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<p>Automated counters, employing different methodologies with high speed and efficiency, have significantly contributed to clinical laboratories. These instruments yield precise and accurate results, crucial for diagnosing, treating, and monitoring patients. Nonetheless, these devices possess limitations and vulnerabilities that may influence test outcomes and, in certain instances, cause clinicians to be unsure of making informed decisions. We report a case of a 39-year-old pregnant woman whose initial platelet count, measured by an impedance-based analyzer equipped with automated discriminators, showed a significantly reduced platelet count. The delta check failed, prompting further analysis using a different hematology analyzer with fixed discriminator thresholds, which indicated a normal platelet count accompanied by uncertainty flags. Peripheral smear examination revealed severe microcytosis and erythrocyte fragments, which interfered with accurate platelet discrimination. This case emphasizes the rare pitfalls of impedance-based automated platelet count, particularly in cases of severe microcytosis. To determine platelet size distribution, automated counters use different techniques and discriminator strategies (fixed or floating gates). In severe microcytosis, improper gate closure may lead to pseudo-thrombocytosis. However, in this case, the float-based device could not correctly differentiate between the two cell populations due to saturation of the two peaks related to red blood cells and platelets. This resulted in the incorrect identification of the border between platelets and red blood cells, ultimately resulting in pseudo-thrombocytopenia. Modern hematology analyzers with laser-based technologies can help distinguish platelets from microcytic RBC fragments, but microscopic review remains essential for confirming results. This thought-provoking case highlights a rare but significant diagnostic pitfall. While microcytic red blood cell fragments typically result in pseudo-thrombocytosis, in exceptional scenarios, such as the one described, they may paradoxically cause a pseudo-thrombocytopenia. This phenomenon underscores the inherent limitations of impedance-based hematology analyzers, which often struggle to differentiate between platelets and very small erythrocyte fragments in abnormal samples. To broaden diagnostic horizons and ensure accurate interpretation, laboratory professionals must be well-versed in the principles and limitations of their analyzers, remain attentive to potential sources of analytical error, and routinely perform microscopic reviews to confirm unexpected or questionable results.</p>

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Severe Microcytosis-induced Pseudo-thrombocytopenia: a Case Report and Laboratory Pitfall

  • 期刊论文

  • 发表日期：

    2025年6月10日

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  • Alireza Bayani,
  • Mohammad Jafar Sharifi

摘要

Automated counters, employing different methodologies with high speed and efficiency, have significantly contributed to clinical laboratories. These instruments yield precise and accurate results, crucial for diagnosing, treating, and monitoring patients. Nonetheless, these devices possess limitations and vulnerabilities that may influence test outcomes and, in certain instances, cause clinicians to be unsure of making informed decisions. We report a case of a 39-year-old pregnant woman whose initial platelet count, measured by an impedance-based analyzer equipped with automated discriminators, showed a significantly reduced platelet count. The delta check failed, prompting further analysis using a different hematology analyzer with fixed discriminator thresholds, which indicated a normal platelet count accompanied by uncertainty flags. Peripheral smear examination revealed severe microcytosis and erythrocyte fragments, which interfered with accurate platelet discrimination. This case emphasizes the rare pitfalls of impedance-based automated platelet count, particularly in cases of severe microcytosis. To determine platelet size distribution, automated counters use different techniques and discriminator strategies (fixed or floating gates). In severe microcytosis, improper gate closure may lead to pseudo-thrombocytosis. However, in this case, the float-based device could not correctly differentiate between the two cell populations due to saturation of the two peaks related to red blood cells and platelets. This resulted in the incorrect identification of the border between platelets and red blood cells, ultimately resulting in pseudo-thrombocytopenia. Modern hematology analyzers with laser-based technologies can help distinguish platelets from microcytic RBC fragments, but microscopic review remains essential for confirming results. This thought-provoking case highlights a rare but significant diagnostic pitfall. While microcytic red blood cell fragments typically result in pseudo-thrombocytosis, in exceptional scenarios, such as the one described, they may paradoxically cause a pseudo-thrombocytopenia. This phenomenon underscores the inherent limitations of impedance-based hematology analyzers, which often struggle to differentiate between platelets and very small erythrocyte fragments in abnormal samples. To broaden diagnostic horizons and ensure accurate interpretation, laboratory professionals must be well-versed in the principles and limitations of their analyzers, remain attentive to potential sources of analytical error, and routinely perform microscopic reviews to confirm unexpected or questionable results.