Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 178 Emergency 2014; 2 (4): 178-179 CASE REPORT Essential Thrombocytosis Following Multiple Psychic Traumas Rezvan Sadr Mohammadi1, Mehrdad Mahdian2, Reza Bidaki3*, Seyed-Ali Mostafavi4,5 1. Department of Clinical Psychology, Kar Higher Education Institute of Rafsanjan, Rafsanjan, Iran 2. Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran 3. Department of Psychology, Rafsanjan University of Medical Sciences, Rafsanjan, Iran 4. Psychiatry Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran 5. Iranian Petroleum Industry, Health Research Institute (IPIHRI), NIOC Central Hospital, Tehran, Iran Abstract The associations between exposure to traumatic events and psychiatric disorders such as posttraumatic stress dis- order (PTSD), depression, and anxiety have been established. It is important that clinicians notice to this phenome- non and avoid from inappropriate interpretations and additional laboratory tests. Here, a case of 45-year-old man with Essential thrombocytosis developed after multiple psychic traumas was introduced. Key words: Stress disorders, post-traumatic; thrombocytosis; case management; case reports Cite this article as: Sadr Mohammadi R, Mahdian M, Bidaki R, Mostafavi SA. Essential thrombocytosis following multiple psychic traumas. Emergency. 2014;2(4):178-9. Introduction: 1 ssential thrombocytosis (ET) is a hematological disease that may causes venous thrombosis in different parts of the body. ET was determined by abnormal megakaryocyte proliferation with a rare inci- dence of 2.5 to 7 per 1,000,000 population (1-3). It can be associated with both thrombosis and hemorrhage (2, 3). Thrombocytosis describes with elevated platelet count above 450 × 103/mm3, which can be primary including ET or secondary including iron deficiency, infection, blood loss, and malignancy (2). In previous literatures the associations between exposure to trau- matic events and psychiatric disorders such as post- traumatic stress disorder (PTSD), depression, and anxi- ety have been established. Also a relationship between depression, anxiety, stress and neurochemical function- ing impairment was determined in previous studies (4). Recent investigations have suggested that responses to traumatic stressors also appear to have a physiological foundation that could result in disorders of immune function and complete blood cell count. Rises in leuko- cyte, lymphocyte and T-cell counts as well as changing in cell mediated immune system have been reported, too (5, 6). In this report a case of a 45-year-old man with ET which developed after multiple psychic trau- mas was reported. Case presentation: A 45-year-old married man, employee of agriculture fac- ulty, referred to psychiatric emergency department after *Corresponding Author: Reza Bidaki; Department of Psychiatry, Moradi Hos- pital, Moalem St, Rafsanjan, Iran. Phone: +983915230081; Fax: +983915230086. Email: Reza_Bidaki@yahoo.com Received: July 2014; Accepted: July 2014 experiencing a stressful situation. He had a cystic mass in his right inguinal area about 6 months ago. His mother died due to ovarian cancer lasted during 24 years and his younger aunt deceased because of gastric cancer lasting for 8 years. Patient’s uncle has also been treated for chronic lymphocytic leukemia (CLL) since 2007. The pa- tient was previously well until his cyst concerned as ma- lignancy and involved in obsessions. After visiting it was found that there is a simple infectious cyst cured follow- ing appropriate antibiotic use. Shortly later, he experi- enced headaches that were different from the previous ones; a pulsating severe headache in occipital area that was accompanied with neck muscles’ spasm and exacer- bate with head movement. This headache had not re- sponded to conventional analgesics. He didn’t have a his- tory of joint pain, bleeding or other symptoms. He didn't use any drug in recent months. The patient was visited again (Blood pressure=130/100 mmHg, Pulse rate=78/minute, Respiratory rate= 13/minute, Tempera- ture=36.8C◦) and serum laboratory test requested for him. The results were normal except for platelets count that was 1,150,000/µl. Blood smear showed an increased megakaryocyte and normal for other type of blood cells. Abdomino-pelvic ultrasonography didn’t present any additional findings. The patient’s stress exacerbated and obsessive thoughts came back in his mind again and his professional performance affected. He was constantly distracted and had problem for concentration. His physi- cian ordered new tests again while his platelet count was unexpectedly increased to 1,630,000/µl. The patient consulted with a psychiatrist. After one session consulta- tion and using stress reduction techniques, the symp- toms gradually disappeared by means of appropriate E mailto:Reza_Bidaki@yahoo.com This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 179 Sadr Mohammadi et al exercise and nutritional