Contributions
Abstract: PB1604
Type: Publication Only
Session title: Iron metabolism, deficiency and overload
Background
Iron deficiency anemia (IDA) is typically associated with either normal or elevated platelet counts, likely due to a low iron content in the bone marrow that induces a bias toward megakaryocyte commitment in the megakaryocyte-erythroid progenitors. A much less frequent presentation is iron deficiency-associated thrombocytopenia (IDAT), be it at the time of diagnosis or secondary to iron replacement therapy.
Aims
Given the rarity of these findings, as well as the limited literature available, these cases can lead to diagnostic confusion and unnecessary invasive procedures. Here we present the case of a severe IDA and thrombocytopenia with subsequent progression of the thrombocytopenia after initiation of iron replacement therapy.
Methods
A qualitative case study from the authors’ institution diagnosed with the help of standard hematological parameters.
Results
A 45 year old woman was referred to the Emergency Department because of severe anemia (Hemoglobin 4.3 g/dL) and thrombocytopenia (PLT 85 x10^3/µL) in a routine analysis. Her medical history showed an earlier untreated episode of IDA due to menorrhagia, but at the moment the patient reported normal menstruations. The complete blood count showed a microcytic, hypochromic pattern (MCV 62.5 fL, MCHC 28.4 g/dL, RDW 22.1%, WBC 4.14 x10^3/µL), without alterations in the rest of the work-up (no fever, LDH 142 UI/L, total bilirubin 0.56 mg/dL, DAT negative, reticulocytes 20.40 x10^3/µL, creatinine 0.69 mg/dL, no schistocytes in peripheral blood smear). The patient was hospitalized in the department of Internal Medicine for further study and treatment, initiating blood transfusion and intravenous iron replacement therapy the same day. The iron studies showed a ferritin level of <1 ng/mL, total serum iron 8 µg/dL, transferrin 406 mg/dL, and transferrin saturation index 1%. Further diagnostic procedures included abdominal ecography, gastroscopy, colonoscopy, thoracoabdominal CT, bone marrow aspirate, and gynecological work-up, all without alterations. The patient was discharged after 13 days of hospitalization, continuing with oral iron supplementation. The blood parameters during the hospitalization and at 45 days can be seen in the figure.
Conclusion
This case illustrates how easily the differential diagnosis of an IDA can be complicated by the association of a thrombocytopenia. Discarding hemolysis, thrombotic thrombocytopenic purpura and hemolytic uremic syndrome can usually be done within the Emergency Deparment, but other pathologies like malignancy or IDA secondary to bleeding caused by immune thrombocytopenia (ITP) can be more challenging without being well aware of this uncommon presentation. Studies comparing IDAT and ITP have found that the former usually present with more profound anemia and less severe thrombocytopenia, as well as significantly shorter platelet recovery time. Excluding malignancy, on the other hand, requires invasive procedures that might well be avoided if an early suspicion of IDAT is being addressed. Women of childbearing age with a history of menorrhagia fits the bill in this regard, as they also comprise the majority of the previously reported cases. As demonstrated, the rapid response to intravenous iron replacement therapy, even with an initial worsening of the platelet-count, obviates other invasive diagnostic procedures.
Keyword(s): Iron deficiency anemia, Thrombocytopenia
Abstract: PB1604
Type: Publication Only
Session title: Iron metabolism, deficiency and overload
Background
Iron deficiency anemia (IDA) is typically associated with either normal or elevated platelet counts, likely due to a low iron content in the bone marrow that induces a bias toward megakaryocyte commitment in the megakaryocyte-erythroid progenitors. A much less frequent presentation is iron deficiency-associated thrombocytopenia (IDAT), be it at the time of diagnosis or secondary to iron replacement therapy.
Aims
Given the rarity of these findings, as well as the limited literature available, these cases can lead to diagnostic confusion and unnecessary invasive procedures. Here we present the case of a severe IDA and thrombocytopenia with subsequent progression of the thrombocytopenia after initiation of iron replacement therapy.
Methods
A qualitative case study from the authors’ institution diagnosed with the help of standard hematological parameters.
Results
A 45 year old woman was referred to the Emergency Department because of severe anemia (Hemoglobin 4.3 g/dL) and thrombocytopenia (PLT 85 x10^3/µL) in a routine analysis. Her medical history showed an earlier untreated episode of IDA due to menorrhagia, but at the moment the patient reported normal menstruations. The complete blood count showed a microcytic, hypochromic pattern (MCV 62.5 fL, MCHC 28.4 g/dL, RDW 22.1%, WBC 4.14 x10^3/µL), without alterations in the rest of the work-up (no fever, LDH 142 UI/L, total bilirubin 0.56 mg/dL, DAT negative, reticulocytes 20.40 x10^3/µL, creatinine 0.69 mg/dL, no schistocytes in peripheral blood smear). The patient was hospitalized in the department of Internal Medicine for further study and treatment, initiating blood transfusion and intravenous iron replacement therapy the same day. The iron studies showed a ferritin level of <1 ng/mL, total serum iron 8 µg/dL, transferrin 406 mg/dL, and transferrin saturation index 1%. Further diagnostic procedures included abdominal ecography, gastroscopy, colonoscopy, thoracoabdominal CT, bone marrow aspirate, and gynecological work-up, all without alterations. The patient was discharged after 13 days of hospitalization, continuing with oral iron supplementation. The blood parameters during the hospitalization and at 45 days can be seen in the figure.
Conclusion
This case illustrates how easily the differential diagnosis of an IDA can be complicated by the association of a thrombocytopenia. Discarding hemolysis, thrombotic thrombocytopenic purpura and hemolytic uremic syndrome can usually be done within the Emergency Deparment, but other pathologies like malignancy or IDA secondary to bleeding caused by immune thrombocytopenia (ITP) can be more challenging without being well aware of this uncommon presentation. Studies comparing IDAT and ITP have found that the former usually present with more profound anemia and less severe thrombocytopenia, as well as significantly shorter platelet recovery time. Excluding malignancy, on the other hand, requires invasive procedures that might well be avoided if an early suspicion of IDAT is being addressed. Women of childbearing age with a history of menorrhagia fits the bill in this regard, as they also comprise the majority of the previously reported cases. As demonstrated, the rapid response to intravenous iron replacement therapy, even with an initial worsening of the platelet-count, obviates other invasive diagnostic procedures.
Keyword(s): Iron deficiency anemia, Thrombocytopenia