Thrombocytosis: Difference between revisions
 
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===Autonomous thrombocytosis (AT)<ref>Schafer, "Thrombocytosis," N Engl J Med 2004;350:1211-9.</ref>===
===Autonomous thrombocytosis (AT)<ref>Schafer, "Thrombocytosis," N Engl J Med 2004;350:1211-9.</ref>===
*Accounts for 15% of cases
*Accounts for 15% of cases
*A primary problem that results from [[myeloproliferative disorders]] or [[myelodysplastic disorders]], such as essential [[thrombocytopenia]] or [[polycythemia vera]].  
*A primary problem that results from [[myeloproliferative disorders]] or [[myelodysplastic syndrome]]s, such as essential [[thrombocytopenia]] or [[polycythemia vera]].  
*Complications, such as bleeding and/or thrombosis, are more likely with AT than with RT so it is clinically important to differentiate reactive thrombocytosis versus autonomous thrombocytosis.   
*Complications, such as bleeding and/or thrombosis, are more likely with AT than with RT so it is clinically important to differentiate reactive thrombocytosis versus autonomous thrombocytosis.   
*There are no diagnostic studies to differentiate RT versus AT.
*There are no diagnostic studies to differentiate RT versus AT.
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*Thrombosis (leading cause of morbidity and mortality)
*Thrombosis (leading cause of morbidity and mortality)
**Arteries (more common)
**Arteries (more common)
***Stroke, TIA, MI, unstable angina
***[[Stroke]], [[TIA]], [[MI]], [[unstable angina]]
**Venous system
**Venous system
***[[DVT]], [[PE]], [[Budd-Chiari syndrome]]
***[[DVT]], [[PE]], [[Budd-Chiari syndrome]]
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**Generally in the nasal and bucchal mucosa and the GI tract
**Generally in the nasal and bucchal mucosa and the GI tract
*Vasomotor symptoms (due to microvascular disturbances)
*Vasomotor symptoms (due to microvascular disturbances)
**Headache, lightheadedness, syncope, acral paresthesia, atypical chest pain, livedo reticularis, erythromelalgia, and transient visual disturbances
**[[Headache]], lightheadedness, [[syncope]], acral [[paresthesia]], atypical [[chest pain]], livedo reticularis, erythromelalgia, and transient [[visual disturbances]]


==Differential Diagnosis<ref>Tefferi, "Diagnosis and Clinical Manifestations of Essential Thrombocythemia," UpToDate, Jul. 2017.</ref>==
==Differential Diagnosis<ref>Tefferi, "Diagnosis and Clinical Manifestations of Essential Thrombocythemia," UpToDate, Jul. 2017.</ref>==
===Reactive thrombocytosis===
===Reactive thrombocytosis===
* Acute blood loss
* Acute [[hemorrhage|blood loss]]
* Acute hemolytic anemia
* Acute [[hemolytic anemia]]
* Iron deficiency anemia
* Iron deficiency [[anemia]]
* Treatment of [[vitamin B12 deficiency]]
* Treatment of [[vitamin B12 deficiency]]
*Rebound effect after thrombocytopenia treatment
* Rebound effect after [[thrombocytopenia]] treatment
* Metastatic cancer
* Metastatic cancer
* [[Lymphoma]]
* [[Lymphoma]]
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* Thermal [[burn]]
* Thermal [[burn]]
* [[MI]]
* [[MI]]
* Severe trauma
* Severe [[trauma]]
* [[Acute pancreatitis]]
* [[Acute pancreatitis]]
* Post-surgery, especially splenectomy
* Post-surgery, especially [[splenectomy]]
* CABG
* CABG
* [[TB]]
* [[TB]]
* Acute bacterial/viral infections
* Acute [[bacterial disease|bacterial]]/[[viruses|viral]] infections
* Asplenia
* [[asplenic patient|Asplenia]]
* [[Allergic reaction]]
* [[Allergic reaction]]
* Medication reactions: vincristine, epinephrine, glucocorticoids, IL-1B, ATRA, thrombopoietin, LMWH (uptodate)
* Medication reactions: vincristine, [[epinephrine]], [[glucocorticoids]], IL-1B, ATRA, thrombopoietin, [[LMWH]]<ref>uptodate</ref>


===Autonomous thrombocytosis===
===Autonomous thrombocytosis===
* Essential thrombocytopenia
* [[Essential thrombocytosis]]
* [[Polycythemia vera]]
* [[Polycythemia vera]]
* Mixed myelodysplastic and/or myeloproliferative syndrome
* Mixed [[myelodysplastic syndrome|myelodysplastic]] and/or [[myeloproliferative disorders|myeloproliferative syndrome]]


===Spurious (false) thrombocytosis===
===Spurious (false) thrombocytosis===
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====Asymptomatic====
====Asymptomatic====
*81mg [[ASA]] PO daily.
*81mg [[ASA]] PO daily.
*If high risk  for thrombotic event (>60 yrs, history of thrombosis, or known JAK2 mutation), consider 15mg/kg hydroxyurea PO daily.  Consult if available.   
*If high risk  for thrombotic event (>60 yrs, history of thrombosis, or known JAK2 mutation), consider 15mg/kg [[hydroxyurea]] PO daily.  Consult if available.   
*Second line agents include IFN-alpha, anagrelide, and pipobroman.
*Second line agents include [[interferon-α]], anagrelide, and pipobroman.


