DISCUSSION
The mechanisms causing reactive thrombocytosis in iron deficiency anemia
are unknown. There are several reports to elucidate the mechanisms of
reactive thrombocytosis from the aspect of thrombopoietic cytokines.
Akan et al assayed the serum levels of thrombopoietin, erythropoietin,
leukemia inhibitory factor, IL-6 and IL-11, but none of these cytokines
had any effect on reactive thrombocytosis in iron deficiency anemia.(4)
A case report of V. Uzel et al about severe thrombocytosis in iron
deficiency anemic 12 years old girl concluded that the cause of
thrombocytosis in iron deficiency is not fully understood. The fact that
the increase in EPO stimulates TPO receptors (c-mpl) in iron deficiency
is known to result in thrombocytosis. However, it is very important that
children should be evaluated immediately for infection and iron
deficiency before performing further examinations. (5)
Treating the reactive thrombocytosis caused by iron deficiency with iron
supplements has shown to be very effective and would rapidly correct the
platelet count.
In a case report by Kristin Bergmann et al of 34 old woman who had
undergone bariatric surgery 5 years previously, a diagnosis of reactive
thrombocytosis due to iron deficiency secondary to iron malabsorption
was made. Their finding emphasizes the importance of regular control of
the possible need for iron supplementation following bariatric surgery(6).
In another case report of arterial and venous thrombosis caused by
reactive thrombocytosis and iron deficiency anemia, Deepak Venugopalan
Pathiyil et al concluded the patient’s significant response to treatment
with simple iron replacement.
The clinical examination for this patient is suggesting the presence of
anemia (the severe pallor in the hands and conjunctiva). Also, the
hyperpigmentation in her tongue is suggesting the presence of Pigmented
fungiform papilla because there are no associated skin, nail, or other
cutaneous changes.
The pigmented fungiform papilla is a normal variant of the tongue that
has no associated pathologic significance. This finding usually presents
in late childhood and does not change over time (7).
More common in patients with dark skin but may be found in any race.
The characteristics and colour of the pigmentation vary and the most
common presentation is diffuse patches or macules on the dorsal surface
of the tongue. The patches may be seen on the anterior and lateral
surface of the tongue or at the tip of the tongue. The colour variation
of these patches may range from brown to dark black(8).
In this case, the patient refused to do iron studies and bone marrow
biopsy. She was offered counselling many times on how these
investigations would help with the management. Therefore, No iron
supplements were prescribed to the patient. She only agreed to have a
short course of antibiotics (Ceftriaxone IV injection) and 3 units of
blood.
The patient improved quickly after the treatment commenced. The platelet
count rapidly decreased on the 4th day after admission
and returned to normal level on the 12th day.