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The patient presented with extensive bruising. CBC showed thrombocytopenia, baseline coagulation profile was normal, and PB smear showed platelet clumping. Due to the severity of bruising, child abuse was suspected as thrombocytopenia was initially misconstrued as being caused by EDTA-related platelet clumping. Further coagulation work-up revealed low von Willebrand factor antigen and ristocetin cofactor activity, and molecular testing confirmed vWD type 2B [ 3 ].
The latter is an in vivo consumption of platelet, which results in true thrombocytopenia. This morphologic observation may help further separate the two conditions presumptively upon examination of PB smear; refer to Figure 2 for morphologic comparison and Table 2 for comparative features.
Other possible preanalytical factors to consider upon investigating platelet clumps include the collection method, that is, capillary venous or line draws. Capillary collections are prone to clotting and formation of platelet clumps. Viral infection, drugs, and medications, especially chemotherapeutic agents, are all possible inducers of platelet clumping [ 5 , 6 ]. Clumping can also be due to a combination of more than one of the above factors, and it is possible that a transient viral infection was a confounding cause in our patient note the atypical lymphocyte suggestive of a viral infection seen in Figure 1 and the CBC results listed in Table 1 showing the fluctuation in WBC, RBC, and Hgb levels coinciding with episodes of clumping and returning to normal levels along with the platelet count.
From a practical laboratory point of view, investigation of platelet clumping may include the following steps until a nonclumping smear is obtained, noting that Steps 3 and 4 are reserved for the rare instances, where Steps 1 and 2 do not resolve the platelet clumping. Step 1. Verify method of blood draw e. Step 2. Test a blood sample collected in sodium citrate. Step 3. Test a sample collected in heparin.
If Step 3 is not possible, proceed to Step 4. Step 4. Obtain a sample in ammonium oxalate, and count platelets utilizing a hemocytometer grid, if available, as per described methods [ 4 ]. Reporting platelet counts on samples that show platelet clumps can be a challenge.
The authors declare that there are no competing interests regarding the publication of this paper. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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