OPEN ACCESS Annals of Medicine and Medical Education ISSN: 2468-4937 2016 3(2):7-10 DOI 10.12973/amme.2016.00148a
Intravenous Iron Infusion Induced Severe Temporary Thrombocytopenia Case in Iron Deficiency Anemia: A Review Cüneyt Kahraman Dumlupinar University School of Medicine, TURKEY
Serdar Üçgün Dumlupinar University School of Medicine, TURKEY
Nilüfer Kuzeyli Kahraman DPU Evliya Celebi Education and Research Hospital, TURKEY Received 23 March 2016 ▪ Revised 5 April 2016 ▪ Accepted 15 April 2016
ABSTRACT Iron deficiency anemia is generally associated with microcytic anemia and thrombocytosis. The mechanism of this increase has been found to be related to the increased generation of erythropoietin in iron deficiency. Rare cases of thrombocytopenia have been reported, but even more rarely seen are cases of thrombocytopenia that develop after iron replacement. Sudden decrease in platelet level following intravenous iron treatment is likely related to the stem cell trafficking phenomenon. When iron is insufficient, excessive erythropoietin stimulation could lead to thrombocytosis. However, when iron sources are usable, erythropoiesis might be dominant, and temporary reduction might be seen in megakaryopoiesis and leucopoiesis. It must be kept in mind that the iron sucrose complex treatment could be involved in the etiology of isolated thrombocytopenia. Keywords: anemia, iron deficiency, thrombocytopenia
INTRODUCTION Iron deficiency anemia (IDA) is a common disease. IDA differs from other types of anemia, both in terms of its association with underlying diseases that might require a different approach, and also in terms of its simple, safe and effective treatment. IDA is generally associated with microcytic anemia and thrombocytosis. The mechanism of this increase has been found to be related to the increased generation of erythropoietin in iron deficiency [1]. Rare cases of thrombocytopenia have been reported [2-3], but even more rarely seen are cases of thrombocytopenia that develop after iron replacement [4,5,6]. In this article, we will discuss a severe and temporary thrombocytopenia case that developed after intravenous iron infusion.
© Authors. Terms and conditions of Creative Commons Attribution 4.0 International (CC BY 4.0) apply. Correspondence: Cüneyt Kahraman, Dumlupinar University School of Medicine, Assistant professor o IInternal Medicine, M.D., Division of Internal Medicine, Kütahya, Turkey.
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CARE REPORT A 17-year-old male patient presented to our Internal Diseases department with complaints of fatigue, shortness of breath and facial paleness, all of which had started about 3 months prior. There were no chronic diseases or ongoing, long term medication use in his history. His mother had also developed severe anemia in the past and received blood transfusion at certain intervals. In the physical examination conducted on the patient, his general condition was good and he was fully conscious but had pale skin, and conjunctiva icterus or hepatosplenomegaly was not found. All other system findings were normal. In the laboratory, the following values were obtained: hgb: 7.6 g/dL (normal range: 11.0 – 15.1 g/dL), mcv (mean corpuscular volume ): 66 fL (normal range: 79 – 97 fL) wbc: 6.1 × 103/μL (normal range: 4 – 11 × 103/μL), plt: 340 × 103/mcL (normal range: 150 – 400 × 103/μL), iron level: 27 μg/dL (normal range: 37 – 170 μg/dL), total iron binding capacity: 449 μg/dL (normal range: 250 – 450 μg/dL), ferritin level: 3 ng/mL. Thalassemia could not be found due to hemoglobin electrophoresis. After reviewing available findings, an intravenous iron sucrose treatment was planned to address the iron deficiency. In peripheral blood smear, a hypochromic microcytic appearance was present; abnormal cells were not found. A complete abdominal ultrasound was performed; hepatosplenomegaly was not found. Stool samples were taken for parasites and an occult blood test was conducted. No parasites or eggs were found, and occult blood was negative. Starting from the first day of hospitalization, 100 mg/day of iron sucrose complex was administered intravenously. On the 7th day of treatment, platelet values decreased. The patient’s treatment was suspended since the platelet value dropped back to 68 × 103/mcL. During the untreated control period, platelet values showed a gradual increase in three days (83 -128-159 × 103/mcL) (Figure 1) and reached normal levels. Thrombocytopenia was attributed to the iron sucrose complex administered intravenously. Platelet levels were normal in follow-ups.
DISCUSSION Drug-induced thrombocytopenia occurs as a result of bone marrow suppression and the destruction of platelets in the peripheral blood via immune and non-immune mechanisms. Thrombocytopenia associated with intravenous iron sucrose treatment is quite rare. While reactive thrombocytosis is generally seen in IDA, platelet levels are normal [7, 8] or even reduced [2, 9] in severe iron deficiency cases. Sudden decrease in platelet level following intravenous iron treatment is likely related to the stem cell trafficking phenomenon. The lack of erythrocyte precursors (iron) might lead to the erythropoiesis of pluripotent hemopoietic stem cells. In fact, the effectiveness of the erythropoietin treatment in platelet level shows that it is dependent on the presence of iron stores. When iron is insufficient, excessive erythropoietin stimulation could lead to thrombocytosis. However, when iron sources are usable, erythropoiesis might be dominant, and temporary reduction might be seen in megakaryopoiesis and leukopoiesis [10]. But, contrary to other cases, isolated thrombocytopenia was seen instead of leukopenia in our case.
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Figure 1. Platelet count change from day to day
Clinical diagnosis of drug-induced thrombocytopenia is made if thrombocytopenia improves after discontinuing the suspected drug and thrombocytopenia does not develop in the follow-ups. In our case, the diagnosis of iron sucrose complex induced thrombocytopenia was clinically established when the number of platelets reached normal levels after discontinuing the iron sucrose treatment and thrombocytopenia did not develop in the followups.
RESULT As in our case, iron sucrose infusion induced thrombocytopenia is very rarely seen. If the IDA is severe enough, it could cause a temporary reduction in megakaryopoiesis and leukopoiesis. The decreased number of platelets might be associated with iron replacement treatment. It must be kept in mind that the iron sucrose complex treatment could be involved in the etiology of isolated thrombocytopenia.
DISCLOSURE None of the authors has a financial interest in any of the products or methods mentioned in this article.
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