What is the appropriate management for a patient with a history of anemia and current laboratory results indicating leukocytosis, anemia, and thrombocytosis?

Management of Leukocytosis, Thrombocytosis, and Anemia in a Young Female

This patient requires urgent evaluation for a myeloproliferative neoplasm or reactive process, with immediate peripheral blood smear examination, iron studies, and assessment for underlying inflammatory or infectious conditions. 1

Interpretation of Laboratory Findings

The CBC reveals three significant abnormalities that require systematic evaluation:

• Leukocytosis (WBC 14.5) with absolute neutrophilia (8.0) and lymphocytosis (5.0) suggests either reactive process or myeloproliferative disorder 1
• Thrombocytosis (platelets 508) is moderate and can be reactive or clonal 2
• Normal hematocrit (46.9) and RBC (5.31) appear inconsistent with a history of anemia, requiring clarification of current versus historical anemia status 3

Immediate Diagnostic Workup

Essential First-Line Testing

Peripheral blood smear examination is mandatory to assess for abnormal cells, schistocytes, and morphologic features that distinguish reactive from clonal processes 1, 3

Complete iron studies including serum ferritin and transferrin saturation must be obtained, as iron deficiency can paradoxically cause both thrombocytosis and leukocytosis even with normal hemoglobin 4

Inflammatory markers including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) should be measured to identify reactive causes 2

Reticulocyte count is essential to determine if the bone marrow is responding appropriately and to assess for hemolysis or occult bleeding 1, 5

Rule Out Critical Diagnoses

Exclude myeloproliferative neoplasm through bone marrow aspiration and biopsy with cytogenetic analysis if initial workup suggests clonal process 1

Assess for infection by obtaining blood cultures and screening for common pathogens, particularly if fever or systemic symptoms present 2

Check for hemolysis with LDH, haptoglobin, indirect bilirubin, and direct antiglobulin test (Coombs) 1

Liver function tests including GGT should be performed, as elevated GGT with cytopenias may indicate hepatobiliary involvement 1

Risk Stratification Based on Pattern

If Reactive Process (Most Likely)

The combination of moderate leukocytosis, thrombocytosis, and history of anemia most commonly represents:

• Iron deficiency anemia can cause extreme thrombocytosis (even >2000) and leukocytosis, which rapidly resolves with iron supplementation 4
• Inflammatory conditions including inflammatory bowel disease produce this triad of findings 2
• Acute infection particularly if accompanied by fever or systemic symptoms 2

If Myeloproliferative Neoplasm

Symptomatic thrombocytosis management includes hydroxyurea, anti-aggregants, anagrelide, or apheresis depending on thromboembolic risk 2

Symptomatic leukocytosis management includes hydroxyurea, apheresis, imatinib (if CML), or clinical trial enrollment 2

Critical Pitfalls to Avoid

Do not assume normal hematocrit excludes significant pathology - the patient's history of anemia requires explanation for current normal values, which could represent recent treatment, dehydration, or resolution of previous iron deficiency 3

Do not delay peripheral smear review - automated counts can miss critical morphologic abnormalities including blasts, dysplasia, or microangiopathic changes 1, 6

Do not overlook drug-induced cytopenias - common culprits include ribavirin, interferon, NSAIDs, antibiotics, and chemotherapy agents 1

Thrombocytosis correlates with iron deficiency due to rapid consumption of available iron, and VTE risk may be increased 2

Management Algorithm

1. Obtain peripheral smear, iron studies, CRP, reticulocyte count immediately 1, 3
2. If iron deficiency confirmed: Initiate iron supplementation and monitor CBC weekly - expect rapid normalization of platelets and WBC 4
3. If inflammatory markers elevated: Investigate underlying inflammatory or infectious cause 2
4. If smear shows abnormal cells or no clear reactive cause: Proceed to bone marrow biopsy with cytogenetics 1
5. If myeloproliferative neoplasm confirmed: Initiate cytoreductive therapy per disease-specific guidelines 2