Case Presentation: 77 year old man with history of renal cell cancer status post ablation a year ago presented to primary care physician with difficulty swallowing and weight loss for 3 weeks. Examination was normal. Routine labs showed thrombocytosis to 1170×10⁹ with platelet count of 300×10⁹ a month ago. He was referred to the emergency room. Hematology was consulted. Labs showed ESR of 105, CRP of 170 and mild anemia with vitamin B12 and intrinsic factor deficiency although his iron studies were normal. vWF, JAK 2 mutation, calreticulin mutation, flow cytometry, CT scan of chest and abdomen were negative. Upper GI endoscopy showed candidiasis of middle 1/3 of oesophagus with mild gastritis. He was started on omeprazole and fluconazole with eventual normalization of platelets within a month.
Discussion:
Around 80% cases of extreme thrombocytosis are reactive with infection associated in about 1/3 cases. Chronic infections like TB have mostly been associated with extreme thrombocytosis. Our patient had interesting cause of thrombocytosis as it was caused by Candidal oesphagitis, a condition not mentioned in literature to be associated with such a high grade of thrombocytosis. Thrombopoietic growth factors (eg, thrombopoietin, IL-6) which are also cytokines have been implicated as the cause of reactive thrombocytosis in various infectious. Other causes of reactive thrombocytosis include postsplenectomy (19%), malignancy (14%),trauma (14%),inflammation (noninfectious)(9%), blood loss(6%) ,rebound thrombocytosis (3%) and uncertain causes (4%). In non reactive category or autonomous thrombocytosis chronic myeloid leukemia, primary myelofibrosis, polycythemia vera, myelodysplastic syndrome variants, and chronic myelomonocytic leukemia are major causes. In the absence of specific mutations (JAK2/Calreticulin) autonomous (essential) thrombocytosis is difficult to ascertain. Persistent thromboctyosis >450,000 with absence of underlying causes and a normal bone marrow with normal megakaryocytosis is needed to cinch the diagnosis.
Hemorrhage and thrombosis are most commons complications of thrombocytosis. The rate of complications is much higher in autonomous than reactive thrombocytosis (24% versus 1-3%). Bleeding is more often seen with extreme thrombocytosis, often due to acquired von Willebrands syndrome secondary to adhesion of large VW multimers to the platelets. In case of bleeding discontinuation of antiplatelet agents, replacement of deficient coagulation factors and platelet apheresis are major options. For thrombotic complications, anticoagulation and antiplatelet agents are used along with reduction of platelets below 600,000 as a target goal.
Conclusions: – Oesophageal candidiasis has not been defined in literature causing extreme thromocytosis but our patient had thrombocytosis secondary to it.