What is the appropriate management for a 24-year-old female patient with microcytic hypochromic anemia, neutrophilic leukocytosis, and reactive thrombocytosis?

Management of Microcytic Hypochromic Anemia with Leukocytosis and Thrombocytosis in a 24-Year-Old Female

The most appropriate management for this 24-year-old female with microcytic hypochromic anemia, neutrophilic leukocytosis, and reactive thrombocytosis is to initiate oral iron supplementation with ferrous sulfate 200 mg three times daily for at least 3 months while investigating for underlying causes of iron deficiency.

Diagnostic Evaluation

This patient presents with:

• Microcytic hypochromic anemia (Hb: 10 g/dL)
• Leukocytosis (WBC: 12,000-14,000/mm³)
• Thrombocytosis (Platelets: 510,000-570,000/mm³)
• Absolute lymphocytosis (4,914/mm³)
• Peripheral smear showing reactive lymphocytes and reactive thrombocytosis

Initial Workup Should Include:

1. Iron studies:

   • Serum ferritin
   • Total iron binding capacity (TIBC)
   • Transferrin saturation
   • Serum iron

2. GI evaluation (for patients >45 years or with GI symptoms):

   • Upper GI endoscopy with small bowel biopsy
   • Colonoscopy or barium enema 1

3. Gynecological assessment:

   • Menstrual history (menorrhagia evaluation)
   • Pictorial blood loss assessment charts may help quantify menstrual loss 1

4. Additional tests to consider:

   • Inflammatory markers (ESR, CRP) to assess for chronic inflammation
   • Celiac disease screening (anti-endomysial antibodies and IgA levels)
   • Renal function tests

Treatment Approach

1. Iron Supplementation

• First-line therapy: Oral ferrous sulfate 200 mg three times daily (providing 65 mg elemental iron per tablet) 1, 2
• Alternative oral preparations if intolerance occurs: Ferrous gluconate or ferrous fumarate 1
• Duration: Continue for 3 months after correction of anemia to replenish iron stores 1, 3
• Monitoring: Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of therapy 1
• Adjunctive therapy: Consider adding ascorbic acid to enhance iron absorption if response is poor 1

2. Management of Thrombocytosis and Leukocytosis

• In iron deficiency anemia, thrombocytosis and leukocytosis are often reactive and typically resolve with iron supplementation 4
• No specific treatment for the thrombocytosis or leukocytosis is required unless symptoms develop
• Monitor complete blood count during iron therapy to confirm resolution

3. Follow-up

• Monitor hemoglobin, MCV, and platelet count after 4 weeks of iron therapy
• If no improvement in hemoglobin after 4 weeks, evaluate:
  • Compliance with iron therapy
  • Ongoing blood loss
  • Malabsorption issues
  • Need for parenteral iron
• Once normal, monitor hemoglobin concentration and red cell indices every three months for one year and then after a further year 1

Important Considerations

Differential Diagnosis

1. Iron deficiency anemia (most likely): Common in young women due to menstrual blood loss
2. Anemia of chronic disease: Less likely given the thrombocytosis and young age
3. Thalassemia: Consider if iron studies are normal or if anemia persists despite iron therapy
4. Chronic myelogenous leukemia: Should be excluded if blood counts don't normalize with iron therapy

When to Consider Alternative Diagnoses

If there is inadequate response to oral iron therapy:

• Consider bone marrow examination and cytogenetic studies to rule out myeloproliferative disorders 1
• Test for TMPRSS6 mutations if iron-refractory iron deficiency anemia is suspected 1, 5
• Consider intravenous iron if oral iron is not tolerated or ineffective 1, 3

Indications for Parenteral Iron

• Intolerance to at least two oral iron preparations
• Non-compliance with oral therapy
• Malabsorption
• Ongoing blood loss exceeding oral iron absorption capacity 1, 3

Conclusion

The clinical picture strongly suggests iron deficiency anemia with reactive thrombocytosis and leukocytosis. With appropriate iron supplementation, both the anemia and the elevated cell counts should normalize. If they don't, further investigation for underlying hematological disorders would be warranted.