California Association for

Medical Laboratory Technology

Distance Learning Program

Hematology Case Studies: Platelets

by
Helen M. Sowers, MA, CLS
Dept of Biological Science (ret.)
California State University, East Bay
Hayward, CA

Dora W. Goto, MS, CLS,

MT(ASCP)
Laboratory Manager
Bay Valley Medical Group
Hayward, CA

Course Number: DL-985

1 .0 CE/Contact Hour
Level of Difficulty: Intermediate
California Association for Medical Laboratory Technology.
Permission to reprint any part of these materials, other than for credit from CAMLT, must
be obtained in writing from the CAMLT Executive Office.

CAMLT is approved by the California Department of Health Services as a

CA CLS Accrediting Agency (#0021)
and this course is is approved by ASCLS for the P.A.C.E. Program (#519)
1895 Mowry Ave, Suite 112
Fremont, CA 94538-1766
Phone: 510-792-4441
FAX: 510-792-3045
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the expiration date printed on your license. If some of your units are made up of Distance
Learning courses, please allow yourself enough time to retake the test in the event you do
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CAMLT Distance Learning Course DL-985

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HEMATOLOGY CASE STUDIES: PLATELETS

OBJECTIVES:
After completing this course the participant will be able to:
1. Differentiate among the causes of thrombocythemia.
2. Explain how to determine the platelet count when the count is above the upper reportable
range of the analyzer.
3. Estimate the platelet count from the blood smear.
4. List the signs and symptoms of Essential Thrombocythemia.
5. Enumerate the causes of thrombocytopenia.
6. Discuss the causes of pseudothrombocytopenia.
7. Explain the methods of determining the causes of pseudothrombocytopenia.
Case #1
A 44-year-old woman comes in for a complete blood count (CBC) as part of a routine
physical exam. The results from the hematology analyzer, Cell-Dyn 1700 (Abbott
Diagnostics), are:
WBC
Lym
MID
Gran

7.5 K/L
28.7 %
10.4 %
60.9 %

PLT

>>>> K/L

RBC
HGB
HCT
MCV
MCH
MCHC
RDW

4.22 M/L
12.4 g/dL
38.6 %
91.4 fL
29.3 pg
32.0 g/dL
13.5 %

MID cells may include less frequently

occurring and rare cells correlating to
monocytes, eosinophils, basophils,
blasts, and other precursor white cells.

Questions:
1. What is abnormal about her CBC?
2. Which parts can be reported?
3. What procedures can be done regarding the abnormal result?
Answers:
1. The platelet count is above the upper reportable range.
2. The WBC histogram and 3-part differential are normal and can be reported. The RBC
histogram is normal and can be reported.
3. To determine the platelet count:
a. Make a 1:1 dilution of the whole blood and re-run the platelet count. Correct the platelet
count for the dilution.
b. Make a smear of the whole blood and examine for platelet morphology and numbers.

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Discussion:
The platelet count on 1:1 diluted blood was 534, so the platelet count is 2 x 534 = 1,068
K/L (normal is 150-400 K/L).
On blood smears made from EDTA-blood and stained with a Romanowsky stain, platelets
are round or oval, 2-4 m in diameter, and separated from one another. The platelet count can be
estimated from the smear. At 1000x magnification (oil immersion), this is equivalent to about 730 platelets per oil immersion field (OIF). Count the number of platelets in 10 oil immersion
fields. Divide the total by 10 to get the average number of platelets per field. Each platelet seen
on the smear equates to approximately 15,000/L. Multiply the average number per OIF to get
the platelet estimate1. See Image #1. In this case the average number of platelets per field was
70. The estimate equals 70 x 15,000 = 1,050 K/L. Thus the platelet estimate derived from the
smear in Images #1 and #2 correlates with the corrected platelet count of 1,068 K/L.

The causes of increased platelet counts include:

Inflammatory disorders
Iron deficiency anemia
Splenectomy
Chronic granulocytic leukemia
Polycythemia vera
Undetected cancer
Essential (primary) thrombocythemia
Since the patient had no symptoms, no history of splenectomy, and normal WBC and RBC
hemograms, all except essential (primary) thrombocythemia can be eliminated or are unlikely.
Essential (Primary) Thrombocythemia2
Essential thrombocythemia (ET) is a myeloproliferative disease. These diseases are a group
of disorders that share features that include the clonal overproduction of one or more blood cell
lines. Clonal diseases begin with a mutation in one or more bone marrow cell lines.
Myeloproliferative diseases include polycythemia vera, myelofibrosis, chronic granulocytic
leukemia, and essential thrombocythemia.

