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Thrombocytosis

Introduction

Synonyms and keywords: Platelet count raised; thrombocythemia

Overview

Overview

Thrombocytosis is the presence of high platelet counts in the blood, and can be either reactive or primary (also termed essential and caused by a myeloproliferative disease). Although often symptomless (particularly when it is a secondary reaction), it can predispose to thrombosis in some patients.

Definition
  • 95% of the population will have a platelet count between 100,000 and 450,000 per mm³. Thrombocytosis is defined as >500,000. Extreme thrombocytosis is defined as >1,000,000. Generally, a normal platelet count ranges from 150,000 and 450,000 per mm³. These limits, however, are determined by the 2.5th lower and upper percentile, and a deviation does not necessary imply any form of disease. Nevertheless, counts over 750,000 (and especially over a million) are considered serious enough to warrant investigation and intervention.

References

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Historical Perspective

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References

Classification

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References

Pathophysiology

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Overview

Pathophysiology

Thrombocytosis is either reactive or autonomous. In one study of 91 patients with platelet count >600,000, 70% were reactive and 22% autonomous. In 280 patients with platelet count >1,000,000 82% were reactive and 14% were autonomous. 8% had both. Among reactive causes of thrombocytosis, infection (30%), Post-surgical (15%), Both (30%), Malignancy (10%), Post splenectomy (10%) and acute blood loss/iron deficiency (10%) are the most common causes.

Autonomous causes of thrombocytosis include Essential Thrombocytosis, Chronic Myelogenous Leukemia (CML), Polycythemia Vera, Agnogenic Myeloid Metaplasia and Myelodysplasia. The degree of thrombocytosis does not help determine whether the thrombocytosis is reactive or not.

References

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Faizan Sheraz, M.D. [2]

Causes

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Overview

Causes

Increase platelet counts can be due to a number of disease processes:

References

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Faizan Sheraz, M.D. [2]

Differentiating Thrombocytosis from other Diseases

Overview

Thrombocytosis Differential Diagnosis

Differentiating the diseases that can cause thrombocytosis :

Category Condition Etiology Mechanism Inherited Acquried Clinical manifestations Para−clinical findings Gold standard Associated findings
Demography History Symptoms Signs
Lab Findings Imaging
Fever Appearance Bleeding BP Splenomegaly Jaundice Other CBC PBS Bone marrow exam PT PTT
Increased megakaryocyte proliferation Accelerated platelet release Reduced platelet turnover Plt HB WBC
Autonomous thrombocytosis Hematologic malignancies Essential thrombocythemia[1]
  • Acquired mutation of JAK2, CALR, or MPL
+ – – – + Mean age >60 years old, female > male ±
  • Flushing
+ Nl + – ↑↑ ↑ ↑ Nl Nl Bone marrow biopsy
  • Thrombo-hemorrhagic complications
Polycythemia vera[2]
  • Acquired mutation of JAK2
+ – – – + Mean age >60 years old –
  • Facial plethora
± Nl + – ↑ ↑↑ ↑ ↑ ↑ Bone marrow biopsy
  • Thrombo-hemorrhagic complications
Primary myelofibrosis[3] + – – – + Mean age >60 years old, male> female – + Nl + + ↑/↓ ↓ ↓ ↑ ↑ Bone marrow biopsy
  • Thrombo-hemorrhagic complications
  • Variable risk for development of acute leukemia
Chronic myeloid leukemia[4] + – – – + Mean age >50 years old, male> female History of exposure to: + + Nl + – ↑ ↓ ↑
  • ↑ Proportion of metamyelocytes and other white blood cells at various stages of maturation
↑ ↑ Bone marrow biopsy
  • Increase of immature myeloid cells
Acute myeloid leukemia[5]
  • Unknown
+ – – – + Median age of 63 years old + + Nl + + ↑/↓ ↓ ↑/↓
  • “Dry tap” on aspiration
  • Leukemic cells
↑ ↑ NA Bone marrow examination + clinical manifestation
Myelodysplastic syndromes[6] + – – ± + Elderly Exposure to: ± + Nl + + ↑/↓ ↓ ↓ Nl Nl NA Bone marrow examination + clinical manifestation
Condition Etiology Increased megakaryocyte proliferation Accelerated platelet release Reduced platelet turnover Inherited Acquried Demography History Fever Appearance Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT Imaging Gold standard Associated findings
Familial thrombocytosis[7][8] + – – + – Rare familial disease, middle age male and female –
  • Normal
– Nl – – – ↑ Nl Nl Nl Nl NA Genetic study
Reactive thrombocytosis Anemia/

