Severe thrombocytosis and anemia associated with celiac disease in a young female patient: a case report

Celiac disease - a pluripathological model in pediatric practice

Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.

Celiac Disease Masquerading as Extreme Thrombocytosis and Severe Anemia in a 52-Year-Old Female Patient: A Rare Case Presentation and Literature Review

Celiac disease (CD) is a chronic autoimmune disorder characterized by an immune-mediated response to gluten, resulting in small intestinal mucosal damage. While gastrointestinal (GI) symptoms are commonly associated with CD, atypical presentations can pose diagnostic challenges, particularly when hematological abnormalities are the primary manifestation. We report a case of a 52-year-old female patient who presented with paraesthesia, numbness in her hands and feet, marked thinness, extreme thrombocytosis, severe anemia, and mild electrolyte imbalance. Physical examination was unremarkable, except for the notable thinness. GI symptoms were absent, and there was no family history of gastroenterological diseases. Diagnostic evaluations, including serological tests and duodenal biopsy, confirmed the diagnosis of CD with grade 4 Marsh 3C classification. This case emphasizes the significance of considering CD as a potential cause for atypical hematological manifestations, such as extreme thrombocytosis secondary to severe anemia. Prompt recognition and appropriate management, including adherence to a gluten-free diet, can lead to symptom improvement and resolution of hematological abnormalities. It is crucial for healthcare professionals to recognize and be familiar with these atypical presentations to promote early diagnosis and enhance patient outcomes.

Serum or plasma ferritin concentration as an index of iron deficiency and overload

BACKGROUND

Reference standard indices of iron deficiency and iron overload are generally invasive, expensive, and can be unpleasant or occasionally risky. Ferritin is an iron storage protein and its concentration in the plasma or serum reflects iron stores; low ferritin indicates iron deficiency, while elevated ferritin reflects risk of iron overload. However, ferritin is also an acute-phase protein and its levels are elevated in inflammation and infection. The use of ferritin as a diagnostic test of iron deficiency and overload is a common clinical practice.

OBJECTIVES

To determine the diagnostic accuracy of ferritin concentrations (serum or plasma) for detecting iron deficiency and risk of iron overload in primary and secondary iron-loading syndromes.

SEARCH METHODS

We searched the following databases (10 June 2020): DARE (Cochrane Library) Issue 2 of 4 2015, HTA (Cochrane Library) Issue 4 of 4 2016, CENTRAL (Cochrane Library) Issue 6 of 12 2020, MEDLINE (OVID) 1946 to 9 June 2020, Embase (OVID) 1947 to week 23 2020, CINAHL (Ebsco) 1982 to June 2020, Web of Science (ISI) SCI, SSCI, CPCI-exp & CPCI-SSH to June 2020, POPLINE 16/8/18, Open Grey (10/6/20), TRoPHI (10/6/20), Bibliomap (10/6/20), IBECS (10/6/20), SCIELO (10/6/20), Global Index Medicus (10/6/20) AIM, IMSEAR, WPRIM, IMEMR, LILACS (10/6/20), PAHO (10/6/20), WHOLIS 10/6/20, IndMED (16/8/18) and Native Health Research Database (10/6/20). We also searched two trials registers and contacted relevant organisations for unpublished studies.

SELECTION CRITERIA

We included all study designs seeking to evaluate serum or plasma ferritin concentrations measured by any current or previously available quantitative assay as an index of iron status in individuals of any age, sex, clinical and physiological status from any country.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. We designed the data extraction form to record results for ferritin concentration as the index test, and bone marrow iron content for iron deficiency and liver iron content for iron overload as the reference standards. Two other authors further extracted and validated the number of true positive, true negative, false positive, false negative cases, and extracted or derived the sensitivity, specificity, positive and negative predictive values for each threshold presented for iron deficiency and iron overload in included studies. We assessed risk of bias and applicability using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. We used GRADE assessment to enable the quality of evidence and hence strength of evidence for our conclusions.