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In ET there is overproduction of megakaryocytes, the precursor to platelets (thrombocytes).

Abnormalities in platelet aggregation and adhesiveness tests suggest defective platelet function3.
In about half the patients with ET there is a mutation of the JAK2 (Janus kinase 2) gene in their
blood cells. In the others the cause is unknown.
ET occurs mostly in adults. There are about 0.1 to 2.4 new cases per 100,000 in the U.S.
each year. The disease does not ordinarily shorten life expectancy, but serious complications can
occur, so the patient needs to be followed by a physician.
Many patients have no symptoms. In others signs, symptoms and complications of ET result
from the increased numbers of platelets in the peripheral blood. Since platelets are involved in
the process of clot formation in response to blood vessel injury, the most common complication
of ET is blockage of blood vessels by excess platelets (thrombosis). Less often the increased
platelets cause bleeding.
Signs, symptoms, and complications include:
Burning or throbbing in the feet
Headache, dizziness, and weakness or numbness on one side to the body or other signs of
inadequate blood flow to the brain
Thrombosis (abnormal clotting)
Unexpected or exaggerated bleeding (infrequent, associated with very high platelet
count)
Enlarged spleen
Complications of pregnancy
Diagnosis of ET may occur when a higher than normal platelet count occurs on a routine
blood count (as with this patient), or on a blood count that is ordered on a patient who has a
blood clot, unexpected bleeding, or an enlarged spleen and there is no other cause for the
increased numbers of platelets. In ET the platelet count is over 600 K/L blood and remains
high in subsequent counts. Although the diagnosis cannot be made by laboratory tests alone, the
following may be useful: JAK2 mutation in blood cells, slightly lower than normal blood
hemoglobin and slightly higher WBC count, no evidence of other myeloproliferative diseases,
and an examination of the bone marrow. The bone marrow will show a significant increase in
megakaryocytes and masses of platelets.
Treatment of patients with ET is based on the risk of clotting or bleeding complications. If
there are no signs or symptoms, the patient is seen for regular checkups. If the patient has high
risk as determined by previous clotting or bleeding episodes, a history of a clot, cardiovascular
risk factors--diabetes, high cholesterol, smoking, hypertension, obesity--therapy may be
considered.
Drug therapy may include aspirin, hydroxyurea, anagrelide, or interferon alfa. Aspirin,
although decreasing clotting, may increase the risk of bleeding. When the platelet count is very
high and the patient suffers acute clotting, plateletpheresis may be done on an emergency basis.
This patient had no symptoms and was given follow-up appointments.

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Case #2
A 38-year-old female inpatient has the following results on her initial complete blood
count on Coulter Gen-S (Beckman-Coulter):
WBC
NE
LY
MO
EO
BA

8.9 K/L
57.9 %
33.4 %
6.3 %
1.9 %
0.5 %

Suspect/Definitive Messages/Flags:
Micro/Fragmented Red Cells
Giant Platelets
Platelet clumps

RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLT
MPV

4.86
14.4
42.5
87.4
29.8
34.0
12.5
64
6.9

M/L
g/dL
%
fL
pg
g/dL
%
K/fL
fL

R flag on Platelet Count & MPV

Comments:
Do not verify platelets; review first
and redraw if necessary

Questions
1. What is abnormal about the blood count?
2. Which parts of the CBC can be reported?
3. What would you do to investigate the abnormal result?
Answers:
1. The platelet count is abnormally low and there are flags for microcytic or fragmented
RBC, giant platelets, or platelet clumps.
2. The WBC histogram and differential are normal and can be reported.
3. The platelet and RBC histogram patterns are consistent with platelet clumps, fragmented
red cells, or microcytic red cells. Make and review the smear (See Image #3) for platelet
clumps, fragmented red cells, or small red cells before verifying the platelet count.