blood loss[9]

+ – – – + Any – + Nl to ↓ – – Depends on the etilogy ↑ ↓ Nl Nl Nl NA Clinical manifestation
  • Required iron studies
Infection Chronic infections + + – – + Any + ± Nl to ↓ – ± Depends on the etilogy ↑ ↓ ↑ Nl Nl
  • Depends on the etiology
Culture Depends on the etilogy
Tuberculosis + + – – + Any
  • History of close contact
+
  • Cachectic
– Nl – – ↑ Nl ↑ Nl Nl
  • Cavitation on chest imaging
Clinical manifestation+ culture
Acute bacterial and viral infections + + – – + Any
  • History of close contact
+
  • Acutely ill
– Nl – – Depends on the etilogy ↑ ↑ Nl Nl
  • Depends on the etiology
Clinical manifestation+ culture
  • Depends on the etiology
Inflammation Vasculitides[10]
  • Unknown
+ + – ± + Any
  • Family history of rheumatologic disorders
+
  • Acutely ill
+ Nl – – ↑ Nl to ↓ ↑ Nl to ↑ Nl to ↑
  • Depends on the type
Clinical manifestation+ culture
  • Depends on the type
Acute pancreatitis + + – – + Any +
  • Acutely ill
– Nl to ↓ – + ↑ Nl to ↓ ↑ Nl to ↑ Nl to ↑ Clinical manifestation
Malignancy[11] + + – ± ± Any
  • Prior malignancy
  • Exposure to chemicals
  • Family history of malignancy
+
  • Cachectic
– Nl to ↓ Depends on the type –
  • Tenderness
↑ Nl to ↓ ↑ Nl to ↑ Nl to ↑
  • Depends on the type
Biopsy
Condition Etiology Increased megakaryocyte proliferation Accelerated platelet release Reduced platelet turnover Inherited Acquried Demography History Fever Appearance Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT Imaging Gold standard Associated findings
Tissue damage Thermal burns[12] – + – – + Any
  • Thermal burn
+
  • Acutely ill
± Nl to ↓ – ± ↑ Nl to ↓ ↑ Nl to ↑ Nl to ↑
  • Depend on the involvement
Clinical manifestation
Trauma[13] – + – – + Any ±
  • Acutely ill
± Nl to ↓ – – ↑ Nl to ↓ ↑ Nl Nl
  • Depend on the involvement
  • Fracture on X-rays
Clinical manifestation
  • Sepsis
  • Associated with higher rates of complications
Myocardial infarction[14] – + – – + Elderly ±
  • Acutely ill
  • Diaphoretic
– Nl to ↓ – – ↑ Nl to ↓ ↑ Nl Nl Clinical manifestation + enzymes elevation