MAIN RESULTS

Our search was conducted initially in 2014 and updated in 2017, 2018 and 2020 (10 June). We identified 21,217 records and screened 14,244 records after duplicates were removed. We assessed 316 records in full text. We excluded 190 studies (193 records) with reasons and included 108 studies (111 records) in the qualitative and quantitative analysis. There were 11 studies (12 records) that we screened from the last search update and appeared eligible for a future analysis. We decided to enter these as awaiting classification. We stratified the analysis first by participant clinical status: apparently healthy and non-healthy populations. We then stratified by age and pregnancy status as: infants and children, adolescents, pregnant women, and adults. Iron deficiency We included 72 studies (75 records) involving 6059 participants. Apparently healthy populations Five studies screened for iron deficiency in people without apparent illness. In the general adult population, three studies reported sensitivities of 63% to 100% at the optimum cutoff for ferritin, with corresponding specificities of 92% to 98%, but the ferritin cutoffs varied between studies. One study in healthy children reported a sensitivity of 74% and a specificity of 77%. One study in pregnant women reported a sensitivity of 88% and a specificity of 100%. Overall confidence in these estimates was very low because of potential bias, indirectness, and sparse and heterogenous evidence. No studies screened for iron overload in apparently healthy people. People presenting for medical care There were 63 studies among adults presenting for medical care (5042 participants). For a sample of 1000 subjects with a 35% prevalence of iron deficiency (of the included studies in this category) and supposing a 85% specificity, there would be 315 iron-deficient subjects correctly classified as having iron deficiency and 35 iron-deficient subjects incorrectly classified as not having iron deficiency, leading to a 90% sensitivity. Thresholds proposed by the authors of the included studies ranged between 12 to 200 µg/L. The estimated diagnostic odds ratio was 50. Among non-healthy adults using a fixed threshold of 30 μg/L (nine studies, 512 participants, low-certainty evidence), the pooled estimate for sensitivity was 79% with a 95% confidence interval of (58%, 91%) and specificity of 98%, with a 95% confidence interval of (91%, 100%). The estimated diagnostic odds ratio was 140, a relatively highly informative test. Iron overload We included 36 studies (36 records) involving 1927 participants. All studies concerned non-healthy populations. There were no studies targeting either infants, children, or pregnant women. Among all populations (one threshold for males and females; 36 studies, 1927 participants, very low-certainty evidence): for a sample of 1000 subjects with a 42% prevalence of iron overload (of the included studies in this category) and supposing a 65% specificity, there would be 332 iron-overloaded subjects correctly classified as having iron overload and 85 iron-overloaded subjects incorrectly classified as not having iron overload, leading to a 80% sensitivity. The estimated diagnostic odds ratio was 8.

AUTHORS' CONCLUSIONS

At a threshold of 30 micrograms/L, there is low-certainty evidence that blood ferritin concentration is reasonably sensitive and a very specific test for iron deficiency in people presenting for medical care. There is very low certainty that high concentrations of ferritin provide a sensitive test for iron overload in people where this condition is suspected. There is insufficient evidence to know whether ferritin concentration performs similarly when screening asymptomatic people for iron deficiency or overload.

Association of non-malignant diseases with thrombocytosis: a prospective cohort study in general practice

BACKGROUND

Thrombocytosis is an excess of platelets, which is diagnosed as a platelet count >400 × 10⁹/l. An association of thrombocytosis with undiagnosed cancer has recently been established, but the association with non-malignant disease has not been studied in primary care.

AIM

To examine, in English primary care, the 1-year incidence of non-malignant diseases in patients with new thrombocytosis and the incidence of pre-existing non-malignant diseases in patients who develop new thrombocytosis.

DESIGN AND SETTING

Prospective cohort study using English Clinical Practice Research Datalink data from 2000 to 2013.

METHOD

Newly incident and pre-existing rates of non-malignant diseases associated with thrombocytosis were compared between patients with thrombocytosis and age- and sex-matched patients with a normal platelet count. Fifteen candidate non-malignant diseases were identified from literature searches.

