Case report describes thrombocytopenia secondary to iron deficiency anemia

Case report describes thrombocytopenia secondary to iron deficiency anemia

A recently published report describes the diagnosis and treatment of a case of thrombocytopenia associated with iron deficiency anemia secondary to recurrent nosebleeds.

Although iron deficiency anemia (IDA) is the most common type of anemia worldwide, it is rarely associated with thrombocytopenia. A report published in the Journal of Pediatrics and Child Health describes a case of thrombocytopenia associated with IDA secondary to recurrent epistaxis.

Although thrombocytosis is known to be associated with IDA and is a reaction to megakaryocyte stimulation following increased erythropoietin signaling, thrombocytopenia secondary to IDA is rare and has no clear mechanism. Concurrent anemia and thrombocytopenia can also have many other causes.

“The combination of anemia and thrombocytopenia often raises concerns about immune thrombocytopenia, Evans syndrome, bone marrow failure syndromes, malignancies, autoimmune diseases such as systemic lupus erythematosus, and bacterial infections (eg. , Helicobacter pylori) and viral (eg, parvovirus)”. the authors wrote. Differentiation of IDA-associated thrombocytopenia from other possible etiologies influences further evaluation and management strategies.

There is a lack of literature on IDA-associated thrombocytopenia in children, and the recently published case report adds evidence for the association between IDA and thrombocytopenia. The case involved a 12-year-old boy who visited the emergency department after experiencing a fainting episode at his home. His blood pressure was normal, but he had a resting tachycardia of 120 beats per minute and a systolic ejection murmur at the left sternal border.

The patient had no known family history of hematologic or neoplastic disorders, but according to his parents, he had been experiencing daily nosebleeds since the age of 5 years. Medical records from 4 years earlier showed that the boy had normal hemoglobin and platelet counts at that time. Laboratory tests on admission to the emergency department demonstrated substantial anemia with a hemoglobin level of 3.3 g/dL and thrombocytopenia with a platelet count of 24 x 109/L. The patient had an iron binding capacity of 455 μg/dL and a transferrin saturation of 5%, confirming iron deficiency and therefore ADH.

He received a transfusion of 10 ml/kg of packed red blood cells divided into 4 portions while admitted to the intensive care unit for cardiac monitoring. The patient’s hemoglobin levels increased to 7.2 g/dL and a regimen of oral ferrous sulfate was started to improve iron production. Oxymetazoline was recommended as needed for acute nosebleeds and a nasal hygiene regimen after a direct nasal endoscopy showed a prominent Kiesselbach’s plexus but no signs of plexopathy.

At a follow-up 10 days after discharge, the patient’s anemia had further improved and rebound thrombocytosis had occurred, with platelet levels of 977 x 109/L. His platelet count had normalized to 251 x 109/L 2 weeks after discharge. The frequency and intensity of the patient’s nosebleeds had also decreased at 2-week follow-up. At 20-month follow-up, he still experienced mild iron deficiency, but his hemoglobin had improved further and his platelet count ranged from 272 to 392 x 103/dL. These results suggest that IDA-induced thrombocytopenia responds well to oral supplementation and may not require invasive procedures.

This case demonstrates the typical evaluation strategy for a patient presenting with both anemia and thrombocytopenia. A complete blood count, coagulation studies, iron and ferritin levels, blood smears, and tests for factors involved in hemolysis are key evaluations. If these tests do not help determine the etiology, a bone marrow biopsy and advanced hematologic, autoimmune, and nutritional studies are recommended.

“Our experience highlights the importance of including IDA-induced thrombocytopenia in the differential for pediatric patients without evidence of other etiologies of low platelet counts,” the authors concluded. However, more research is needed to determine the mechanism of IDA-induced thrombocytopenia.

Reference

Ghaznavi C, Ameen S, Srinivas M, Duncavage E, Saini S. Severe thrombocytopenia in the setting of anemia: review of the role of iron deficiency. J Pediatrics Child Health. Published online October 21, 2022. doi:10.1111/jpc.16256

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