Medication[15] Vincristine[16] – + – – + Any –
  • Cachectic
– Nl + – ↑ Nl to ↓ ↑ Nl to ↑ Nl to ↑
  • Depends on the etiology
Clinical manifestation + history of drug consumption
Epinephrine[17]
  • Unknown
  • Activation of chloride transport
+ + – – + Any –
  • Acutely ill
  • Diaphoretic
– Nl to ↓ – – ↑ ↑ ↑ Nl Nl
  • Depends on the etiology
Clinical manifestation + history of drug consumption
Glucocorticoids[18]
  • Stimulate megakaryocytopoiesis
+ + – – + Any + Nl to ↓ – – ↑ Nl to ↓ ↑ Nl to ↑ Nl to ↑
  • Depends on the etiology
Clinical manifestation + history of drug consumption
Antibiotics[19] + + – – + Any + Nl ± Nl – –
  • Depends on the etiology
↑ Nl ↑ Nl Nl
  • Depends on the etiology
Clinical manifestation + history of drug consumption
Thrombopoietin[20][21]
  • Stimulate megakaryocytopoiesis
  • Thrombopoiesis
+ – – – + Any +
  • Chronically ill
– Nl to ↑ – –
  • Depends on the etiology
↑ ↑ ↑ Nl Nl
  • Depends on the etiology
Clinical manifestation + history of drug consumption
Condition Etiology Increased megakaryocyte proliferation Accelerated platelet release Reduced platelet turnover Inherited Acquried Demography History Fever Appearance Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT Imaging Gold standard Associated findings
Other Post-splenectomy or functional asplenia[22] – – + – + Any ±
  • Normal
+ Nl Asplenia – – ↑ ↓ ↑ Nl Nl Clinical manifestation
Allergic reactions[23]
  • Unknown
  • Activation of chloride transport
+ + – – + Any –
  • Acutely ill
  • Diaphoretic
– Nl to ↓ – – ↑ ↑ ↑ Nl Nl
  • Depends on the etiology
Clinical manifestation
  • Poor prognosis
Exercise[24] + + – – + Athlete
  • Exercise
– Normal – Nl – – NA ↑ ↑ ↑ Nl Nl
  • Depends on the etiology
Clinical manifestation NA
Pseudothrombocytosis Mixed cryoglobulinemia[25]
  • Falsely elevated
– – – – – Any –
  • Atypical cutaneous ulcers
  • Palpable purpura
– Nl – – ↑ Nl to ↓ ↑
  • Cytoplasmic fragments
Nl Nl Nl NA Skin biopsy
Cytoplasmic fragments[26]
  • Falsely elevated
– – – – – Any NA – Normal – Nl – – NA ↑ Nl Nl
  • Cytoplasmic fragments
Nl Nl Nl Nl Repeat NA

