Thrombocytosis in Thalassemia major

doi:10.21203/rs.3.rs-1998089/v1

Download PDF

Research Article

Thrombocytosis in Thalassemia major

https://doi.org/10.21203/rs.3.rs-1998089/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

To investigate underlying cause for thrombocytosis in children suffering from Thalassemia major.

Methods

A cohort of (n=41) children suffering from Thalassemia major were included in the study. They had a persistent platelet count of > 400x109/l for a period of three months. Primary and secondary cause of thrombocytosis were sought as the underlying pathologies.

Result

In significant percentage (44%) of children no underlying cause for thrombocytosis was detected.

Conclusion

In depth studies are required to find cause of thrombocytosis in children suffering from Thalassemia major.

Thalassemia major

thrombocytosis.

Pediatric thrombocytosis is an increase of platelet count beyond upper limit of normal in children. In healthy pediatric population the normal count platelet is in between 250x10⁹/l and 400x10⁹/l. A higher platelet count over 2 SD defines a condition of thrombocytosis. In vast majority of children unlike the adult population thrombocytosis is secondary or reactive in nature and hence requires no active treatment.

A persistent platelet counts of > 1000x10⁹/l for a period of three months the underlying pathology in most children is clonal in nature.¹ The common reactive cause leading to thrombocytosis in children include infections which might either be bacterial, viral, parasitic or fungal. Inflammatory cause come next which may include diseases like rheumatoid arthritis, inflammatory bowel disease, Kawasaki syndrome, vasculitis and collagen vascular disease. Surgical causes include post splenectomy, post-surgical recovery, trauma, burns and blood loss. Hemolytic anemia, iron deficiency hypersplenism and congenital or idiopathic nephrotic syndrome may also lead to thrombocytosis.¹

Primary thrombocytosis in children may be investigated e.g., mutational analysis for BCR-ABL1, JAK 2 V617F, CAL-R and MPL1 analysis. if no obvious cause of secondary thrombocytosis is found. It should be suspected in children with hepatosplenomegaly, bleeding or thrombotic disorders, elevated platelet count beyond three months or if family history of thrombotic disorders is present. Primary thrombocytosis however is extremely rare in childhood with incidence of one per million while secondary or reactive thrombocytosis is quite common in pediatric age occurring in 3–13% of hospitalized children.²

The study was carried at Armed Forces Institute of Transfusion (AFIT) Rawalpindi from June to December 2020 after obtaining permission from its Ethical review Committee. Inclusion criteria had children diagnosed as Thalassemia major by DNA mutation analysis at Armed Forces Institute of Pathology (AFIP) Rawalpindi. These children (n = 41) had a platelet count of > 1000x10⁹/l for a period of three months. Children were between three to five years of age and on prescribed transfusion regimens for more than a year. The maximum interval from diagnosis to first transfusion was three months. The initial base line platelet counts at the start of study were done on Sysmex™ XN 3600 and platelet counts confirmed manually by an expert Hematologist on peripheral blood film. At the start thorough workup for ruling out secondary thrombosis was carried out which included complete physical and systemic examination by an expert Pediatrician, followed by lab investigations including CBC, peripheral blood examination, DAT, IAT, serum ferritin, serum iron, soluble transferrin receptors, CRP, ESR, ultrasound abdomen, urine analysis, stool analysis and all relevant inflammatory markers performed at Shifa International hospital Islamabad. All these investigations were carried out before and after follow-up period of the study. Out of (n = 41) all children (n = 23) who had serum ferritin levels of over 1000ng/ml (N = 7 to 140 ng/ml) were advised iron chelation therapy by deferoxamine. Transfusion protocols of all (n = 41) children were evaluated also revised were necessary. Twenty-three (n = 23) parents managed to start the chelation therapy. These children (n = 41) were followed up regularly by their platelet counts monthly (June-Dec 2021). Out of total cohort of (n = 41) eleven (n = 11) children still had a platelet count of over 1000x10⁹/l after six months hence BCR ABL1, JAK2 V617F, CAL-R and MPN-1 mutations mutation analysis was done at AFIT.

Out of forty-one (n = 30) thirty children reverted back to normal platelet counts of < 400x10⁹/l within six months. Of the remaining eleven children (n = 11) the counts still persisted over > 1000x10⁹/l. JAK2 V617F, CAL - R and MPN-1 mutations mutation analysis was negative for all these subjects. Out of thirty (n = 30) children whose platelet count reverted back to normal included (n = 23) children put on iron chelation therapy. Secondary thrombocytosis parameters were negative (n = 41) children. Out of twenty-three (n = 23) children put on chelation therapy with raised ferritin levels twenty (n = 20) achieved normal ferritin levels at the end of study.

