Platelet Paradox: Carotid Embolism and Menorrhagia in a Patient with Severe Reactive Thrombocytosis
Sushma Helagalli Paramashivaiah1, Alejandro Blaubach1, Saman Zafar1, Aparna Prabhu1
1Neurology, Jefferson Einstein Medical Center
Objective:
To report a rare case of carotid thromboembolism from reactive thrombocytosis secondary to iron-deficiency anemia, emphasizing the challenge of managing coexisting bleeding and thrombosis. 
Background:
Reactive thrombocytosis is common in iron-deficiency anemia but, when severe, may paradoxically lead to both bleeding and thrombosis. Iron deficiency enhances thrombopoietin-driven megakaryopoiesis, producing hyperreactive platelets, and rare cases of carotid thrombus or stroke have been reported in this setting. 
Design/Methods:
Case Report and literature review.
Results:

A 49-year-old woman with a history of gastric bypass and menorrhagia presented with transient left arm weakness and right eye blindness, preceded by central vision loss that resolved spontaneously. The examination was normal. Laboratory studies revealed leukocytosis (15,600/μL), anemia (hemoglobin 7.4 g/dL), and marked thrombocytosis (1,074,000/μL) with giant platelets on smear. CT angiography demonstrated a 6-mm non-obstructive embolus at the right carotid bifurcation. With no vascular risk factors or identifiable embolic sources, hematologic evaluation was pursued. Platelet-pheresis was performed and complicated by a right femoral peri-catheter thrombus, for which she was started on apixaban for three months. Hydroxyurea was initiated for the elevated platelet count. Her hospitalization was further complicated by severe menorrhagia due to uterine fibroids requiring multiple transfusions. Molecular testing for JAK2, CALR, and MPL mutations was negative, and thrombophilia workup was unremarkable. Thrombocytosis was attributed to iron-deficiency anemia from chronic blood loss, representing a paradoxical state of bleeding and thrombosis. At follow-up, her platelet count had normalized, and hemoglobin improved after treating her iron-deficiency anemia. The patient was started on clopidogrel for secondary stroke prevention.  

Conclusions:
This case highlights the complex interplay between anemia-induced reactive thrombocytosis and thromboembolic risk, emphasizing that even secondary thrombocytosis may precipitate arterial thrombosis and that effective management requires treating both the hematologic imbalance and the underlying source of blood loss. 
10.1212/WNL.0000000000215370
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