Ethylenediaminetetraacetic Acid (EDTA)Dependent Pseudothrombocytopenia: A

Case Report of an Incidental but Important

Finding
Rod S. Hagerman D.O.Undersea, Dive, and Submarine Medical OfficerCommander
Submarine Group TenUS NavyKings Bay, Naval Submarine BaseKings Bay, GA

Introduction:
Ethylenediaminetetraacetic acid (EDTA) is a commonly used anticoagulant in sampling tubes
designed for determination of complete blood counts. Associated with this anticoagulant is a
phenomenon that is well known to cause erroneous reports of low platelet counts by
automated analyzers. (7) This phenomenon of EDTA-induced pseudothrombocytopenia has
been reported rarely in both normal individuals and in association with a variety of diseases,
such as infections with human immunodeficiency virus, rubella, and cytomegalovirus;
autoimmune disorders; neoplastic diseases; thrombotic disorders; and possibly trauma. (5) It
occurs with an incidence of approximately 0.1% in the general population (7) and has never
been associated with hemorrhagic diathesis or platelet dysfunction. However, failure to
recognize this form of Pseudothrombocytopenia (PTCP) may lead a subject with a normal
platelet count, to be considered as if he had severe thrombocytopenia. (8) Needless
evaluations, canceled surgical procedures, avoidance of conduction anesthesia, unwarranted
splenectomies, and undue patient expense and anxiety (5) are all potential outcomes for an
individual with this form of in vitro artifact. Since its initial description in 1969, this
condition has become commonly associated with hospitalized patients, especially seriously ill
ones. PTCP has also been reported, although less commonly in healthy subjects undergoing
routine blood counts. (6)
The following is a case of an 18-year-old man who, aside from a psychiatric condition, was a
healthy individual in which the incidental finding of EDTA-PTCP had no association.

Case Presentation:
An anxious 18 year-old male with an unremarkable medical history presented to ambulatory
care after complaining of vague chest pain and difficulty breathing following his morning
exercise session. The patient denied any traumatic events associated with physical training
that morning, and his coworkers had not noticed any changes in his performance level. The
patient stated that the symptoms began after the activity was completed and described his
problem as an inability to "catch his breath."
The patient is a naval service member awaiting orders for rigorous duty as a Navy Diver
when the incident occurred. He was noted to have begun use of an ephedra-containing
supplement approximately 4 days before his presentation to the clinic.

Aside from the recent supplement use, the only medicine he utilized was fexofenadine for
seasonal allergies. He denied tobacco and alcohol use during the interview. His family history
was remarkable for cardiovascular disease on both sides of his family, but none of which
were considered premature by age criteria. Additionally, his mother's family had a significant
history of anxiety disorders, panic attacks, and attention deficit disorder.

Physical Exam:
Upon arrival to the clinic, the patient's temperature was 98.3 F, blood pressure was 128/80
mmHg, and his pulse was 102 beats per minute. His respirations also were rapid at 22 breaths
per minute. His head and neck exam was unremarkable. His heart rate was tachycardic with a
regular rhythm. There were no appreciable gallops, murmurs, or rubs with exam. Breath
sounds were equal bilaterally without crackles or wheezes. His abdominal exam was
unremarkable, as was his extremity exam. Neurological exam was notable only for obvious
bilateral resting hand tremors. An EKG revealed sinus tachycardia with no ST or T wave
changes. His pulse oximetry was also normal at 99%. Labs were drawn and included a
complete blood count. The Chest x-ray was consistent with hyperaerated lungs with some
flattening of the diaphragms. Spirometry followed and was found to be normal. By the time
these later studies were completed, his CBC was returned with a critical value of 34 x 103
platelets. The rest of the CBC was normal.

Clinic Course:
Upon reviewing his initial labs, the patient was brought back into the exam room for a closer
inspection of his integument for signs of petechiae or echymosis consistent with a platelet
disorder. This follow up exam remained normal, and his history remained devoid of clues for
easy bruising, gingival bleeding or bloody bowel movements.
After reinspection was complete, a microscopic review of the sample was conducted.
Numerous megakaryocytes appeared to be present in each high power field, but upon further
review, the finding was consistent with groups of thrombocytes tightly clumped together. The
patient's blood was redrawn and run immediately. The follow up platelet count was normal at
219 x 103. The same sample was run again 10 minutes later and found to be 108 x 103. Again,
microscopic exam revealed significant clumping.
Upon determination of incidental pseudothrombocytopenia, a clinical diagnosis of
generalized anxiety disorder was made. The diagnosis was supported by a long-standing
history of similar symptoms, which extended into his early teenage years. He was released
with a prescription of diazepam and a consult to Mental Health for a routine follow-up
evaluation.
The patient returned the next day reporting a positive response to the medication. A clear
notation was made in his medical record regarding his unusual reaction to the EDTA in the
lavender top collection tubes. Much like an allergy to medication, pseudothrombocytopenia
was recorded in his permanent medical record.

