Extreme Thrombocytosis in a Post Splenectomy Patient, a Rare Case Report
1) Y. R. Lamture
Professor, Department of General Surgery, Jawaharlal Nehru MedicalCollege Wardha, Datta Meghe University of Medical Sciences, Wardha, Maharashtra, India
2) Dr. RanjitAmbad
Associate Professor, Department of Biochemistry, Datta Meghe medical college Nagpur.
Datta Meghe University of Medical Sciences, Wardha, Maharashtra, India 3)Dr. DilipGode
Professor, Department of Surgery, Datta Meghe medical college Nagpur. Datta Meghe University of Medical Sciences, Wardha, Maharashtra, India
[email protected] 4) Dr Aditya Mundada
Resident, Department of General Surgery, Jawaharlal Nehru Medical College Wardha, Datta Meghe University of Medical Sciences, Wardha, Maharashtra, India
Corresponding Author- Dr. Md. Jawed Akther
Professor, Department of General Surgery, Jawaharlal Nehru Medical College Wardha, Datta Meghe University of Medical Sciences, Wardha, Maharashtra,
[email protected] Abstract
Background
The normal platelet in healthremains from 1.5 L to 4.5 L/μL. Thrombocytosis can be defined as a platelet count 5 L/μL. Platelet counts >10 L/μLis very rare and it is known as extreme thrombocytosis.But usually happens to occur in myeloproliferative diseases or after spleen removal.Venousthrombosisin patient’s spleen removal have platelet counts in between 6L to 8 L/μL most of the time and its incidence is around 5%.platelet hyper aggregation is the ultimate outcome of these raised platelet count.Cause of thrombocytosis has no role in platelethyper aggregation; Hence, the choice of therapy is to prescribe platelet- antiaggregating medication such as aspirin. In a case of very platelet counts more than 10L/μL extreme thrombocytosis) along with associated arterial or venous thrombosis, treatment option is to give cytoreductive agents such asanagrelide orhydroxyurea observingplatelet counts is mandatory.
Casereport
A 48-yeargentleman presented extreme thrombocytosis after splenectomy.In post- operativeperiod, reactive thrombocytosis was seen in this patient. Thrombocyte count was increased to 1498 K/μL on postoperative day 8. Patient was investigated for common causes of thrombocytosis like myeloproliferative diseases and malignancies. To prevent thrombotic events low molecular weight heparin and aspirin was prescribed. The patient remained asymptomatic till discharge; Thrombocytosis gradually declined to 500 k/μL on post- operative day 15.
Discussion
The overall pathologicalsignificance of a raised thrombocyte count isusually neglected, it can be suggestive of presence of an associatedsepsis. Here it is our better try to find out relationship between raised platelet count and spleen removal. Another importance lies in a prevention of thromboembolic episodes.
Conclusions
Splenectomy was is a very common cause of thrombocytosis. the hyposplenism, could have precipitated extreme thrombocytosis in present case.
Keywords: essentialthrombocytosis, increased platelet count, primary thrombocytosis, Infection
Introduction
The normal platelet in healthremains from 1.5 L to 4.5 L/μL. Thrombocytosis can be considered if asathrombocytosis more than 5 L/μL. Platelet counts >10 L/μLis very rare and it is known as extreme thrombocytosis.But usually happens to occur in myeloproliferative diseases or after spleen removal.Venousthrombosisin patient’s spleen removal have platelet counts in between 6L to 8 L/μL most of the time and its incidence is around 5%. platelet hyper aggregation is the ultimate outcome of these raised platelet count.Cause of thrombocytosis has no role in platelethyper aggregation; Hence, the choice of therapy is to prescribe platelet-antiaggregating medication such as aspirin. In a case of very platelet counts more than 10L/μL extreme thrombocytosis) along with associated arterial or venous thrombosis, treatment option is to give cytoreductive agents such asanagrelide orhydroxyurea observingplatelet counts is mandatory 1.The common etiologies of reactive thrombocytosis are infection, trauma, surgery, and occultmalignancy. Splenectomy was found to be one of the maincauses of thrombocytosis. The probability of thrombocytosis in patients who have had splenectomy is about 75∼82% and about 9% of all reactive thrombocytosis occurrences are caused by this procedure. The platelet count in reactive thrombocytosis is expected to normalize after their solution of the underlying condition. We experienced a patient of extreme thrombocytosis after splenectomy without any complications such as bleeding or thrombosis.
CASE REPORT
A 48-year-gentle man brought to casualtywith history of road side vehicular accident having pain in abdomen.Characteristic wascontinuous, non-tolerable, and localised but vague in characteristic. On examination found to have tenderness in lefthypochondriac region. a vague palpablelumpof size 100 to 120mm below left costal margin. Due presence of guarding and rigidity it was not assessed properly. An ultrasound of the abdomen showed evidence of rupture of spleen of grade 4.