====Thrombosis due to AT====
====Thrombosis due to AT====
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*81mg [[ASA]] PO daily.
*81mg [[ASA]] PO daily.
*Consult heme/onc
*Consult heme/onc
*Consider 3-5 million U IFN alpha SQ daily if <40 years old.  15mg/kg hydroxyurea PO daily if >40 years old.  Goal platelet count <400,000/microL.
*Consider 3-5 million U [[interferon-α]] SQ daily if <40 years old.  15mg/kg [[hydroxyurea]] PO daily if >40 years old.  Goal platelet count <400,000/microL.
*Platelet apheresis if platelet count >800,000/microL.
*Platelet apheresis if platelet count >800,000/microL.


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*Discontinue antiplatelet medications.
*Discontinue antiplatelet medications.
*Consult.
*Consult.
*Consider 3-5 million U IFN alpha SQ daily if <40 years old.  15mg/kg hydroxyurea PO daily if >40 years old.  Goal platelet count <400,000/microL.<ref>Bleeker, "Thrombocytosis: Diagnostic Evaluation, Thrombotic Risk Stratification, and Risk-Based Management Strategies," Thrombosis. 2011; 2011: 536062. Published online 2011 Jun 8. doi:10.1155/2011/536062.</ref>
*Consider 3-5 million U [[interferon-α]] SQ daily if <40 years old.  15mg/kg [[hydroxyurea]] PO daily if >40 years old.  Goal platelet count <400,000/microL.<ref>Bleeker, "Thrombocytosis: Diagnostic Evaluation, Thrombotic Risk Stratification, and Risk-Based Management Strategies," Thrombosis. 2011; 2011: 536062. Published online 2011 Jun 8. doi:10.1155/2011/536062.</ref>


==Disposition==
==Disposition==

Latest revision as of 23:46, 30 September 2019

Background

  • Defined as a platelet count >450,000/microL.

Reactive thrombocytosis (RT)

  • Most common cause of thrombocytosis, accounting for 85% of cases.
  • A reaction to another process, such as inflammation, infection, cancer, or iron deficiency.
  • Rarely causes complications even with extremely elevated platelet counts (>1,000,000/microL).

Autonomous thrombocytosis (AT)[1]

  • Accounts for 15% of cases
  • A primary problem that results from myeloproliferative disorders or myelodysplastic syndromes, such as essential thrombocytopenia or polycythemia vera.
  • Complications, such as bleeding and/or thrombosis, are more likely with AT than with RT so it is clinically important to differentiate reactive thrombocytosis versus autonomous thrombocytosis.
  • There are no diagnostic studies to differentiate RT versus AT.

Clinical Features[2]

Generally asymptomatic and found on routine lab testing; complications are typically from AT disorders

Differential Diagnosis[3]

Reactive thrombocytosis

Autonomous thrombocytosis

Spurious (false) thrombocytosis

  • Mixed cryoglobulinemia
  • Cytoplasmic fragments
  • Bacteremia

Evaluation

Workup

  • Labs
    • CBC, ESR, CRP, iron studies, LDH
  • CXR
  • Fecal occult blood test

Diagnosis

  • platelet count >450,000/microL.

Management

Reactive thrombocytosis

  • Treat underlying disease.

Autonomous thrombocytosis

Asymptomatic

  • 81mg ASA PO daily.
  • If high risk for thrombotic event (>60 yrs, history of thrombosis, or known JAK2 mutation), consider 15mg/kg hydroxyurea PO daily. Consult if available.
  • Second line agents include interferon-α, anagrelide, and pipobroman.

Thrombosis due to AT

  • Anticoagulation with LMWH.
  • 81mg ASA PO daily.
  • Consult heme/onc
  • Consider 3-5 million U interferon-α SQ daily if <40 years old. 15mg/kg hydroxyurea PO daily if >40 years old. Goal platelet count <400,000/microL.
  • Platelet apheresis if platelet count >800,000/microL.

Bleeding due to AT

  • Discontinue antiplatelet medications.
  • Consult.
  • Consider 3-5 million U interferon-α SQ daily if <40 years old. 15mg/kg hydroxyurea PO daily if >40 years old. Goal platelet count <400,000/microL.[5]

Disposition

Reactive thrombocytosis

  • Disposition is based on underlying disorder.

Autonomous thrombocytosis

  • If asymptomatic, consider outpatient treatment with close follow up.
  • If thrombosis or bleeding complications, should be admitted for stabilization and further work up.

External Links

References

  1. ↑ Schafer, "Thrombocytosis," N Engl J Med 2004;350:1211-9.
  2. ↑ Tefferi, "Diagnosis and Clinical Manifestations of Essential Thrombocythemia," UpToDate, Jul. 2017.
  3. ↑ Tefferi, "Diagnosis and Clinical Manifestations of Essential Thrombocythemia," UpToDate, Jul. 2017.
  4. ↑ uptodate
  5. ↑ Bleeker, "Thrombocytosis: Diagnostic Evaluation, Thrombotic Risk Stratification, and Risk-Based Management Strategies," Thrombosis. 2011; 2011: 536062. Published online 2011 Jun 8. doi:10.1155/2011/536062.
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