Discussion:
Although the differential diagnosis of thrombocytopenia encompasses a diverse list of
potential underlying etiologies, most cases fall with two major categories: impaired platelet

production or accelerated platelet destruction. However, when a patient reports for evaluation
with an abnormally low platelet count in the absence of a history consistent with
thrombocytopenia, pseudothrombocytopenia should be suspected. (3) The term
pseudothrombocytopenia is used to define a state with a falsely low platelet count reported by
automated hematology analyzers due to platelet clumping. (10) Commonly, this clumping is
caused by an alteration of the platelet surface glycoproteins when they are incubated with a
calcium chelator such as EDTA. (3) These modified platelet antigens then react to antiplatelet autoantibodies (Immunoglobulins of both the IgG and IgM types (2)) to form these
large agglutinates. (1) Despite the fact that some resource state that the aggregation of
platelets in patients with EDTA-dependent PTCP can be prevented by the use of other
anticoagulants such as sodium citrate or heparin (9), we have found that even these agents
can induce platelet clumping, and thus spuriously low platelet counts. The addition of
aminoglycosides also is cited as a useful way to diagnose EDTA-PTCP and to even evaluate
these patients appropriately in routine testing. (4)

Table 1: Time post venapuncture w.platelet concentration with three different anticoagulants:
EDTA,Heparin, and Sodium citrate

To substantiate the diagnosis in our patient, we collected blood specimens by venepuncture in

different tubes each containing EDTA, sodium citrate, and heparin. The blood specimens
were then measured with a Sysmex SF-3000 hematology analyzer which is based on laser
technology. These three tubes were measured at times 0, 2, 4, 6, 8, 10, and 30 minutes from
venepuncture. Immediately after analysis at these respective times, slides were also made
and inspected. All three agents were observed to induce a decreasing platelet count by
automated analysis with EDTA and Heparin following a similar slope to 10 minutes post-

venepuncture. Platelet counts in the Sodium citrate sample also fell, yet this appeared to be
considerably less than the other two specimens. (Table 1) The microscopic images illustrated
these numeric findings with increasing clumping as time increased. (Figures 1 through 6)
Figures 1 and 2: Microscopic images of blood anticoagulated with EDTA at time
of blood draw and 10 minutes later. Increased clumping in figure 2.

Figures 3 and 4: Microscopic images of blood anticoagulated with Heparin at time

of blood draw and 10 minutes later. Notes the increased clumping in Figure 4

Figures 5 and 6: Microscopic images of blood anticoagulated with sodium citrate

at time of blood draw and 10 minutes later. Note the increased clumping in Figure
6 but not as notable as in Figures 2 and 4.

Given these findings, similar agglutination appears to occur with other anticoagulants. In
anticoagulant-sensitive patients, aside from adding aminoglycosides to collected samples, the
best analytic course appears to be immediately running the freshly drawn samples (11)
without the use of anticoagulants at all. (2) Microscopic examination of sequential samples
also appears to enable the diagnosis of EDTA-PTCP, since the platelet clumping will be
readily apparent. (3)

Given the widespread use of EDTA-containing vacutainers for blood collection, identification
of PTCP requires a high index of suspicion after the identification of thrombocytopenia in the
absence of a suggestive medical history. Examination of the peripheral blood smear provides
evidence of PTCP in the form of platelet clumping. This, in addition to prompt analysis of
freshly-collected samples, will help to decrease, if not eliminate, needless laboratory testing
and unwarranted transfusions. (3) Our patient is an example of an otherwise healthy
individual who, in light of his current condition, was suspicious for EDTA-PTCP.
Nonetheless, an awareness of this particular condition is necessary, because its lack of
recognition may lead subjects with a normal platelet count to be considered, and at times
treated, as if they were severely thrombocytopenic. (1) A picture only more complicated if
other comorbid conditions exist in which to cloud the medical history with potential causes
for "true" thrombocytopenia.

References:
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Epidemiological Study of 112 Cases, With 10-Year Follow-Up. American Journal of
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With EDTA- and Temperature-Independent Antibodies of the IgM Type. European
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9. Ahn, H. L., et al. (2002). EDTA-Dependent Pseudothrombocytopenia Confirmed by

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