References

  1. ↑ Brière, Jean B (2007). Orphanet Journal of Rare Diseases. 2 (1): 3. doi:10.1186/1750-1172-2-3. ISSN 1750-1172. Missing or empty |title= (help)
  2. ↑ Arber, D. A.; Orazi, A.; Hasserjian, R.; Thiele, J.; Borowitz, M. J.; Le Beau, M. M.; Bloomfield, C. D.; Cazzola, M.; Vardiman, J. W. (2016). “The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia”. Blood. 127 (20): 2391–2405. doi:10.1182/blood-2016-03-643544. ISSN 0006-4971.
  3. ↑ Tefferi, Ayalew; Lasho, Terra L.; Jimma, Thitina; Finke, Christy M.; Gangat, Naseema; Vaidya, Rakhee; Begna, Kebede H.; Al-Kali, Aref; Ketterling, Rhett P.; Hanson, Curtis A.; Pardanani, Animesh (2012). “One Thousand Patients With Primary Myelofibrosis: The Mayo Clinic Experience”. Mayo Clinic Proceedings. 87 (1): 25–33. doi:10.1016/j.mayocp.2011.11.001. ISSN 0025-6196.
  4. ↑ Thompson, Philip A.; Kantarjian, Hagop M.; Cortes, Jorge E. (2015). “Diagnosis and Treatment of Chronic Myeloid Leukemia in 2015”. Mayo Clinic Proceedings. 90 (10): 1440–1454. doi:10.1016/j.mayocp.2015.08.010. ISSN 0025-6196.
  5. ↑ Rose-Inman, Hayley; Kuehl, Damon (2014). “Acute Leukemia”. Emergency Medicine Clinics of North America. 32 (3): 579–596. doi:10.1016/j.emc.2014.04.004. ISSN 0733-8627.
  6. ↑ Natelson, Ethan A.; Pyatt, David (2013). “Acquired Myelodysplasia or Myelodysplastic Syndrome: Clearing the Fog”. Advances in Hematology. 2013: 1–11. doi:10.1155/2013/309637. ISSN 1687-9104.
  7. ↑ Ding, J. (2004). “Familial essential thrombocythemia associated with a dominant-positive activating mutation of the c-MPL gene, which encodes for the receptor for thrombopoietin”. Blood. 103 (11): 4198–4200. doi:10.1182/blood-2003-10-3471. ISSN 0006-4971.
  8. ↑ Wiestner, A.; Padosch, S. A.; Ghilardi, N.; Cesar, J. M.; Odriozola, J.; Shapiro, A.; Skoda, R. C. (2000). “Hereditary thrombocythaemia is a genetically heterogeneous disorder: exclusion of TPO and MPL in two families with hereditary thrombocythaemia”. British Journal of Haematology. 110 (1): 104–109. doi:10.1046/j.1365-2141.2000.02169.x. ISSN 0007-1048.
  9. ↑ Kuter, David J. (1996). “The Physiology of Platelet Production”. Stem Cells. 14 (S1): 88–101. doi:10.1002/stem.5530140711. ISSN 1066-5099.
  10. ↑ Hamblin T, Oscier D (September 1978). “Polyarteritis presenting with thrombocytosis and palliated by plasma exchange”. Postgrad Med J. 54 (635): 615–7. PMC 2425233. PMID 82963.
  11. ↑ Yang, Chen; Jiang, Hui; Huang, Shaozhuo; Hong, Hui; Huang, Xiaowen; Wang, Xiaojie; Liao, Weixin; Wang, Xueyi; Chen, Xuewen; Jiang, Liming (2018). “The prognostic role of pretreatment thrombocytosis in gastric cancer”. Medicine. 97 (31): e11763. doi:10.1097/MD.0000000000011763. ISSN 0025-7974.
  12. ↑ Dinsdale, R. J.; Devi, A.; Hampson, P.; Wearn, C. M.; Bamford, A. L.; Hazeldine, J.; Bishop, J.; Ahmed, S.; Watson, C.; Lord, J. M.; Moiemen, N.; Harrison, P. (2017). “Changes in novel haematological parameters following thermal injury: A prospective observational cohort study”. Scientific Reports. 7 (1). doi:10.1038/s41598-017-03222-w. ISSN 2045-2322.
  13. ↑ Salim, Ali; Hadjizacharia, Pantelis; DuBose, Joseph; Kobayashi, Leslie; Inaba, Kenji; Chan, Linda S.; Margulies, Daniel R. (2009). “What is the Significance of Thrombocytosis in Patients With Trauma?”. The Journal of Trauma: Injury, Infection, and Critical Care. 66 (5): 1349–1354. doi:10.1097/TA.0b013e318191b8af. ISSN 0022-5282.
  14. ↑ Nanavati, Amit; Patel, Nainesh; Burke, James (2012). “Thrombocytosis and Coronary Occlusion”. JACC: Cardiovascular Interventions. 5 (6): e18–e19. doi:10.1016/j.jcin.2011.12.018. ISSN 1936-8798.
