosis. Want to view more content from Cancer Therapy Advisor?
Incidental thrombocytosis: Should it concern the anesthesiologist?
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.
Reactive Thrombocytosis (Secondary Thrombocythemia)
The clinical importance of an elevated platelet count is often overlooked, particularly as a diagnostic clue to the presence of an underlying infection. We sought to better describe the relationship between thrombocytosis and inflammatory conditions, with a focus on infectious causes. Secondary thrombocytosis was more common than primary, with infectious causes accounting for nearly half the cases. Clinical and laboratory characteristics associated with an infectious cause of thrombocytosis included fever, tachycardia, weight loss, hypoalbuminemia, neutrophilia, leukocytosis and anemia. Patients with thrombocytosis secondary to infection had a more rapid normalization of platelet count, but higher risk of dying, than those with secondary, non-infectious causes. Thrombocytosis may have prognostic implications as a clinical parameter. The laboratory finding of thrombocytosis, defined as an abnormally elevated platelet count, is not generally recognized as a clinical indicator of infection.