CAMLT Distance Learning Course DL-985

California Association for Medical Laboratory Technology

Discussion:
The platelet count was below normal, a condition known as thrombocytopenia.
The causes of decreased platelet counts are4:
Decreased Production
Leukemia or lymphoma
Cancer treatments such as radiation or chemotherapy
Various anemias
Toxic chemicals
Medications: diuretics, chloramphenicol
Viruses: chickenpox, mumps, Epstein-Barr, parvovirus, AIDS
Alcohol in excess
Genetic conditions: Wiskott-Aldrich, May-Hegglin, Bernard-Soulier syndromes
Abnormal distribution
Splenomegaly with sequestration in the spleen
Increased destruction
Autoimmune diseases: Idiopathic (immune) thrombocytopenic purpura
Medications: quinine, antibiotics containing sulfa, Dilantin, vancomycin,
rifampin, heparin-induced thrombocytopenia
Surgery: man-made heart valves, blood vessel grafts, bypass machines
Infection: septicemia
Pregnancy: about 5% of pregnant women develop mild decrease
Thrombotic thrombocytopenic purpura
Disseminated intravascular coagulation
Pseudothrombocytopenia
Partial clotting of specimen
EDTA-platelet clumping
Platelet satellitism around WBCs
Cold agglutinins
Giant platelets
Results of the blood smear evaluation (Case #2, Image #3):
The smear showed numerous platelet clumps (make sure to examine the edges of the
smear since the clumps may migrate there; Images #4 and #5). There were no giant platelets,
fragmented RBC, or small RBC. To obtain an automated platelet count, obtain a blood specimen
drawn into Sodium Citrate (NaCitrate).

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Results of the platelet count on the NaCitrate specimen (Case #2, Image #6):
There were no flags or error messages. The platelet count of 289 K/L needs to be
corrected for the dilution of the blood by liquid NaCitrate as follows:
289 x 1.1 (dilution factor) = 318 K/L
The diagnosis is EDTA-platelet clumping. This condition may persist for decades without any
evidence of abnormal hemostasis. EDTA-platelet clumping needs to be recognized and
documented in the patients chart to prevent unnecessary treatment for thrombocytopenia, and to
guide future laboratory tests.

Causes of pseudothrombocytopenia are as follows:

Partial clotting of the specimen:
With a low platelet count the first procedure is to examine the specimen for evidence of
clotting as well as to make a smear and look for evidence of platelet clumping. When
blood clots, platelets adhere to the clot and are removed from the fluid blood. If evidence
of micro-clots or clumping is seen, obtain a new specimen.
EDTA-Induced Platelet Agglutination (EIPA) (EDTA-platelet clumping):
EIPA is an in-vitro phenomenon due to the presence of naturally occurring autoantibody
against a cryptantigen on the GPIIb/IIIa platelet receptor. Under normal in vivo
conditions this antigen is not accessible for antibody binding (crypt or hidden antigen).
When calcium is chelated by EDTA, the GPIIb protein undergoes a structural change that
exposes the cryptantigen. The antibody can then bind to the exposed site and crosslink to
other platelets causing agglutination. The condition occurs in 0.1 to 2% of hospitalized
patients5.

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Platelet satellitism
In this phenomenon platelets rosette around neutrophils or rarely around other cells. The
satellite platelets are not counted by automated cell counters, resulting in spurious
thrombocytopenia. Platelet satellitism is caused by EDTA-dependent antiplatelet and
antineutrophil IgG antibodies in the patients plasma (5).
The phenomenon has not been associated with any disease state or drug and is thought to
be benign.
The diagnosis is made by making a blood smear and looking for platelet rosettes: Images
#7 and #8. This needs to be documented in the patients chart.

Cold agglutinins
Spontaneous EDTA-independent agglutination associated with cold antibodies is rare.
The condition should be considered when agglutination occurs in citrate and heparin as
well as EDTA anticoagulants. This phenomenon is temperature dependent. The
specimen should be maintained at 37 C or warmed to 37 C to obtain an accurate
platelet count6.

CAMLT Distance Learning Course DL-985

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Giant platelets
Giant platelets that are 36 fL or larger will be counted as red cells (See Images #9 and
#10) in most automated electronic platelet counters, resulting in spuriously low platelet
counts. Low platelet counts along with instrument flagging of giant platelets should
prompt the operator to confirm the abnormal platelet count by blood smear
review/platelet estimate or perform a manual platelet count. The confirmatory method of
choice employs a manual platelet count using phase-contrast microscopy. Manual
platelet counts include three steps: dilution of the blood with simultaneous lysis of RBCs
with ammonium oxalate; sampling the diluted suspension into a measured volume using a
hemocytometer; and counting the platelets in that volume1. When significant numbers of
giant platelets are counted as red cells, spuriously low platelet counts cannot be reported.
The platelet estimate or manual platelet count must be reported in the place of automated
platelet count.