Primary thrombocytosis is very rare amongst children with Thalassemia major.³ Underlying iron deficiency in Thalassemia major is thought to be key main reason for a raised platelet count.⁴ The pathogenesis of thrombocytosis in Thalassemia major secondary to iron deficiency is not also not fully understood. Various grey areas still remain unanswered.⁵ EPO may stimulate TPO receptors (c-MPL) in Thalassemic children having iron deficiency resulting in thrombocytosis. But unfortunately, the underlying mechanism is still unproven and not clear.⁶ Several studies have reported a relationship between ferritin status in Thalassemia major and platelet parameters.^7,8 Kadikoylu et al. found no correlation between platelet counts and serum ferritin in stepwise logistic regression test.⁹ Kuku et al also found no significant relationship between platelet counts and serum ferritin levels. Monitoring soluble serum transferrin receptors or Zinc protoporphyrin is useful in diagnosing true iron deficiency and may be use instead of serum ferritin levels to determine iron deficiency in such patients.¹⁰

All our patients (n = 41) with thrombocytosis were anemic. However, Holbro et al. in his land mark study found that the platelet counts did not show significant association to the cause of anemia. His correlation analysis revealed that platelet counts have weak correlation to the degree of anemia irrespective of the etiology.¹¹ Bhoopalan et al. found this is likely due to the increased thrombopoietic activity of erythropoietin which is secreted in response to the degree of anemia.¹²

In Pediatric thrombocytosis due to Thalassemia major no extensive diagnostic workup is needed if secondary cause or reactive thrombocytosis is apparent.

If, however primary thrombocytosis is suspected, the described diagnostic algorithm may be followed according to the recommendations published in a review article.¹³ If a platelet count > 450,000/µL persists longer than 6 weeks, then obtain a detailed family history and blood counts of each family member is suggested; genetic testing for BCR-ABL1, JAK2V617F, CALR, and MPLW515L is carried out where ever necessary. Furthermore, bone marrow biopsy may be performed. If the bone marrow shows hyperproliferation of megakaryocytes and any of the above genetic testing is positive, the patient most likely has a myeloproliferative disorder, including primary thrombocytosis. If, however the genetic testing is negative but the bone marrow shows megakaryocyte hyperproliferation or family history is positive additional genetic testing for an alternate TPO or MPL mutation is sugessted.¹³

Persistent thrombocytosis is basis of hypercoagulable state which leads to high incidence of thrombosis in children.¹⁴ Low serum ferritin levels by chelation resulted in reduced platelet count.¹⁵ Many studies have addressed this phenomenon but have failed to find any significant correlation of serum ferritin levels with high platelet count.¹⁶ Furthermore, all our patients with thrombocytosis had low hemoglobin but numerous studies have failed to pin the cause of secondary increase of platelet count to anemia in children.¹⁷ We failed to determine underlying reason of persistently high platelet count in cohort of eleven children.¹⁸ Underlying pathology for thrombocytosis must be found as this leads to a severe hypercoagulable state with numerous complications.¹⁹ This obviously can only be managed adequately if we know the cause.²⁰ We did not have access to particular mutations of children included in the study due to institutional policies.

In significant percentage (44%) of children we could not find underlying cause for thrombocytosis.

number

Liter

Standard deviation

e.g.,

for example

BCR-ABL1

Break point cluster region-Abelson

JAK 2 V617F

Janus associated kinase

CAL-R

Calreticulin gene

MPL1

Human mpl gene

EPO

Erythropoietin

TPO

Thrombopoietin

c-MPL

Human c-mpl gene

MPLW515L

Somatic activating mutation in the transmembrane domain of MPL

Competing interest statement

The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report. We certify that the submission is original work and is not under review at any other publication.

Ethical approval and consent to participate

Ethical approval was taken from Armed forces Institute of Transfusion Rawalpindi. All authors gave their consent to participate.

Availability of data and material

No data sets are available in this study.

Funding

No funding was obtained from any source

5.Consent for publication

Not applicable

Acknowledgements

Not applicable

Corresponding author: Mohammad Abdul Naeem (MN)

MBBS BSc CHPE MCPS FCPP FCPS FRCP(Glasg) PhD PostDoc

Consultant Hematologist Combined Military Hospital Lahore Pakistan.

Mobile 0092+3335945945.

email: [email protected]

ORCID ID 0000-0002-6073-2063

Mohammad Aamir, (MA) Professor of Clinical Chemistry, Shifa International Hospital Islamabad. Mobile 0092+30006003119

email: [email protected]

Farhat Ijaz, (FI) Associate Professor of Physiology Combined Military Hospital Lahore Pakistan. Mobile 0092+3317357409 email: [email protected]
Nayyar Amin, (NA) Senior Scientific Officer, Armed Forces Institute of Transfusion Rawalpindi. Mobile 0092+3219553442

email: [email protected]

Author Contributions

1. Conceptualization: MN

2. Data curation: MN

3. Formal analysis: MN

4. Funding acquisition: MN

5. Investigation: NA

6. Methodology: MN

7. Project administration: MN

8. Resources: MN

9. Software: FI

10. Supervision: MA

11. Validation: MA

12. Visualization: MN

13. Writing original draft: MN

14. Review and Editing: FI

All authors read and approved the final manuscript.