Blood examination shows evidence of low haemoglobinlevel (8 g/dL) and a platelet count of 2.50lakh/μL. patient was subjected for a computed tomography scan of the abdomen without contrast examination.it shows rupture of spleen of grade 4.
(see Figure 1).
Figure 1Computed tomography scan without contrast shows the tear in spleen (arrow).
He developed hypotension with tachycardia. Simultaneous resuscitation with blood transfusion along with emergency laparotomy performed. As there was evidence of injury to splenic pediclesplenectomy was performed (see figure 2).Histolopathogy was consistent with normal ruptured spleen.
Figure 2 shows ruptured spleen
In post-operativeperiodplateletcount was raised rapidly suggestive of reactive thrombocytosis. This rise ranges from3 lakh /μL on day ofsplenectomy to1498 K/μL on 8thpostoperative day (seeTable 1). Patient was investigated for common causes of thrombocytosis like myeloproliferative diseases and malignancies. To prevent thrombotic events low molecular weight heparin and aspirin was prescribed. Post-operative period was uneventful. Thrombocytosis gradually declined to 500 k/μL on post-operative day 15. Low molecular weight heparin was discontinued but ask him to take aspirin for 3 months.
Table 1
Platelet count in post-operative period after spleen removal
parameter On
admission
Post-operative period
1 3 5 8 10 12 13 15
Platelet count K/μL
240 300 500 799 1498 1407 769 638 500
At follow-up after six months, the patient's complete blood count along with platelets were fortunately normal without any adverse thrombotic or cardiac event. He continueswith
hispneumococcal meningococcal vaccinations as per protocol. Supplementation of cytotoxic drugs like hydroxy urea or anagrelide not required in this case.
Discussion
Raise platelet count is a known event due to infection, trauma, or post-operative status. The thrombocyte countin response to such event usually normalisedwhen the underline cause treated. Secondary aetiology of a raisedthrombocyte countlike myeloproliferative disorders or occult cancerneeds to be find out in such cases1. In one study done by Tefferi A et al2,it was observed that primary thrombocytosis present in 20% and most of cases have reactive thrombocytosis.
Extreme thrombocytosismeans platelet count >10L/μL, reactive thrombocytosis is acommonestcause.In studydone by Buss D.H. et al3, including 280 participants, reactive thrombocytosis was observed in in more than 81% and myeloproliferative disorder in approximately 15% and postsplenectomystatus was found to be aetiologies of extreme reactive thrombocytosis.
Essential thrombocytosis is defined as the increased levels of platelets not due to myeloproliferative disorders andplatelets more than 6 lakhs/μL, along with bone marrow biopsy showing megakaryocytic hyperplasia4.
Reactive thrombocytosis is considered due to thought to result excess production more than of one thrombopoietic elements lead to stimulation ofmegakaryocytesout of all these elements interleukin (IL)-6 plays basic stimulator in reactive thrombocytosis 5 platelet regulation is very important function of the spleen, platelets mainly catabolised in a spleen hence raised levels of it observed in hyposplenism. Thrombocytosisisanacceptable situation after spleen removal 6.Palwasha N et al1 in his case report presented with a case of extreme thrombocytosis was as a result of combination of multiple factors. Not only post splenectomy status but also have vitamin B12 deficiency and anaemia were precipitated the event.
In his study of Santhosh-Kumar CR et al5 around 776 patients were having thrombocytosiswith platelet count more than5 lakhsevaluated to know its cause. The most commonaetiology was infection in 22%, rebound thrombocytosisin 20%, tissue trauma in 18%, chronic inflammatory diseasefor 13% and cancer in 6% of patients. Thrombocytosis due to number of aetiologies in same patient observed in 5.9 % of study participants. Platelet count more than 10 lakhs may be due to myeloproliferative disorders, or after spleen removal6,7,8.. Few of the related studies were reported by Mohammad et. al. 9, Walinjkar et.
al. 10, Gupta et. al. 11 and Abbafati et. al.12. Studies on hepatic disorders 13, work related morbidities 14 and obstetric care 15 related to effects on overall blood picture were reviewed.
Conclusion
Splenectomy was is a very common cause of thrombocytosis. the hyposplenism,could have precipitated extreme thrombocytosis in present case. Our findings support the well-known thrombocytosis post-splenectomy hypothesis and demonstrate the difference in the response of the platelet count by surgical indication. In addition, our findings indicate that patients
with post-splenectomy should be considered to have a different 'normal range' for platelet count than non-splenectomized patients. In testing the findings of this study and better addressing the significance of "abnormal" platelet counts in asplenic patients, a prospective examination with standardised platelet count intervals would be useful.
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