RESULTS

In the thrombocytosis cohort of 39 850 patients, 4579 (11.5%) were newly diagnosed with any one of the candidate diseases, compared with 443 out of 9684 patients (4.6%) in the normal platelet count cohort (relative risk [RR] 2.5, 95% confidence intervals [CI] = 2.3 to 2.8); iron-deficiency anaemia was the most common new diagnosis (4.5% of patients with thrombocytosis, RR 4.9, 95% CI = 4.0 to 6.1). A total of 22 612 (57.0%) patients with thrombocytosis had a pre-existing non-malignant diagnosis compared with 4846 patients (50%) in the normal platelet count cohort (odds ratio 1.3, 95% CI = 1.2 to 1.4). There was no statistically significant difference in cancer diagnoses between patients with and without pre-existing disease in the thrombocytosis cohort.

CONCLUSION

Thrombocytosis is associated with several non-malignant diseases. Clinicians can use these findings as part of their holistic diagnostic approach to help guide further investigations and management of patients with thrombocytosis.

Bleeding versus Clotting: A Complex Case of a Large Fibroid Uterus Causing Menorrhagia and a DVT

A 43-year-old woman presented with severe anaemia secondary to menorrhagia. Pelvic ultrasound showed a large intramural posterior fundal fibroid. Hysteroscopy showed the fibroid distorting the endometrial cavity, precluding Mirena® device insertion. As she was initially hesitant to have a hysterectomy, medical management with the oral contraceptive pill (OCP) and tranexamic acid was instituted, with good effect. Months later, after a long road trip, she presented with left leg swelling, and a Doppler ultrasound confirmed an extensive deep vein thrombosis (DVT). She was commenced on warfarin for anticoagulation but presented again with menorrhagia precipitated by overanticoagulation. After initial stabilization with multiple blood transfusions and reversal of anticoagulation, the warfarin was ceased in favour of enoxaparin and she underwent inferior vena cava (IVC) filter insertion prior to a total abdominal hysterectomy. Mass effect from large uterine fibroids can cause venous thromboembolism (VTE). A duplex ultrasound of the lower limbs if a woman presents with a large fibroid could identify asymptomatic DVTs in such women. A prehysterectomy IVC filter would then reduce their risk of postoperative pulmonary embolism. Medical management of menorrhagia with procoagulants should be avoided for management of menorrhagia in such women given their higher risk of developing VTE.

Severe anemia from heavy menstrual bleeding requires heightened attention

OBJECTIVE

The objective of the study was to analyze the behaviors of women that resulted in menstrually related severe anemia (hemoglobin <5 g/dL) from a single public hospital serving indigent women.

STUDY DESIGN

This was a retrospective cohort study of all women identified as having been treated at Harbor-UCLA Medical Center for excessive menstruation (International Classification of Diseases, ninth revision, codes 285.9, 6256.2) and hemoglobin values less than 5 g/dL in the 6 years from 2008 to 2013.

RESULTS

Approvals were obtained from the Human Subjects and Research Committees. This search identified 271 women with those 2 diagnoses; 122 were excluded because their severe anemia had nonmenstrual causes. The remaining 149 women had 168 episodes with hemoglobin levels below 5 g/dL attributed to chronic excessive menstrual bleeding. Mean age was 41 years (range, 19-55 years). Mean body mass index was 28.9 kg/m(2) (range, 18-57 kg/m(2)); 58.2% were actively bleeding at presentation, and 90.4% reported chronic excessive blood loss. Two thirds recognized heavy bleeding that had persisted for more than 6 months without seeking help. However, 7.8% described their bleeding as normal, and 40.5% had received at least 1 previous transfusion. Mean nadir hemoglobin was 4.15 g/dL (range, 1.6-4.9 g/dL). Mean corpuscular volume was 62.2 fL (range, 47.7-99.8 fL) and mean corpuscular hemoglobin concentration was 29.2 g/dL (range, 25.7-33.6 g/dL). Nearly a quarter had reactive thrombocytosis, which might have created a hypercoagulable state. Bleeding was ultimately attributed to leiomyoma in 47.9%; cancer was detected in 4.8%. A total of 33.9% were discharged without being offered any therapy to prevent subsequent bleeding; 3.0% declined any medical therapy; 35.1% were lost to follow-up prior to receiving effective therapy; and 26.8% had multiple subsequent transfusions before seeking/receiving definitive treatments.

