A recently published report describes the diagnosis and treatment of a case of iron-deficiency anemia–associated thrombocytopenia secondary to recurrent nosebleeds.
While iron-deficiency anemia (IDA) is the most common type of anemia globally, it is only rarely associated with thrombocytopenia. A report published in the Journal of Paediatrics and Child Health describes a case of IDA-associated thrombocytopenia secondary to recurrent epistaxis.
While thrombocytosis is known to be associated with IDA and is a reaction to megakaryocyte stimulation after increased erythropoietin signaling, thrombocytopenia secondary to IDA is rare and does not have a clear mechanism. Concurrent anemia and thrombocytopenia may also have a host of other causes.
“The combination of anemia and thrombocytopenia most commonly raises concerns for immune thrombocytopenia, Evans syndrome, bone marrow failure syndromes, malignancy, autoimmune conditions such as systemic lupus erythematosus, and both bacterial (e.g. Helicobacter pylori) and viral (e.g. Parvovirus) infection,” the authors wrote. Differentiating IDA-associated thrombocytopenia from other potential etiologies influences further assessments and management strategies.
There is a lack of literature on IDA-associated thrombocytopenia in children, and the recently published case report adds evidence of 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 home. His blood pressure was normal, but he had tachycardia at rest with 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 nosebleeds daily since he was 5 years of age. Medical records from 4 years prior showed that the boy had normal hemoglobin and platelet counts at that time. Laboratory testing upon admission to the emergency department demonstrated substantial anemia with hemoglobin levels of 3.3 g/dL and thrombocytopenia with a platelet count of 24 x 109/L. The patient showed an iron binding capacity of 455 μg/dL and a transferrin saturation of 5%, which confirmed iron deficiency and thus IDA.
He received a transfusion of 10 ml/kg of packed red blood cells split 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 he was started on a regimen of oral ferrous sulfate to improve iron production. Oxymetazoline as needed for acute nosebleeds and a nasal hygiene regimen were recommended after a direct nasal endoscopy showed prominent Kiesselbach plexus but no signs of plexopathy.
At a follow-up 10 days post discharge, the patient’s anemia had improved further and rebound thrombocytosis had occurred, with platelet levels of 977 x 109/L. His platelet count had normalized to 251 x 109/L by 2 weeks post discharge. The frequency and intensity of the patient’s nosebleeds had also decreased at the 2-week follow-up. At 20 months of follow-up, he still experienced mild iron deficiency, but his hemoglobin had improved even further, and platelet counts hovered between 272 and 392 x 103/dL. These results suggest IDA-induced thrombocytopenia responds well to oral supplementation and may not require invasive procedures.
This case demonstrates the typical workup strategy for a patient presenting in with both anemia and thrombocytopenia. A complete blood count, coagulation studies, iron and ferritin levels, blood smear, and testing for factors involved in hemolysis are all key assessments. If those tests do not help determine the etiology, 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 for other etiologies of low platelet counts,” the authors concluded. However, further research is needed to determine the mechanism of IDA-induced thrombocytopenia.
Ghaznavi C, Ameen S, Srinivas M, Duncavage E, Saini S. Severe thrombocytopenia in the setting of anaemia: The role of iron-deficiency revisited. J Paediatr Child Health. Published online October 21, 2022. doi:10.1111/jpc.16256