diet. Bone marrow aspiration was suggested to him but he didn’t accept. Discussion: Thrombocytosis is usually observed in a variety of un- derlying conditions, which may cause an acute and temporary rise in platelets count (such as major sur- gery, trauma and acute hemorrhage), more persistent thrombocytosis (like chronic infection and inflamma- tion, iron deficiency or neoplasia), or even a lifelong permanent increase in platelet count (2, 7, 8). Reactive thrombocytosis is a condition that levels of thrombo- poietin, IL-6, other cytokines, or catecholamines would be risen (9, 10). Boscarino, J. A. reported a distorted immune and neuroendocrine systems following PTSD (11). Patients with positive PTSD were more likely to have abnormally high leukocyte, lymphocyte, and T-cell counts. Some other studies have reported changes in complete blood cell count, profile of blood lymphocytes, leukocytes and immune system as well as increased level of inflammatory cytokines following PTSD (11- 13). As well Glover, D. A. and et al. reported altered im- mune function and lymphocyte in patients following PTSD (14). Morath, J. et al., also declared that chronic PTSD is associated with clinically elevated T-cells, hy- persensitive immune responses, and the presence of biological markers. PTSD is consistent with a wide range of inflammatory diseases (15) one of which may be thrombocytosis. Although altered lymphocyte and immune functions have been known in patients with PTSD, essential thrombocytosis is a rare phenomenon. This report has introduced an individual exposure to traumatic stress which has currently lower social sup- port with higher rates of post-traumatic stress and as- sociated disorders. Here, the patient had multiple psy- chic traumas. Although our case was asymptomatic, he didn’t have stable thrombocytosis and always had a platelet count more than 450,000 /µl with a rising trend. He was exposed to an emotional shock or a dis- tressful situation that produced a significant impres- sion, especially on the subconscious mind. The throm- bocytosis may be rarely occurred following the stress of related disorders like PTSD. It is important for clini- cians to notice this phenomenon and avoid from inap- propriate interpretation and additional laboratory tests. Acknowledgments: None Conflict of interest: Authors declared no conflict of interest. Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Boscarino JA. Posttraumatic stress disorder and physical illness: results from clinical and epidemiologic studies. Ann N Y Acad Sci. 2004;1032:141-53. 2. Schafer AI. Thrombocytosis and thrombocythemia. Blood Rev. 2001;15(4):159-66. 3. Vafaie M, Jaseb K, Ghanavat M, Pedram M, Rahiminia T. Asymtomatic essential thrombocythemia in a child: a rare case report. Int J Hematol Oncol Stem Cell Res. 2013;7(2):35- 7. 4. Chrousos GP, Gold PW. The concepts of stress and stress system disorders. Overview of physical and behavioral homeostasis. JAMA. 1992;267(9):1244-52. 5. Hohwu L, Li J, Olsen J, Sorensen TI, Obel C. Severe maternal stress exposure due to bereavement before, during and after pregnancy and risk of overweight and obesity in young adult men: a Danish National Cohort Study. PLoS One. 2014;9(5):e97490. 6. Boscarino JA. Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Psychosom Med. 1997;59(6):605-14. 7. Ohyashiki K, Akahane D, Gotoh A, et al. Uncontrolled thrombocytosis in polycythemia vera is a risk for thrombosis, regardless of JAK2(V617F) mutational status. Leukemia. 2007;21(12):2544-5. 8. Vannucchi AM, Barbui T. Thrombocytosis and thrombosis. Hematology Am Soc Hematol Educ Program. 2007:363-70. 9. Alexandrakis MG, Passam FH, Perisinakis K, et al. Serum proinflammatory cytokines and its relationship to clinical parameters in lung cancer patients with reactive thrombocytosis. Respir Med. 2002;96(8):553-8. 10. Araneda M, Krishnan V, Hall K, Kalbfleisch J, Krishnaswamy G, Krishnan K. Reactive and clonal thrombocytosis: proinflammatory and hematopoietic cytokines and acute phase proteins. South Med J. 2001;94(4):417-20. 11. Boscarino JA, Chang J. Higher abnormal leukocyte and lymphocyte counts 20 years after exposure to severe stress: research and clinical implications. Psychosom Med. 1999;61(3):378-86. 12. Gill JM, Saligan L, Woods S, Page G. PTSD is associated with an excess of inflammatory immune activities. Perspect Psychiatr Care. 2009;45(4):262-77. 13. Wilson SN, van der Kolk B, Burbridge J, Fisler R, Kradin R. Phenotype of blood lymphocytes in PTSD suggests chronic immune activation. Psychosomatics. 1999;40(3):222-5. 14. Glover DA, Steele AC, Stuber ML, Fahey JL. Preliminary evidence for lymphocyte distribution differences at rest and after acute psychological stress in PTSD-symptomatic women. Brain Behav Immun. 2005;19(3):243-51. 15. Morath J, Gola H, Sommershof A, et al. The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: evidence from a randomized controlled trial. J Psychiatr Res. 2014;54:1-10.