P0654 - Not Another Migraine: An Atypical Presentation of Iron Deficiency Anemia

Case Presentation

19-year-old female with past medical history of type I diabetes mellitus and migraine, well-controlled medically, presented to the emergency department with four day history of 10/10 headache without an identifiable trigger. Pain at onset felt like her classical migraine, characterized by sharp, left sided pain, and photophobia. After two days of pain, she was evaluated at an urgent care facility and subsequently treated with diphenhydramine, prochlorperazine, and toradol to moderate effect. Over the next forty-eight hours, symptoms progressively worsened with right arm heaviness. In the emergency department CT venogram of the head identified sagittal venous sinus thrombosis. Patient lacked personal of family history of thrombosis. The patient was started on a heparin infusion with gradual improvement of all symptoms and was eventually transitioned to apixaban for long term anticoagulation.

Lab Data

WBC: 8.4; Hgb: 9.6; Hct: 30.9; Plt:580 and reaching maximum of 854; MCV: 79.2; Ferritin 7. Hypercoagulability panel test including: lupus anticoagulant, Factor V Leiden, Proteins C and S, Antithrombin III, PNH panel, Homocysteine level, and ANA were unrevealing. Myeloproliferative neoplasm (MPN) workup was negative for BCR-ABL translocation, JAK2 V617F, CALR, MPL mutation and bone marrow morphological findings for MPN. After intravenous iron treatment, platelets did improve to 494 and hemoglobin to 13 suggesting severe reactive thrombocytosis to iron deficiency anemia.

Discussion

Cerebral venous thrombosis is a poorly understood and rare cause of stroke in all ages, with studies reporting an incidence of 0.22 to 1.57 per 100,000 people and a seventy percent female predominance. Oral contraceptives, tobacco, and rheumatologic diseases are postulated to increase risk. Because presentation is typically more benign and insidious than other causes of stroke, average time from symptom onset to diagnosis is seven days. Patients diagnosed in a timely manner typically have good neurologic outcomes, but delays increase risk for progression of thrombosis with consequent seizures or herniation.
In contrast, iron deficiency anemia is a global health crisis, affecting more than two billion people worldwide mainly children and young women. In developing countries, factors such as famine, extreme poverty, and parasitic infections are often causative and difficult to avoid. Since clinical signs are frequently familiar, gradual, and nonspecific changes, such as fatigue or difficulty concentrating, it can be easy to forget that thrombocytosis is also a well-documented sequelae of iron deficiency. Though thrombocytosis in this setting is typically benign, there have been a handful of previous case reports implicating thrombotic manifestation.

For our patient only positive findings were severe thrombocytosis and severe iron deficiency anemia. With repletion of iron, her labs improved and she remains symptom free. This patient, at the juncture between childhood and adulthood, presented with a rare and severe consequence of an extremely common health problem calling for surveillance.