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A 69-year-old man with long-standing thrombocytopenia.

CASE DESCRIPTION

A 69-year-old man presented with a long-standing thrombocytopenia and microcytic anemia. The automated platelet count was 67 X [10.sup.3]/[micro]L (reference interval, 150-450 X [10.sup.3] /[micro]L); therefore, EDTA-dependent pseudothrombocytopenia was excluded. The hemoglobin concentration was 10.5 g/dL (reference interval, 14-18 g/dL). The patient denied having petechiae and reported no excessive bleeding in daily life. The patient had no family history of coagulation disorders. The following image was seen on a blood smear (Fig. 1).

[FIGURE 1 OMITTED]

Questions

1. Why should the automated platelet count be interpreted cautiously in this patient?

2. What techniques are still able to provide a reliable platelet count?

3. What do the cytoplasmic inclusion bodies found in neutrophilic leukocytes suggest?

Answers

The blood smear revealed giant thrombocytes (red arrow). These cells are often not recognized as platelets by automatic blood count analyzers, hence the thrombocytopenia. Confirmation comes from manual platelet counts, either by using a hemocytometer or via indirect estimation from the blood smear (e.g., according to the Fonio method).

The abundant cytoplasmic inclusions in neutrophilic leukocytes (black arrow) morphologically resemble Dohle bodies, which are frequently found in macrothrombocytopenias, such as May-Hegglin anomaly (1). Indeed, that was the final diagnosis for our patient. The aberrant erythrocyte morphology is due to iron-deficiency anemia, a common phenomenon in patients with May-Hegglin anomaly.

Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b)drafting or revising the article for intellectual content; and(c)final approval Of the published article.

Authors' Disclosures or Potential Conflicts of Interest: No authors declared anypotential conflicts of interest.

Reference

(1.) Althaus K, Greinacher A. MYH9-related platelet disorders. Semin Thromb Hemost 2009;35:189-203.

Martin Ehrenschwender [1] * and Juergen Koessler [2]

[1] Department of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany; [2] Institute of Clinical Biochemistry and Pathobiochemistry with Division of Laboratory Medicine, University of Wuerzburg, Wuerzburg, Germany.

* Address correspondence to this author at: Department of Medical Microbiology and Hygiene, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany. Fax +49-941-9446402; e-mail martin.ehrenschwender@ klinik.uni-regensburg.de.

Received September 29, 2011; accepted November 18, 2011.

DOI: 10.1373/clinchem.2011.176826

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Article Details
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Title Annotation:What is Your Guess?
Author:Ehrenschwender, Martin; Koessler, Juergen
Publication:Clinical Chemistry
Geographic Code:4EUGE
Date:May 1, 2012
Words:390
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