CONCLUSION

Even when faced with potentially life-threatening anemia because of chronic, excessive menstrual blood loss, some women are not impressed with the serious nature of their problem. Women will benefit from recognizing the health consequences of chronic excessive blood loss. Chronic excessive blood loss should be treated as both an urgent and potentially recurrent problem; physicians should address this clinical concern proactively.

Hematological manifestations of celiac disease

Celiac disease, an autoimmune disease once thought to be uncommon, is now being increasingly identified. Our improved diagnostic modalities have allowed us to diagnose more and more patients with atypical symptoms who improve on gluten-free diet (GFD). We discuss here the latest findings regarding the various hematological manifestations of celiac disease and their management. Anemia remains the most common hematological manifestation of celiac disease due to many mechanisms, and can be the sole presenting symptom. Other manifestations include thrombocytosis and thrombocythemia, leukopenia, thromboembolism, increased bleeding tendency, IgA deficiency, splenic dysfunction, and lymphoma. The diagnosis of celiac disease should always be kept in mind when a patient presents with unexplained and isolated hematological finding. Once diagnosed, patients should adhere to GFD and be educated about the potential complications of this disease. We herein present an algorithm for adequate management and follow-up.

Persistent thrombocytosis in elderly patients with rare hyposplenias that mimic essential thrombocythemia

When elderly patients present with persistent thrombocytosis, myeloproliferative disease, iron-deficiency anemia or post-splenectomy status are suspected along with autoimmune diseases. Reported here are the cases of two elderly patients with persistent thrombocytosis due to hyposplenia, which is very rarely diagnosed in old age. Case 1 was a 72-year-old man whose thrombocytosis was due to non-familial type isolated congenital asplenia. Case 2 was a 74-year-old man whose thrombocytosis was caused by an atrophied spleen resulting from perforated stomach ulcer-related panperitonitis that had been treated 20 years previously. Both patients had thrombocyte counts exceeding >500,000/μl in association with small vestigial spleen tissue on a computed tomography scan and positive Howell-Jolly bodies on the blood smear. A correct diagnosis is essential for the management of persistent thrombocytosis.

Venous thromboembolism as a complication of uterine fibroids: a retrospective descriptive study

This study describes cases of fibroids with venous thromboembolism (VTE) managed at UHWI between the years 1999-2004. We examined records to find patients with fibroids and VTE diagnosed before or after surgery. We found 438 women with VTE and 72 of these (16.4%) with fibroids. A total of 1,979 patients had fibroids during the period; cases were therefore 3.63% of fibroids. Cases were younger, median age 44 years than the total cohort: the median age was 57 and the mean age was 55.43 (SD 19.87) p = 0.000 about 9.5 years older than cases. Age over 50 years was less common in cases 27% vs 52% p = 0.0001 as were other risk factors for VTE such as cancer 4.9 vs 14% p = 0.03; diabetes 8.6 vs 25.2% p = 0.004 and cardiac disease 8.6% vs 26.6% p = 0.002 . However, thrombocytosis was more frequent, 23% vs 9% p = 0.008. Other risk factors were not significantly different. A total of 21 cases (29.1%) had surgery for fibroids; 15 (71.4%) hysterectomy, and six (28.5%) myomectomy. Most cases 67/72 (93%) had VTE without surgery. Of the five cases with VTE after surgery for fibroids, none had prophylactic heparin. Of the cases, 15 died--23% of women with VTE at PM and 0.8% of those with fibroids.