Conflict-of-interest statement

Ethical approval Statement

All experimental protocols were approved by a name of the ethics committee.

All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Written informed consent was obtained from all participants or if participants are under 16, from a parent and/or legal guardian.

Chiarello P, Magnolia M, Rubino M, Liguori S, Miniero R. Thrombocytosis in children. Minerva Pediatr. 2011;63(6):507–13.
Alison D, Peter D. Extreme thrombocytosis in admissions to paediatric intensive care: no requirement for treatment. Arch Dis Child 2007 Jun; 92(6): 515–16.
Majid V, Kaveh J, Majid G, Mohamad P, Tooran R. Asymptomatic Essential Thrombocythemia in a Child: A Rare Case Report. Int J Hematol Oncol Stem Cell Res. 2013;7(2):35–7.
Cao A, Galanello R. Beta-thalassemia. Genet Med. 2010 Feb;12(2):61–76.
Sara T, Sheree S, Sally L. Thrombocytosis in a Patient with Alpha Thalassemia Trait. Lab Med Winter. 2015;46:e7–12.
Rayko E, Adam B, Kristine J, Stefanie K, Lidia S, Werner S, Robert E, Kathrin L, Barbara S, Hans M, Vineeta K, Christoph G. Iron deficiency alters megakaryopoiesis and platelet phenotype independent of thrombopoietin. Amer Jour of Hem. 2014;89:524–29.
Amit K, Archana T. Iron Overload in Beta Thalassaemia Major and Intermedia Patients Maedica 2013; 8(4): 328–32.
Khawaji M, Hazzazi A, Ageeli M, Mawkili Y, Darbashi A, Aboathiyah A, et al. Clinical and hematological features among β-thalassemia major patients in Jazan region: A hospital-based study. J Family Med Prim Care. 2020;9:412–7.
Kadikoylu G, Irfan Y, Zahit B, Taskin S. Platelet parameters in women with iron deficiency anemia. Jour Nat Med Ass Turk. 2006;98:398–402.
Kuku I, Emin K, Saim Y, Remzi G, Ahmet B. Platelet counts in adults with iron deficiency anemia 2009 Platelets https://doi.org/10.1080/09537100903137306.
Holbro N, Åsa G, Thomas G. Differential distribution of endoplasmic reticulum controls metabotropic signaling and plasticity at hippocampal synapses PNAS 2009;106(35):15055-60.
Bhoopalan S, Lily H, Mitchell J. Erythropoietin regulation of red blood cell production. 2020 https://doi.org/10.12688/f1000research.26648.1.
Nicole K, Katherine M. Chastain M, Mahler, Bussel B. Primary thrombocytosis in children. 2014 Haematologica; 99(4):620–28.
Bleeker JS, Hogan WJ. Thrombocytosis: diagnostic evaluation, thrombotic risk stratification, and risk-based management strategies. Thrombosis. 2011; 2011:536062. doi:10.1155/2011/536062.
Abdulkader A, Ehab H, Mohammed P. Iron Overload and Platelet Function. Investig Med High Impact Case Rep. 2016;4(4):2324709616675645.
Han D, Ma C, Zhao L, Gao Y, Su Y. Relationship between Iron Metabolism and Platelet Parameters in Patients with Iron Deficiency Anemia. 2018 Dec;26(6):1738–1741.
Evstatiev R, Bukaty A, Jimenez K, Kulnigg-Dabsch S, Surman L, Schmid W, Eferl R, Lippert K, Scheiber-Mojdehkar B, Kvasnicka HM, Khare V, Gasche C. Iron deficiency alters megakaryopoiesis and platelet phenotype independent of thrombopoietin. Am J Hematol. 2014;89(5):524–9.
Rose S, Petersen N, Gardner T, Hamill R, Trautner B. Etiology of thrombocytosis in a general medicine population: analysis of 801 cases with emphasis on infectious causes. cases with emphasis on infectious causes. J Clin Med Res. 2012;4(6):415–23.
Alessandro M, Tiziano B. Thrombocytosis and Thrombosis. Hematology Am Soc Hematol Educ Program. 2007; (1): 363–70.
Amiram E, Eliezer A. The hypercoagulable state in thalassemia. Blood 2002; 99 (1): 36–43

Download PDF

Version 1

posted

You are reading this latest preprint version

Thrombocytosis in Thalassemia major

Status:

Version 1

Abstract

Introduction

Material And Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

Version 1