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.