  15. ↑ Frye JL, Thompson DF (February 1993). “Drug-induced thrombocytosis”. J Clin Pharm Ther. 18 (1): 45–8. PMID 8473359.
  16. ↑ Feliu, E.; Cervantes, F.; Blade, J.; Rozman, C. (1980). “Thrombocytosis in Quiescent Chronic Granulocytic Leukaemia after Vincristine and 6-Mercaptopurine Therapy”. Acta Haematologica. 64 (4): 224–226. doi:10.1159/000207258. ISSN 0001-5792.
  17. ↑ Spalding A, Vaitkevicius H, Dill S, MacKenzie S, Schmaier A, Lockette W (February 1998). “Mechanism of epinephrine-induced platelet aggregation”. Hypertension. 31 (2): 603–7. PMID 9461228.
  18. ↑ Neel, Jennifer A.; Snyder, Laura; Grindem, Carol B. (2012). “Thrombocytosis: a retrospective study of 165 dogs”. Veterinary Clinical Pathology. 41 (2): 216–222. doi:10.1111/j.1939-165X.2012.00416.x. ISSN 0275-6382.
  19. ↑ Scharf RE (November 2012). “Drugs that affect platelet function”. Semin. Thromb. Hemost. 38 (8): 865–83. doi:10.1055/s-0032-1328881. PMID 23111864.
  20. ↑ Hitchcock IS, Kaushansky K (April 2014). “Thrombopoietin from beginning to end”. Br. J. Haematol. 165 (2): 259–68. doi:10.1111/bjh.12772. PMID 24499199.
  21. ↑ Teofili, Luciana; Giona, Fiorina; Martini, Maurizio; Torti, Lorenza; Cenci, Tonia; Foà, Robin; Leone, Giuseppe; Larocca, Luigi M. (2010). “Thrombopoietin Receptor Activation, Thrombopoietin Mimetic Drugs, and Hereditary Thrombocytosis: Remarks on Bone Marrow Fibrosis”. Journal of Clinical Oncology. 28 (19): e317–e318. doi:10.1200/JCO.2010.29.0387. ISSN 0732-183X.
  22. ↑ Vlachaki E, Kalogeridis A, Neokleous N, Perifanis V, Klonizakis F, Ioannidou E, Klonizakis I (May 2012). “Absence of JAK2V617F mutation in patients with beta-thalassemia major and thrombocytosis due to splenectomy”. Mol. Biol. Rep. 39 (5): 6101–5. doi:10.1007/s11033-011-1425-7. PMID 22203487.
  23. ↑ Randi ML, Rossi C, Fabris F, Zerbinati P, Girolami A (December 1995). “Atopic dermatitis and allergic diseases with thrombocytosis: a possible link”. Ann. Allergy Asthma Immunol. 75 (6 Pt 1): 530–2. PMID 8603285.
  24. ↑ Beck WR, Scariot PP, Gobatto CA (2014). “Primary and secondary thrombocytosis induced by exercise and environmental luminosity”. Bratisl Lek Listy. 115 (10): 607–10. PMID 25573725.
  25. ↑ Patel KJ, Hughes CG, Parapia LA (January 1987). “Pseudoleucocytosis and pseudothrombocytosis due to cryoglobulinaemia”. J. Clin. Pathol. 40 (1): 120–1. PMC 1140844. PMID 3818970.
  26. ↑ Akinci, Sema; Hacibekiroglu, Tuba; Basturk, Abdulkadir; Bakanay, Sule Mine; Guney, Tekin; Dilek, Imdat (2013). “Pseudothrombocytosis due to Microerythrocytosis: A Case of Beta Thalassemia Minor Complicated with Iron Deficiency Anemia”. Acta Haematologica. 130 (2): 61–63. doi:10.1159/000346434. ISSN 1421-9662.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Epidemiology and Demographics

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Risk Factors

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Screening

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Natural History, Complications and Prognosis

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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | CT | Ultrasound | Other Imaging Studies | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Surgery | Prevention | Future or Investigational Therapies | Cost Effectiveness of Therapy

Case Studies

Case Studies

Case #1
Acknowledgements

Acknowledgements

The content on this page was first contributed by: BIDMC Resident Report by Duane Pinto, M.D.



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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Faizan Sheraz, M.D. [2]