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ACKNOWLEDGMENTS
Major funding for photographs used in this presentation was provided by:
California Health Foundation and Trust (CHFT)
Healthcare Laboratory Workforce Initiative (HLWI) of the Healthcare Foundation of
Northern and Central California
California Association for Medical Laboratory Technology (CAMLT)
All images were photographed by Dora W. Goto, MS, CLS, MT(ASCP). Many thanks
also to the laboratory staff at Bay Valley Medical Group, Hayward, CA for saving
instrument printouts and corresponding blood smears in support of continuing medical
technology education.
REFERENCES
1. McPherson RA, Rincus, MR. Henrys clinical diagnosis and management by
laboratory methods. 21st ed. Philadelphia, PA: W.B. Saunders Company, 2006.
2. www.lls.org
3. McKenzie S. Clinical Laboratory Hematology. Upper Saddle River, NJ: Pearson
Prentice-Hall; 2004:525
4. http://home.columbus.rr.com/allen/thrombocytopenia.htm
5. http://www.pathoindia.com/newspath107.html
6. Schimmer A, Mody M, Sager M, et al. Platelet Cold Agglutinin: a flow cytometric
analysis, Transfusion Science, Vol 19:3, Sept 1998

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Review Questions
Course #DL-985
Chose the one best answer.
1. 360 platelets are counted in 10 oil immersion fields on a conventionally made blood
smear. The platelet estimate is
a. 36,000/L
b. 54,000/L
c. 360,000/L
d. 540,000/L
2. If the number of platelets is above the reportable range on an automated instrument, the
first recommended procedure is to
a. prepare a smear and count the number of platelets/10 OIF
b. do a manual platelet count
c. report the number of platelets beyond the reportable range without further
analysis
d. dilute the blood and run the diluted blood through the automated instrument
3. Causes of increased platelet counts include all but which of the following:
a. splenectomy
b. platelet satellitism
c. Chronic granulocytic leukemia
d. Essential Thrombocythemia
4.

The most common symptom of Essential Thrombocythemia is

a. thrombosis
b. bleeding
c. burning of the feet
d. enlarged spleen

5. Of the following causes of thrombocytopenia which is classified as increased

destruction?
a. chickenpox
b. disseminated intravascular coagulation
c. chloramphenicol
d. May-Hegglin Anomaly
6. EDTA induced platelet aggregation is caused by
a. fibrin strands in the blood specimen
b. EDTA bridges between platelets
c. a cryptantigen-antibody reaction
d. reaction between platelets and the glass slide

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7. A blood specimen is taken in NaCitrate. The platelet count on an automated instrument

is 305,000/L. What is the corrected platelet count?
a. 33,550/L
b. 277,300/L
c. 335,500/L
d. 305,000/L
8. A blood smear is made on a patient with a low platelet count. Platelets are seen attached
to the periphery of neutrophils. Which of the following applies to this finding?
a. Neutrophils are attempting to phagocytose platelets.
b. The patient may exhibit bleeding problems.
c. It is found in patients who are taking sulfonamides.
d. It is caused by an EDTA dependent antiplatelet-antineutrophil antibody.
9. The best part of the smear to see agglutinated platelets is
a. the edge
b. the central part
c. the thick part
d. agglutinated platelets are not seen on smears
10. Cold agglutinin-caused platelet agglutination can be diagnosed by
a. drawing blood into NaCitrate.
b. maintaining blood at 37 C.
c. drawing blood into heparin.
d. cooling the blood to 15 C.

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Course #DL-985 - HEMATOLOGY CASE STUDIES: PLATELETS

Registration/Answersheet - 1.0 CE Credit
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Please circle the one best answer for each question.

1.
2.
3.
4
5

a
a
a
a
a

b
b
b
b
b

c
c
c
c
c

d
d
d
d
d

6
7
8
9
10

a
a
a
a
a

b
b
b
b
b

c
c
c
c
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d
d
d
d
d

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